Prostate cancer. Mortality and morbidity after non-curative treatment with aspects on diagnosis and treatment.

AIMS OF THE STUDY

To investigate the mortality, need for hospital care and palliative treatments in patients with prostate cancer (PC) treated with non-curative intention (i.e. deferred or hormonal treatment). To evaluate acceptance by patients and complications of a new diagnostic procedure for PC -- transrectal ultrasound (TRUS) and core biopsies. To investigate if knowledge of prostate volume enhances the accuracy of prostate specific antigen (PSA) to indicate non-palpable PC. Finally, to investigate how neo-adjuvant hormonal treatment before radical prostatectomy affected PSA and tumour volume.

METHODS

In a retrospective analysis of all 536 patients with a known diagnosis of PC who died in the city of Göteborg during the years 1988-90, age at diagnosis, survival time, need for hospital care and cause of death were registered (I and II). A questionnaire was sent to 511 patients who underwent TRUS with or without prostatic biopsies (III). In 120 consecutive patients admitted for TURP due to presumed benign prostatic hyperplasia, a comparison was made between PSA and prostate-volume-adjusted (measured via TRUS) PSA (PSADensity) to indicate the presence of non-palpable PC (IV). Of 56 patients who underwent radical prostatectomy, 28 received 3 months' pretreatment with a GnRH-agonist. The effects on tumour volumes (assessed by the planimetric method on whole mount slides) and PSA were studied (V).

RESULTS

Overall, 62% of patients with a known diagnosis of PC died of the disease when all patients were followed from diagnosis until death (up to 25 years). Of patients in stage M0 at diagnosis, 50% died of PC. However, in patients who survived for more than 10 years the mortality reached 63% (I). The average PC patient needed 27 days of hospital stay (geriatric wards excluded) and 185 patients needed at least one palliative TURP, 103 patients palliative radiation therapy and 55 patients procedures due to upper urinary tract obstruction. The lion's share of these resources was consumed by patients who later succumbed to PC (II). Ninety-five per cent of patients reported none or minor discomfort after TRUS of the prostate and 92% if TRUS was combined with transrectal core biopsies of the prostate. Haematuria for > 2 days occurred in 13%, haematospermia > 2 days in 9% and blood in stool > 2 days in 3% among patients who underwent core biopsies but none of these patients needed active treatment. Overall, 4.1% of biopsied patients experienced urinary tract infection (III). The use of PSADensity with a cut-off value of 0.10 ng/ml/cc rendered both higher sensitivity (75 vs 50%) and positive predictive value (0.33 vs 0.15) for indicating non-palpable PC in symptomatic patients with benign findings on digital rectal examination (IV). Pretreatment with a GnRH-agonist resulted in a significant PSA decrease not explained by changes in tumour volume. Tumour volume reduction was found in 36% of the patients.

CONCLUSIONS

According to these studies, PC is a progressive disease with considerable mortality and morbidity when managed by non-curative intention. Since new diagnostic and therapeutic methods described in this thesis are well accepted by patients and may increase the chance of radical surgery, it is reasonable to offer younger patients with long life expectancy the chance of early detection and treatment with curative intention.