The results of this study are not surprising.  Way back in the late 80s,
a Swedish study seemed to show that there was no significant difference
between aggressive treatment for early prostate cancer and watchful
waiting.  That study was one of the bases on which the critics of
aggressive treatment built their case.  But, as Walsh points out in
guide to Surviving Prostate Cancer, the WW group who had done so well in
the Swdish Study were just not followed long enough.  Subsequent studies
showed that similar patients followed longer didn't do as well.

The one criticism I would make of the above news report is that it
states that

"Despite those dire numbers, the results do not necessarily cast doubt
on the policy of watchful waiting for many patients with localized
prostate cancer detected at an early stage, said Dr. Victor R. Grann,
clinical professor of medicine and epidemiology at Columbia University
and co-author of an accompanying editorial."

This would be accurate if it had read "many older patients", but as it
stand it gives men who read it quickly, no matter what their age and
health status, the impression that WW might be a reasonable option for
them.  This is corrected later in the article, but many readers won't
have got that far.

Just my luck.  I guess I'd better refinance.  Dammit.  I won't live long
enough to see Social Security.

They were not using PSA to judge the aggressiveness of the tumor.  The study is
not of much use.  I am not sure how they diagnosed the disease in the first
instance.

SIGNATURE File: Ranking the Presidents: 1.Reagan 2.Eisenhower 3.Kennedy 4.Nixon
5.Bush 6.Hoover 7.Truman  8.T.Roosevelt 9.Coolidge 10.Ford 11.Carter
12.McKinley 13.Taft 14.Harding 15.Harrison 16.Clinton 17.Wilson 18.F.Roosevelt
19.Johnson

I have only read the abstract from this study (is the full text
available on-line?) as well as some of the press reports.  Moul
(Temporarily Deferred Therapy (watchful waiting) for Men Younger Than
70 Years and With Low-Risk Localized Prostate Cancer in the
Prostate-Specific Antigen Era; Corey A. Carter, Timothy Donahue, Leon
Sun, Hongyu Wu, David G. McLeod, Christopher Amling, Raymond Lance,
John Foley, Wade Sexton, Leo Kusuda, Andrew Chung, Douglas Soderdahl,
Stephen Jackman, and Judd W. Moul; Journal of Clinical Oncology, Vol
21, No 21 (November 1), 2003: pp 4001-4008) has shown that for men
with the following characteristics:
    age less than 70 years
    Gleason score less than 6 with no Gleason pattern 4
    no more than three cores positive on biopsy
    clinical stage less than T2
    PSA level less than 20 ng/mL at the time of diagnosis
roughly 25% will show no disease progression after 8 years of WW.  It
appears that this population is pretty well defined after 5 years of
observation (see Moul's Fig. 1).  Epstein's criteria for
insignificant, low-volume disease are even more restrictive than
Moul's and include:
    older age -usually over 65 years
    cancer can not be felt on digital rectal examination
    PSA density is 0.15 or less
    combined Gleason grade or score is 6 or less
    no more than 2 biopsy cores contain cancer
    cores containing cancer should not have more than 50 percent
involvement
Therefor one would expect even more than 25% of the men meeting
Epstein's criteria to show no disease progression at 8 years.  Near
the end of Moul's paper he phrases the key, unanswered question, "The
next analysis to be performed in this review is a comparison of the
outcomes of the 215 patients who started on a course of WW and moved
to definitive therapy with the outcomes of the men who elected
immediate, definitive treatment.  This study is underway and should
provide insight into whether temporarily deferred therapy or WW is a
reasonable management strategy for young men during the PSA era."

Now look at the JAMA paper.  The men involved in this study were
recruited between 1977 and 1984, the pre-PSA era.  PSA and Gleason
scores are unknown and PSA, doppler, biopsy, etc. could not be used as
tools (at least during the early- to mid-phase of the study) to test
for disease progression and move men to definitive therapy should
progression be detected.  All we do know is that the men were staged
T0-T2.  My guess is that far fewer men in the Swedish study had
low-risk disease compared to the men in Moul's study and their PCa
specific mortality rate should be higher (fewer resources to detect
disease progression).  Still, cumulative progression-free survival for
men 15-20 years post-diagnosis was found to be 36.0%!  The prostate
cancer mortality rate for the first 15 years compared to the rate in
years 15-20 barely tested significant at the 95% confidence level.
Hardly anyone dies during the first 5 years after diagnosis so
including these years in the preceding statistic "stacks the deck" so
to speak.  If the prostate cancer mortality rate for years 5-15 was
compared to the rate for years 15-20, I wonder if there would be any
significant difference.

Unless I've misinterpreted something, this study seems to be
consistent with Moul's findings in that there appears to be a
significant percentage (~25%) of men with low-risk PCa who do not
require invasive treatment.  The $64,000 question is how do you
identify these men upfront.  By using Moul's or Epstein's criteria, we
can increase the chances that WW will be succesful, but still, with
Moul's criteria the odds are that 3 out of 4 men will drop out.  In
addition to meeting these criteria you would also need to have a
psyche that would permit you to comfortably live with the disease
while intensely monitoring it and making significant lifestyle
changes.  Perhaps, if Moul reports back that the outcomes were similar
for men who practiced WW and later selected definitive treatment vs.
men who sought immediate treatment, low-risk men will find it easier
to live with the disease and give WW a try...Ron