From the Guidelines
Prostate cancer can be aggressive, but its aggressiveness varies widely among individuals, with some cancers growing slowly and others spreading quickly, as noted in the 2010 NCCN clinical practice guidelines in oncology: prostate cancer early detection 1.
Aggressiveness of Prostate Cancer
The aggressiveness of prostate cancer is typically determined by several factors including the Gleason score, PSA levels, cancer stage, and genetic markers. The Gleason score, ranging from 6 to 10, is a key indicator of aggressiveness, with higher scores signifying more aggressive disease.
- Low-risk prostate cancer, often characterized by a Gleason score of 6, tends to grow slowly and may not require immediate treatment, instead, active surveillance is often recommended, involving regular PSA tests and biopsies 1.
- Intermediate and high-risk cancers, corresponding to Gleason scores of 7-10, are generally more aggressive and require more intensive treatment approaches, such as surgery, radiation therapy, hormone therapy, or a combination of these.
- Age and overall health of the patient also play a crucial role in determining the treatment plan, with older patients or those with significant health issues potentially having different treatment considerations compared to younger, healthier individuals.
Importance of Individualized Treatment Plans
Given the variability in prostate cancer aggressiveness, it is essential to develop individualized treatment plans in consultation with urologists and oncologists. This approach helps balance the effective treatment of the cancer with the minimization of unnecessary treatment side effects, ultimately aiming to improve patient outcomes in terms of morbidity, mortality, and quality of life. As highlighted by the guidelines, the decision to perform further testing, such as a prostate biopsy, should consider factors like PSA levels, changes in PSA over time, patient age, and prostate volume 1.
From the Research
Aggressiveness of Prostate Cancer
- Prostate cancer can range from indolent tumors to aggressive cancers that can be fatal 2.
- The aggressiveness of prostate cancer can vary widely, with some studies suggesting that only about 80% of men with metastatic prostate cancer will respond to first-line hormone manipulation 2.
- Certain molecular markers, such as high serum levels of cathepsin B, survivin, and Her-2/neu, may be associated with more aggressive prostate cancer 2.
Indicators of Aggressiveness
- Traditional prognostic parameters, such as tumor pathologic stage, histologic differentiation (Gleason score), and prostate-specific antigen (PSA) level, can help stratify patients into risk groups 3.
- Additional markers, such as DNA ploidy, proliferation, tumor angiogenesis, and the status of tumor suppressor genes, may also have prognostic significance 3.
- Recent studies have shown that the proportion of patients with high-grade prostate cancer (Gleason sum score 7-10) has increased over time, suggesting a potential increase in aggressive prostate cancer 4.
Screening and Detection
- Digital rectal examination (DRE) has been found to have limited diagnostic value as a screening test for prostate cancer, with a low positive predictive value and cancer detection rate 5.
- Prostate-specific antigen (PSA) screening has been shown to be more effective in detecting prostate cancer, but may also detect indolent disease that may not require treatment 2, 5.
- Annual PSA- and DRE-based prostate cancer screening may be beneficial for high-risk patients, including Black men, men with a family history of prostate cancer, and healthy men aged 70-80 years old 4.
Treatment Decision-Making
- Patient decision-making factors, such as perceived cancer aggressiveness, treatment intent, and primary information source, can influence the choice of treatment for low-risk prostate cancer 6.
- Helping patients understand the diagnosis and treatment options, including active surveillance, may be important in increasing the uptake of less aggressive treatment approaches 6.