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Co-morbidity and management of the man with low-risk, localized prostate cancer

Posted Dec 17 2010 12:00am

At the beginning of November, we commented on a re-analysis of the PLCO data by Crawford et al. a re-analysis that focused on the impact of co-morbidities on treatment and outcomes over time.

In a “Beyond the Abstract” statement on the UroToday web site just over a week ago, Dr. Anthony D’Amico (one of the authors of the paper by Crawford et al.) made some additional and interesting observations on the ramifications of co-morbidities in management decisions for men initially diagnosed with low-risk, localized prostate cancer.

His fundamental point was that, in the PLCO trial, men with at least one significant co-morbidity were much more likely to receive initial management that was non-curative (e.g., active surveillance or hormonal therapy alone) than men with no or minimal co-morbidity. He goes on to note that this may explain why there was an apparently increased risk of death from prostate cancer (adjusted hazard ratio = 1.44; p = 0.08) among men with at least one significant co-morbidity compared to the men with no or minimal co-morbidity.

He argues that the decreased risk of death from prostate cancer afforded by PSA-based screening may only be evident in men willing and able to undergo aggressive and potentially curative treatment at the time of diagnosis. And this takes him to the point of asking a new and distinctly controversial question: Is active surveillance a reasonable initial management strategy for all men with low-risk, localized prostate cancer and one or more co-morbidities?

Dr. D’Amico concludes his comments with the statement, “Future study is needed.”

The “New” Prostate Cancer InfoLink believes that (not for the first time) Dr. D’Amico has posited an extremely important question. If we knew with a high degree of certainty that immediate invasive treatment offered no prostate cancer-specific or overall survival benefit compared to initial active surveillance for newly diagnosed men with low-risk, localized prostate cancer and one or more significant co-morbid conditions, this would radically change the nature of the discussion about management of low-risk disease between doctors and their patients with co-morbid conditions which encompasses a large percentage of the men who get diagnosed with prostate cancer (for one reason or another).

But let us be very clear … Even if we knew that there was no such benefit, we are not stating that such men with one or more co-morbid conditions should absolutely not be given treatment. Appropriate management would need to be discussed and evaluated on a case by case basis. (A significant co-morbidity in one 60-year-old may be of minimal significance in another.) We are simply stating that if we knew the answer to the question, it would help everyone to make better decisions about patient-specific clinical options, which is a concept at the very heart of personalized medicine.

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