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Chodak GW, Thisted RA, Gerber GS.  et al.  Results of conservative management of clinically localized prostate cancer.  N Engl J Med.1994;330:242-248. Scholar
Adolfsson J, Steineck G, Hedlund PO. Deferred treatment of clinically localized low-grade prostate cancer: actual 10-year and projected 15-year follow-up of the Karolinska series.  Urology.1997;50:722-726. Scholar
Johansson JE, Holmberg L, Johansson S, Bergstrom R, Adami HO. Fifteen-year survival in prostate cancer: a prospective, population-based study in Sweden.  JAMA.1997;277:467-471. Scholar
Holmberg L, Bill-Axelson A, Helgesen F.  et al.  A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer.  N Engl J Med.2002;347:781-789. Scholar
 TNM Classification of Malignant Tumors . Revised 3rd ed. Geneva, Switzerland: International Union Against Cancer; 1978.
World Health Organization.  International Histological Classification of TumorsVol 22. Geneva, Switzerland: World Health Organization; 1980.
Cutler SJ, Ederer F. Maximum utilization of the life table method in analyzing survival.  J Chronic Dis.1958;8:699-712. Scholar
Hakulinen T. On long-term relative survival rates.  J Chronic Dis.1977;30:431-443. Scholar
Clayton D, Hills M. Statistical Models in EpidemiologyOxford, England: Oxford University Press; 1993.
Hakulinen T, Abeywickrama K. A computer program package for relative survival analysis.  Comput Programs Biomed.1985;19:197-207. Scholar
Ramaswamy S, Ross KN, Lander ES, Golub TR. A molecular signature of metastasis in primary solid tumors.  Nat Genet.2003;33:49-54. Scholar
Bernards R, Weinberg RA. A progression puzzle.  Nature.2002;418:823. Scholar
Walsh PC, Lepor H. The role of radical prostatectomy in the management of prostatic cancer.  Cancer.1987;60(3 suppl):526-537. Scholar
Gerber GS, Thisted RA, Scardino PT.  et al.  Results of radical prostatectomy in men with clinically localized prostate cancer.  JAMA.1996;276:615-619. Scholar
Blasko JC, Grimm PD, Sylsvester JE, Cavanagh W. The role of external beam radiotherapy with I-125/Pd-103 brachytherapy for prostate carcinoma.  Radiother Oncol.2000;57:273-278. Scholar
Hanks GE, Hanlon AL, Pinover WH, Horwitz EM, Price RA, Schultheiss T. Dose selection for prostate cancer patients based on dose comparison and dose response studies.  Int J Radiat Oncol Biol Phys.2000;46:823-832. Scholar
Oliver SE, Donovan JL, Peters TJ, Frankel S, Hamdy FC, Neal DE. Recent trends in the use of radical prostatectomy in England: the epidemiology of diffusion.  BJU Int.2003;91:331-336. Scholar
Albertsen PC, Fryback DG, Storer BE, Kolon TF, Fine J. Long-term survival among men with conservatively treated localized prostate cancer.  JAMA.1995;274:626-631. Scholar
Aus G, Hugosson J, Norlen L. Long-term survival and mortality in prostate cancer treated with noncurative intent.  J Urol.1995;154(2 pt 1):460-465. Scholar
Borre M, Nerstrom B, Overgaard J. The natural history of prostate carcinoma based on a Danish population treated with no intent to cure.  Cancer.1997;80:917-928. Scholar
Helgesen F, Holmberg L, Johansson JE, Bergstrom R, Adami HO. Trends in prostate cancer survival in Sweden, 1960 through 1988: evidence of increasing diagnosis of nonlethal tumors.  J Natl Cancer Inst.1996;88:1216-1221. Scholar
Adolfsson J, Oksanen H, Salo JO, Steineck G. Localized prostate cancer and 30 years of follow-up in a population-based setting.  Prostate Cancer Prostatic Dis.2000;3:37-42. Scholar
Litwin MS, Hays RD, Fink A.  et al.  Quality-of-life outcomes in men treated for localized prostate cancer.  JAMA.1995;273:129-135. Scholar
Bishoff JT, Motley G, Optenberg SA.  et al.  Incidence of fecal and urinary incontinence following radical perineal and retropubic prostatectomy in a national population.  J Urol.1998;160:454-458. Scholar
Steineck G, Helgesen F, Adolfsson J.  et al.  Quality of life after radical prostatectomy or watchful waiting.  N Engl J Med.2002;347:790-796. Scholar
Catalona WJ, Smith DS, Ratliff TL.  et al.  Measurement of prostate-specific antigen in serum as a screening test for prostate cancer.  N Engl J Med.1991;324:1156-1161. Scholar
Original Contribution
June 9, 2004

Natural History of Early, Localized Prostate Cancer

Author Affiliations

Author Affiliations: Departments of Urology and Clinical Medicine (Drs Johansson, Andrén, and Andersson) and Statistical Unit, Center for Clinical Research (Mr Magnuson), Örebro University Hospital, and Center for Assessment of Medical Technology (Drs Johansson and Andersson), Örebro, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden (Drs Dickman and Adami); Regional Oncologic Center, University Hospital, Uppsala, Sweden (Dr Holmberg); and Department of Epidemiology and the Harvard Center for Cancer Prevention, Harvard School of Public Health, Boston, Mass (Dr Adami).

JAMA. 2004;291(22):2713-2719. doi:10.1001/jama.291.22.2713

Context Among men with early prostate cancer, the natural history without initial therapy determines the potential for survival benefit following radical local treatment. However, little is known about disease progression and mortality beyond 10 to 15 years of watchful waiting.

Objective To examine the long-term natural history of untreated, early stage prostatic cancer.

Design Population-based, cohort study with a mean observation period of 21 years.

Setting Regionally well-defined catchment area in central Sweden (recruitment March 1977 through February 1984).

Patients A consecutive sample of 223 patients (98% of all eligible) with early-stage (T0-T2 NX M0 classification), initially untreated prostatic cancer. Patients with tumor progression were hormonally treated (either by orchiectomy or estrogens) if they had symptoms.

Main Outcome Measures Progression-free, cause-specific, and overall survival.

Results After complete follow-up, 39 (17%) of all patients experienced generalized disease. Most cancers had an indolent course during the first 10 to 15 years. However, further follow-up from 15 (when 49 patients were still alive) to 20 years revealed a substantial decrease in cumulative progression-free survival (from 45.0% to 36.0%), survival without metastases (from 76.9% to 51.2%), and prostate cancer–specific survival (from 78.7% to 54.4%). The prostate cancer mortality rate increased from 15 per 1000 person-years (95% confidence interval, 10-21) during the first 15 years to 44 per 1000 person-years (95% confidence interval, 22-88) beyond 15 years of follow-up (P = .01).

Conclusion Although most prostate cancers diagnosed at an early stage have an indolent course, local tumor progression and aggressive metastatic disease may develop in the long term. These findings would support early radical treatment, notably among patients with an estimated life expectancy exceeding 15 years.