What is the prognosis of prostate cancer with or without treatment?

Prognosis of Prostate Cancer With or Without Treatment

Without treatment, at least one out of three patients will die from prostate cancer within 10 years, while appropriate treatment can significantly improve survival rates depending on cancer stage, grade, and patient factors. 1

Risk Stratification and Prognosis Factors

The prognosis of prostate cancer varies dramatically based on several key factors:

Cancer Stage and Grade

• Very Low/Low Risk: Patients with stage T1-T2a tumors, Gleason score 2-6, and PSA <10 ng/mL have excellent prognosis

  • 5-10 year cancer-specific mortality is very low 1
  • 15-year corrected survival rate of 81% even with watchful waiting 2

• Intermediate Risk: Stage T2b-T2c, Gleason score 7, or PSA 10-20 ng/mL

  • Higher risk of progression without treatment

• High Risk: Stage T3-T4, Gleason score 8-10, or PSA >20 ng/mL

  • 15-year corrected survival rate of 57% for locally advanced cancer (T3-T4) 2
  • 15-year corrected survival rate of only 6% for metastatic disease 2

Patient Life Expectancy

Comorbidity-adjusted life expectancy is crucial in treatment decisions:

• Patients with <5 years life expectancy with high-risk disease: observation may be appropriate 1
• Patients with ≥5 years life expectancy with high-risk disease: treatment recommended 1
• Patients with <10 years life expectancy with low-risk disease: observation recommended 1
• Patients with ≥10 years life expectancy with low-risk disease: treatment options should be considered 1

Prognosis Without Treatment

For untreated prostate cancer:

• In localized disease, 11% died of prostate cancer in a 15-year follow-up study 2
• Without treatment, at least one-third of patients will die from prostate cancer within 10 years 1
• Most early-stage prostate cancers have an indolent course, but local progression and aggressive metastatic disease may develop long-term 1
• Mortality rate significantly increases after 15 years of follow-up compared to the first 5 years 1
• In one study, 25.6% of patients in the deferred treatment group died without ever requiring hormonal therapy 1

Prognosis With Treatment

Treatment outcomes vary by modality:

Active Surveillance (for Very Low/Low Risk)

• Recommended as the preferred option for low-risk disease 1
• Maintains quality of life while preserving the ability to implement curative treatment if needed
• The ProtecT trial showed no significant differences in prostate cancer-specific mortality between active surveillance, surgery, and radiation therapy in predominantly low-risk patients 1

Radical Prostatectomy

• Reduces prostate cancer-related deaths compared to watchful waiting in clinically detected cancer, especially in patients <65 years 1
• Common side effects:
  • Erectile dysfunction in 58% of patients after 2 years 1
  • Urinary leakage in 35% of patients after 2 years 1
  • One-third of patients will have some bladder control problems 1

Radiation Therapy

• Similar cancer control to surgery for localized disease
• Common side effects:
  • Erectile dysfunction in 43% of patients after 2 years 1
  • Bowel problems in 29% of patients after 2 years 1

Metastatic Disease

• 5-year survival rate of only 37% for distant metastases 3
• Addition of androgen receptor pathway inhibitors to androgen deprivation therapy improves survival
  • Abiraterone improved median overall survival from 36.5 to 53.3 months (HR 0.66) 3

Treatment Decision Algorithm Based on Risk and Life Expectancy

1. Very Low Risk + Life Expectancy <20 years: Observation only
2. Very Low Risk + Life Expectancy ≥20 years: Observation, radical prostatectomy, or radiation therapy
3. Low Risk + Life Expectancy <10 years: Observation only
4. Low Risk + Life Expectancy ≥10 years: Observation, radical prostatectomy, or radiation therapy
5. Intermediate Risk + Life Expectancy <10 years: Observation or treatment options
6. Intermediate Risk + Life Expectancy ≥10 years: Radical prostatectomy or radiation therapy
7. High Risk + Life Expectancy <5 years: Observation only
8. High Risk + Life Expectancy ≥5 years: Radical prostatectomy or radiation therapy (with or without hormone therapy) 1

Important Considerations

• Approximately 75% of patients present with cancer localized to the prostate, which has a 5-year survival rate of nearly 100% 3
• Approximately 10% present with metastatic disease, which has a 5-year survival rate of 37% 3
• The decision to treat should consider the "10-year rule": treatment should be offered only if the patient has a comorbidity-adjusted life expectancy of at least 10 years 1
• Age alone is not accurate for estimating life expectancy; comorbidities must be considered 1