Medline: 7939747

Seminars in Oncology 21(5): 560-568, 1994.

Expectant management of clinically localized prostatic cancer.

Whitmore WF


Expectant management, also known as watchful waiting, for localized prostatic cancer, that is stage A (T1a-cNxM0) and stage B (T2a-cNxM0) disease, is a management option because of the protracted course, competing mortalities in this age group, and uncertain benefits of radical prostatectomies or radiotherapy in this disease. It entails regular thorough follow-up examination, treatment of bladder obstruction if any with appropriate modalities, and the use of endocrine therapy as needed. In stage A prostatic cancer, most patients have been under expectant management. The literature shows that: (1) survival with this type of management approaches that for the general age-matched population; (2) clinical progression has been reported in different ways that cannot easily be compared and often do not distinguish transient PSA rises, the type of disease progression that occurs, and other patient factors and comorbidity that affect survival more than does the cancer; (3) the uncertainties in the natural history and response to therapy (and lack of predictive tests) of stage A lesions identified by PSA, transrectal ultrasound, and transrectal needle biopsy; and (4) the appreciably higher cancer specific mortality with stage A2 (up to 25% or more) compared with stage A1 (5% at 10 years) disease. There have been few well-planned trials to compare the results of more aggressive therapy. The Veterans Administration Cooperative Urological Group found no difference in 15-year survival in a randomized study of placebo versus radical prostatectomy in 76 patients, but the study had defects. Although other studies have shown some advantages of radical prostatectomy or of radiation (85% cancer-specific survival at 10 years) balanced against competing mortalities and treatment risks, the actual survival benefits may be small. Stage B has primarily been treated in the US by radical prostatectomy or irradiation. Some investigators have found similar survival in patients with stage B disease randomized to placebo or prostatectomy. Data reviewed by Adolfsson from 2,395 patients (14 reports) having prostatectomy, 2,567 patients (22 reports) undergoing radiotherapy, and 586 (5 studies) expectantly-managed patients, gave weighted mean survivals of 93%, 74% and 84%, respectively. The cancer-specific survival advantage for prostatectomy at 10 years of follow-up was estimated at 10%, and metastatic failures for expectant management was twice the rate for surgical patients. Decision analysis is discussed. For very slow-growing tumors cancer will not be the cause of death, for rapidly-growing cancers, better prognostic tests and more effective therapies are needed. (58 Refs.)

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Dr. G. Quade