The widespread use of PSA measurement has substantially increased the detection of prostate cancer in the western world. A growing number of younger men are diagnosed with clinically localized prostate cancer and they face a particularly challenging choice between multiple treatment options. While aiming to maximize their chances of ultimate disease control, it is especially important to these men to preserve their long-term quality of life in terms of urinary, bowel and erectile function. Younger patients may have additional concerns about taking time out from their employment to attend treatment sessions and recover from treatment-related morbidity, as well as the psychological impact of participating in an active surveillance programme.
There is a perception that surgery is the treatment of choice for clinically localized prostate cancer among men aged <60 years, based on the impression that brachytherapy (BT) and external beam radiation therapy (EBRT) are associated with inferior local disease control and a greater burden of late toxicity. The present report from the group at the Memorial Sloan Kettering Cancer Center (MSKCC)  highlights the importance of mature outcome data about the use of BT-based treatment in the cohort of men with clinically localized prostate cancer aged ≤60 years. They report on a group of 236 men aged ≤60 years treated with BT for clinically localized low- or intermediate-risk prostate cancer, with at least 3 years of follow-up. In all, 28% of the patients were treated with a combination of EBRT and BT, and 19% of patients received neoadjuvant hormone therapy. A total of 64% of patients were potent before receiving treatment and of these, 51% were potent at their last follow-up. The overall 8-year PSA relapse-free survival and cancer-specific survival rates were excellent (96 and 99%, respectively). The former rate is compatible with data from other studies of prostate BT in men aged ≤60 years (Table 1 [2-6]). Their retrospective data suggest that BT-based treatment regimens are effective among this cohort of younger patients with clinically localized prostate cancer.
|Authors, year||No. of patients||Age range, years||Clinical stage||Median follow-up, months||7-year BFFS||8-year BFFS||10-year BFFS|
|Merrick et al. (2006) ||108||45–54||T1c–T2c||57.6||96+|
|Shapiro et al. (2009) ||237||43–59||T1–T2||43.6||86|
|Gomez-Iturriaga Pina et al. (2010) ||96||45–55||T1–T2||63||98.9|
|Burri et al. (2010) ||378||≤60||T1–T2c||68||92|
|Laing et al. (2012) ||76||<55||T1c–T2c||47||96|
Concerns have been raised about the risk of inducing secondary malignancy (SM) after EBRT and BT among younger patients, who may be expected to survive many years after treatment. A large retrospective study of the incidence of SM >5 years after diagnosis of prostate cancer among 140 767 men in the US National Cancer Institute's Surveillance, Epidemiology and End Results programme evaluated the incidence of SM after localized therapy . The men who received EBRT were found to have statistically significantly higher odds of developing SM compared with men who received no radiation therapy. Reassuringly, men treated with radioactive implants or radioisotopes, with or without combined EBRT, did not have significantly higher odds of SM occurring.
In another report to be published in BJU International, the group from MSKCC present their retrospective comparison of the incidence of SM among 2658 patients with localized prostate cancer after definitive treatment with radical prostatectomy, EBRT or BT . Of the 413 patients treated with BT, 166 were aged <65 years. The 10-year SM-free survival for the whole BT-treated group was 87%, which was not significantly different from that of the cohort treated with radical prostatectomy (P = 0.37), Their multivariate analysis suggested that older age (P = 0.01) and history of smoking (P < 0.001) were significant predictors for the development of an SM, whereas treatment intervention was not a significant variable.
Our group have recently presented data on 76 patients under the age of 55 with localized prostate cancer treated with BT-based regimens . The actuarial 8-year PSA-free survival was 96%. Among the 54 patients with preoperative International Index of Erectile Function (IIEF) data available, 81% were potent (IIEF score ≤11) before receiving treatment. At 4-year follow-up, 94% of these patients with IIEF data available were still potent. BT is a convenient, effective and well-tolerated treatment for low- and intermediate-risk clinically localized prostate cancer in men aged ≤60 years, which often preserves erectile function. BT may be considered one of the treatments of choice for these younger patients.