The article "Temporal changes in survival in men with de novo metastatic prostate cancer: Nationwide population-based study," describes the survival of patients with de novo metastatic prostate cancer in the period 1998 – 2016 in the National Prostate Cancer Register (NPCR) of Sweden.
Between the period 1998 – 2001 and 2010 – 2015, median survival increased among all men by six months. The largest increase, 14 months, was seen among men aged 60 – 69.
Improved survival over time was due to prolonged lead time related to a lesser tumor burden at diagnosis reflected by the decreased median PSA at diagnosis that decreased by nearly 50%, from 181 ng/mL in 1998 to 98 ng/ml in 2015. The study also suggested that the increased use of chemotherapy from 2004 and ahead might have contributed to the increased survival. The contribution of chemotherapy to survival is, however, difficult to assess since NPCR until recently only registered primary therapy, which for these men was androgen deprivation therapy. The results from the randomized trials on chemotherapy in men with castration resistant prostate cancer (CRPC) has shown a survival benefit in the magnitude of 2-4 months indicating that the contribution of chemotherapy to the observed survival was marginal also considered that the usage of chemotherapy in Sweden increased slowly over time. On the other hand, the Scandinavian experience of docetaxel usage might result in a better survival benefit as shown in a randomized phase 2 study1 resulting in a 9 months survival benefit may be related to the fact that the control group in that study only received prednisolone compared to the international studies where docetaxel was compared to mitoxantrone combined with prednisolone. Mitoxantrone was never popular in the Swedish setting due to toxicity and the lack of survival benefits when used as monotherapy.
There was likely minimal influence of the new androgen receptor targeting therapy (ART, abiraterone and enzalutamide) on survival in this study since these drugs were introduced in Sweden in 2012 for CRPC. Similarly, the introduction of chemotherapy and ART upfront in men with de novo metastatic was too recent to have affected survival. Thus, future studies are needed to fully evaluate the influence of these and other new treatments (i.e. radionuclides) on survival on the population level. The introduction of organized prostate cancer testing, possibly leading to prostate cancer screening, in addition to newer and more sensitive imaging modalities will likely transform de novo metastatic prostate cancer to a mostly oligometastatic disease with a completely different prognosis. Therefore, data on workup and treatment during the entire Pca disease trajectory is urgently needed. Registration of this information has been initiated in Patient overview Prostate Cancer (PPC) which is a longitudinal registration of treatment and treatment effects as an extension of NPCR. To date, more than 7 000 men with advanced prostate cancer have been registered in PPC.2
Written by: Marcus Westerberg,1 Ingela Franck Lissbrant, MD, PhD,2 Jan Erik Damber, MD, PhD,3 David Robinson, MD,4 Hans Garmo, PhD,5 Pär Stattin, MD, PhD.6
- Department of Mathematics, Uppsala University, Uppsala, Sweden.
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Göteborg, Sahlgrenska University Hospital, Göteborg, Sweden.
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Göteborg, Sahlgrenska University Hospital, Göteborg, Sweden.
- Department of Urology, Ryhov Hospital, Jönköping, Sweden.
- Translational Oncology, and Urology Research (TOUR), School of Cancer and Pharmaceutical Sciences, King's College London, Guy's Hospital, London, UK.
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
References:
- Fosså SD, Jacobsen AB, Ginman C, Jacobsen IN, Overn S, Iversen JR, Urnes T, Dahl AA, Veenstra M, Sandstad B. Weekly docetaxel and prednisolone versus prednisolone alone in androgen-independent prostate cancer: a randomized phase II study. Eur Urol. 2007 Dec;52(6):1691-8. Epub 2007 Feb 8.
- Ingela Franck Lissbrant, Oskar Gauffin, Marcus Westerberg, Marie Hjälm Eriksson, Mats Lambe, Magnus Törnblom, Pär Stattin.Patient-overview Prostate Cancer, longitudinal registration of treatment of advanced prostate cancer in the National Prostate Cancer Register of Sweden. Submitted.