Deaths From Prostate Cancer vs Other Causes: Long-Term Data

Medscape

5 days ago

Men treated for nonmetastatic prostate cancer under current guidelines are up to 6 times less likely to die from their cancer than from other causes, according to data from a Swedish cancer registry.
The study estimated long-term outcomes over up to 30 years in men who received treatment for nonmetastatic prostate cancer that was in line with current National Comprehensive Cancer Network (NCCN) guidelines. Overall, nearly 90% of men with low-risk or favorable intermediate-risk disease were likely to survive their cancer and die from other causes over their life expectancy. While men with high-risk disease had higher death rates from prostate cancer, they were still at least twice as likely to die from other causes.
'Our data support adherence to guideline recommendations for treatment of prostate cancer,' lead author Pietro Scilipoti, MD, of Uppsala University in Uppsala, Sweden, and IRCCS San Raffaele Hospital in Milan, Italy, said in a news release.
'If guideline-recommended treatment is used,' Scilipoti added, 'most people with prostate cancer will live for many years after diagnosis. That includes active surveillance as an excellent treatment strategy for appropriately selected people.'
Kyrollis Attalla, MD, a urologic oncologist at Mount Sinai Hospital in New York City, emphasized the findings among low-risk patients, most of whom underwent active surveillance. The data offer a 'strong and welcome addition to the existing and growing body of evidence demonstrating the superior clinical outcomes among men with low-risk prostate cancer managed with data-driven active surveillance protocols,' Attalla, who wasn't involved in the study, told Medscape Medical News .
The analysis was published online earlier this month in the Journal of the National Comprehensive Cancer Network.
Addressing a Data Gap
Men with nonmetastatic prostate cancer have a long disease trajectory, and it's well known that the competing risk for death from other causes is high. However, there are only limited data on long-term outcomes for men treated for prostate cancer according to current guideline recommendations.
To investigate, Scilipoti and colleagues used Swedish registry data to identify 62,839 men diagnosed with nonmetastatic prostate cancer between 2000 and 2020. At diagnosis, their median age was 67 years and median life expectancy was 18 years. All had a defined risk category and received primary treatment consistent with current NCCN guidelines (v4.2023): Most often that meant radical prostatectomy (42%), radiotherapy with or without androgen deprivation therapy (22%), or active surveillance (20%). Among the 15,531 men with low-risk disease, 71% underwent active surveillance.
The researchers simulated patients' risk of dying from prostate cancer or other causes at 15 and 30 years, according to risk category and life expectancy at diagnosis.
For men with low-risk prostate cancer, the simulated 15-year prostate cancer mortality rate was 5.5%, whereas mortality from other causes was 37%. Prostate cancer mortality was highest among men with very high-risk disease, at 22%, but the rate of death from competing causes was still higher (36%).
At 30 years, the simulated estimate for prostate cancer mortality was 12% among low-risk men, whereas the mortality rate from other causes was 77%. Estimates for men with favorable intermediate-risk cancer were almost identical.
Even for men with higher-risk disease, the likelihood of dying from causes other than prostate cancer was two to three times higher: At 30-years, researchers estimated a 20% mortality rate from prostate cancer vs 67% from other causes among men with high-risk disease, and 30% vs 63% among men with very high-risk disease.
Within each risk category, deaths due to prostate cancer and other causes varied by life expectancy. For example, when men with low-risk disease had a life expectancy of over 15 years, their estimated 15-year prostate cancer mortality was just 2.5%. That rose to 10% among low-risk men with a life expectancy of < 10 years. Mortality from other causes was higher and ranged from 20% to 81%, respectively, in men with a life expectancy of > 15 years and < 10 years.
'This study offers a big sigh of relief for many men facing a prostate cancer diagnosis,' Ahmad Shabsigh, MD, with The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, and member of the NCCN guidelines panel for prostate cancer, said in the news release.
'What's truly striking is that for patients with low-risk prostate cancer, many of whom were on active surveillance, the 30-year mortality risk from the cancer itself was only about 11%,' said Shabsigh, who was not involved in the research. 'It really underscores the power of evidence-based treatment plans and the importance of focusing on a person's overall health, not just their cancer.'
Attala noted that while the overtreatment of prostate cancer has long been an issue, active surveillance has more than doubled over the last decade in the US. 'As our understanding of tumor biology and our ability to risk-stratify men with prostate cancer improved, the rates of offering and implementation of active surveillance for appropriate candidates were seen to increase in tandem,' Attala said.
Still, he added, rates of active surveillance vary widely across practices and individual providers. The new data 'should serve to further attest to the long-term safety of active surveillance for men with low-risk prostate cancer,' Attala said.
He cautioned, however, that patient safety depends on adherence to the quality protocol detailed in the guidelines — and that does not always happen in current practice.
For example, Attala pointed out that confirmatory testing is recommended following a diagnosis of low-risk disease, to facilitate early identification of men who may be at higher risk for future grade reclassification or progression. However, recent data suggest that only a little over half of urologists are offering confirmatory testing following the initial biopsy.
'The rates of grade reclassification with confirmatory testing are not insignificant — upwards of 25% in some studies,' Attala pointed out. 'Altogether, this study and others highlight that optimal outcomes on active surveillance are derived from optimal guideline-driven practices.'