1. Prostate Cancer: A Case for Active Surveillance Philip Kantoff MD Dana-Farber Cancer Institute Professor of Medicine Harvard Medical School

2. Incidence of Prostate Cancer: International Comparisons Dijkman. Eur Urol. 1996;30:281-294.

3. Clinical Incidence of Prostate Cancer Has Changed Dramatically Over Time

4. Copyright ©2006 American Cancer Society From Jemal, A. et al. CA Cancer J Clin 2006;56:106-130. Mortality Rates for Cancer in the US

5. Autopsy Detection of Prostate Cancer in Men of Various Ages Sakr et al. In Vivo. 8:439-43, 1994 Age Cancer 20-30 2% 31-40 29% 41-50 32% 51-60 55% 71-8064%

6. Some Basic Statistics What you find depends on how hard you look –Autopsy prostate cancer: ~50% of men over 50 –Clinical (PSA) prostate cancer: ~16% of men > age 50 –Death from prostate cancer: ~3.0% of men > age 50

7. Risk of Clinical Prostate Cancer Currently risk of prostate cancer is determined by whether you do a biopsy, how many biopsies you do and the frequency of biopsies The number of PSA driven biopsies have dramatically changed in the past 20 years

8. Conclusion: Epidemiology Prostate Cancer is the second leading cause of cancer death among US men The vast majority of men who have and who are diagnosed with prostate cancer will not die from their disease PSA utilization has resulted in an increased incidence of prostate cancer

9. Does Treatment Reduce Mortality?

11. Randomized Study: Surgery Versus Active Surveillance 695 Scandinavian men, 1989-1999 Median f/u 8.2 years Mean age: 64.7 years Mean PSA: 12.8 ng/ml Gleason: 2-6 (61%), 7 (23%), 8-10 (5%)

12. Overall Survival

13. Cancer Specific Survival RR 0.56, p=0.01

14. Cancer Specific Survival Based On Age

15. Increased Risk Of Metastases With Watchful Waiting RR 0.60, p=0.004

16. Conclusions Radical local treatment in a largely non- screened population with localized cancer leads to improved survival The absolute benefit remains small, but is more significant in men < 65 yrs old At this point in followup, 17 RPs for 1 life saved

17. Watchful Waiting 767 Active Surveillance patients in Connecticut Mean age: 68 years Mean f/u: 15.4 years Death certificates, path reviewed Albertson et al

18. Prognosis as a Function of Age and Gleason Score: Localized Disease Albertsen et al. JAMA 280: 975-80

19. Conclusions A subset of men have aggressive disease that poses a threat to their survival Most men with prostate cancer will not die from their disease. Gleason score, determined by biopsy, is the most critical factor in determining prognosis for patients with localized disease Active Surveillance is a reasonable option for men with life expectancy of less than 10 years or for some men with low volume (few biopsy cores positive) Gleason 6 or less tumors