Julia Hayes, MD
Retirement-age men with slow-growing prostate cancer
may wish to consider monitoring their disease rather than being treated
immediately, according to a new study led by investigators at
Dana-Farber Cancer Institute and Massachusetts General Hospital (MGH).
The study results, to be published in the Dec. 1 issue of the Journal of the American Medical Association,
provide information to the thousands of American men in the 65-year-old
age range who each year face the decision of how to deal with newly
diagnosed prostate cancer when the cancer has characteristics that
suggest a very low risk of spreading beyond the prostate.
Because there is limited information comparing outcomes of treatment
options for low-risk disease, investigators developed a computer model
simulating hypothetical patients whose quality of life and response to
treatment were based on reports in medical literature.
"The analysis demonstrates that for this group of prostate cancer
patients, a course of 'active surveillance' in which patients receive a
blood test (PSA) every three to six months, a physical exam every six
months, and periodic re-biopsies of their tumor tissue is a reasonable
alternative to immediate treatment in terms of quality of life," says
study lead author Julia Hayes, MD, of Dana-Farber and the MGH Institute for Technology Assessment.
If surveillance reveals that the cancer has become more of a threat, it can then be treated.
Every year, about 200,000 men are diagnosed with prostate cancer in
the United States, 90 percent of whom receive immediate treatment, which
can include surgery, hormonal treatment, or radiation therapy.
However, in more than 70 percent of men with prostate cancer, the
disease is low-risk, meaning it is unlikely to become life-threatening,
and may not require immediate treatment.
"In recent years, active surveillance has emerged as an alternative
to initial treatment for men with this type of prostate cancer," Hayes
"But, while clinical studies are under way comparing active
surveillance to front-line treatment, it will be years before they yield
definitive results. The computer model we created allows us to
anticipate those studies' findings, and provides information to help men
and their physicians negotiate this difficult decision."
"Our analysis showed that 65-year-old men with low-risk, localized
prostate cancer who chose active surveillance had a higher quality of
life than those who received surgery or radiation right away, in part
because they were able to avoid or delay adverse effects of treatment,"
Patients approach the decision with different sets of preferences:
some may be anxious about leaving the disease untreated; others may be
more concerned about the potential side effects of treatment, which can
include urinary incontinence, erectile dysfunction, and bowel
When these patient preferences were changed in the model, the results
of the model changed, in some cases favoring initial treatment.
Therefore, the authors urge patients to discuss these issues with
their families and doctors in order to choose the approach that best
reflects their own preferences and values.
In the study, researchers used a measure called Quality-Adjusted Life
Expectancy (QALE) to compare active surveillance to initial treatment.
"QALE takes into account both the quality and length of each
patient's life," explains the study's senior author, Pamela McMahon,
PhD, of the Institute for Technology Assessment at MGH.
"It weighs the benefits and side effects of treatment, as well as how
men feel about being treated or not being treated. It's an attempt to
capture the physical and psychological aspects of disease and its
treatment as thoroughly as possible."
One of the main surprises of the study was that active surveillance
held its edge over immediate treatment from a quality-of-life standpoint
even when researchers entered data into their computer model that
exaggerated any negative health effects of active surveillance, Hayes
"Thousands of men each year face the decision of whether to be
treated immediately for low-risk prostate cancer or use active
surveillance," McMahon says. "Our study offers them evidence that can be
a useful starting point for discussions with their families and
The study was conducted as part of a series of comprehensive analyses
of the comparative effectiveness of active surveillance versus
treatment for men with low-risk prostate cancer conducted by the Institute for Clinical and Economic Review (ICER), based at MGH's Institute for Technology Assessment.
ICER has also produced a website for low-risk prostate cancer
patients based on these analyses to aid patients in their
The study was funded in part by grants from the National Cancer
Institute, the U.S. Department of Defense, and the Prostate Cancer
Foundation, and by funding from the Blue Shield of California
Co-authors of the study are: Philip Kantoff, MD, and Christopher
Sweeney, Dana-Farber; Daniel Ollendorf, MPH and Steven Pearson, MD, of
ICER; Michael Barry, MD, and James Stahl, MD, of MGH; Susan Stewart,
PhD, Harvard University Interfaculty Program for Health Systems
Improvement and the National Bureau of Economic Research; and Vibha
Bhatnager, MD, University of California San Diego.