There are no right or wrong answers for men with prostate cancer when trying to decide what treatment to have, or even if they want to have treatment. One vital piece of information that is often left out of the equation is the chance of dying from prostate cancer if a man chooses not to have any treatment at all.
In the pre-PSA period Albertsen PC, Hanley JA, Gleason DF, Barry MJ.JAMA 1998 Sept. 16;280(11):975-80, “Competing Risk Analysis of Men Aged 55 to 74 Years at Diagnosis Managed Conservatively for clinically Localized Prostate Cancer” performed one of the largest studies that evaluated the actual risk of death a man would have if he chose not to have any sort of treatment. The results are summarized:
• Men with tumors that have Gleason scores of 2 to 4 face a 4% to 7% chance of dying from prostate cancer within 15 years of diagnosis depending on their age at diagnosis.
• Men with tumors that have a Gleason score of 5 face a 6% to 11% chance of dying from prostate cancer within 15 years of diagnosis depending on their age at diagnosis
• Men with tumors that have a Gleason score of 6 face a 18% to 30% chance of dying from prostate cancer within 15 years of diagnosis depending on their age at diagnosis
• Men with tumors that have a Gleason scores of 7 face a 42% to 70% chance of dying from prostate cancer within 15 years of diagnosis depending on their age at diagnosis and
• Men with tumors that have Gleason scores of 8 to 10 face a 60% to 87% chance of dying from prostate cancer within 15 years of diagnosis depending on their age at diagnosis.
A possible confounding issue does need to be factored into the decision; these results reflect a time when most men who were diagnosed had already progressed. Today, with the use of PSA testing we are more likely to diagnose prostate cancer at an earlier stage, or when the cancer has not is not as well progressed.
It is also important to remember that in today’s world we have what has been referred to as Gleason Score migration where the actual scores given today may actually have been scored at a lower level when the study was performed. There is an article on this issue at: http://tinyurl.com/2jnpbu.
The other issue is that we do not have similar data that shows what the possibility of dying is with similar Gleason Scores in men who elect to have treatment, either primary of in the case of advanced prostate cancer additional treatment(s).
Joel T. Nowak, M.A., M.S.W.
As you know this issue is becoming more of a problem particularly due to the popular press. We no longer see the lower Gleason scores of less than 6 as noted in the old article. I have recently seen some men on active survailance who upon rebiosy have had an increase from low volume Gleason 6 to higher volume Gleason 7(4+3) desease with minimal changes of their PSA. On the other hand I one patient in his late 40’s who was too heavy for surgery who after his diagnosis lost weight with exercise and a diet without meat and his PSA has lowered from 4.1 to 1.6 and upon rebiopsy with the same technician we found only atypia. Eventually they may figure out which tumor will kill you and which will not.
I was recently at my oncologist at Dana Farber. I asked about the possiblity of getting ipilimumab off label as you know it was recently approved for melanoma. She said they had a trial using it for prostate cancer and the trial was stopped due to severe colitis including one death.
Also something that you don’t hear about in the literature is an uncommen side effect of Casodex and the other current anti-androgens which is pulmonary fibrosis. About 5 months after starting Casodex I developed asthma symptoms. It got better than worse again. About 15 months after starting Casodex my chest CT showed ground glass opacities consistent with interstitial pneumonia/pulmonary fibrosis. My wife searched the literature and found some articles which connected Casodex with those findings. My oncologist also had a case with of full blown pulmonary fibrosis.
We stopped the Casodex and my breathing stablized. I still require inhalers. My recent chest CT showed resolution of the ground glass opacities. I am hoping my breathing improves over time. My symptoms preceded the CT findings.
Over the years I have given out a lot of Casodex and prior to that flutamide and this was news to me and other urologists I spoke to.
Stay well and keep up the good work! In the meantime Iwill try to stay one step ahead of the technology.