Prostate cancer and the prognostic challenge
Prostate cancer develops in the prostate gland, which is the second most common form of cancer among men globally. Approximately 1.3 million men were diagnosed with prostate cancer in 20181,2.
It is difficult to accurately predict the future development of prostate cancer. For some men, prostate cancer grows rapidly and spreads quickly, and is, therefore, a very serious condition that requires aggressive and radical treatment. However, in 85 percent of cases, the cancer grows slowly and only requires active surveillance as opposed to treatment. In fact, for most men diagnosed with prostate cancer, the cancer does not pose a threat to the patient’s life nor does it show any specific symptoms from an early stage. However, at later stages, prostate cancer may cause pain or difficulties urinating as well as problems during sexual intercourse3,4.
The current methods for diagnosing and assessing the aggressiveness of the prostate cancer are heavily dependent on visual assessment and human interpretation. Decisions regarding treatment strategy are therefore made using subjective and qualitative information that may not reflect the pathology of the individual patient’s prostate cancer. Because of this, a substantial number of patients are misclassified, resulting in overtreatment for some and undertreatment for others5,6,7.
Radical treatment such as prostatectomy (partial removal of the prostate) or radiation causes nerve and tissue damage. Studies have shown that 40-80% of the men will suffer from impotence 8,9,10,11 and 10-20% of incontinence9,10,11 as a consequence of treatment. These treatment methods are often chosen even though conservative strategies such as active surveillance would be sufficient for most men diagnosed with prostate cancer. The prognostic challenge results in a decreased quality of life for the prostate cancer patient but also increased costs for the health care system. That the diagnosis and treatment of localized prostate cancer among elderly men is associated with a substantial cost, despite that these men are unlikely to die of prostate cancer, has been demonstrated in several publications12,13.
- Bray, F. et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA. Cancer J. Clin. (2018) doi:10.3322/caac.21492.
- Prostate cancer statistics | World Cancer Research Fund. https://www.wcrf.org/dietandcancer/cancer-trends/prostate-cancer-statistics.(date accessed:2020-06-15).
- Stangelberger, A., Waldert, M. & Djavan, B. Prostate Cancer in Elderly Men. Rev. Urol. 10, 111 (2008).
- Rawla, P. Epidemiology of Prostate Cancer. World J Oncol. 2019;10(2):63–89. World J Oncol. (2019) doi:doi:10.14740/wjon1191.
- Daskivich, T. J. et al. Overtreatment of men with low-risk prostate cancer and significant comorbidity. Cancer (2011) doi:10.1002/cncr.25751.
- Loeb, S. et al. Overdiagnosis and overtreatment of prostate cancer. European Urology (2014) doi:10.1016/j.eururo.2013.12.062.
- Bratt, O. et al. Undertreatment of men in their seventies with high-risk nonmetastatic prostate cancer. Eur. Urol. (2015) doi:10.1016/j.eururo.2014.12.026.
- Van Den Bergh, R. C. N. et al. Sexual function with localized prostate cancer: Active surveillance vs radical therapy. BJU Int. (2012) doi:10.1111/j.1464-410X.2011.10846.x.
- Resnick, M. J. et al. Long-term functional outcomes after treatment for localized prostate cancer. N. Engl. J. Med. (2013) doi:10.1056/NEJMoa1209978.
- Grabbert, M. et al. Long-term functional outcome analysis in a large cohort of patients after radical prostatectomy. Neurourol. Urodyn. 37, 2263–2270 (2018).
- Pompe, R. S. et al. Short- and Long-term Functional Outcomes and Quality of Life after Radical Prostatectomy: Patient-reported Outcomes from a Tertiary High-volume Center. Eur. Urol. Focus 3, 615–620 (2017).
- Aizer, A. A. et al. Cost implications and complications of overtreatment of low-risk prostate cancer in the United States. JNCCN J. Natl. Compr. Cancer Netw. (2015) doi:10.6004/jnccn.2015.0009.
- Trogdon, J. G., Falchook, A. D., Basak, R., Carpenter, W. R. & Chen, R. C. Total Medicare Costs Associated with Diagnosis and Treatment of Prostate Cancer in Elderly Men. JAMA Oncol. 5, 60–66 (2019).