Illustrative Case Series
Treating High-risk Prostate Cancer in an 84-Year-Old Man
By Jerome Yates, MD, Hematology/Immunology Unit, National Institute on Aging, NIHDr. Yates reports no financial relationships relevant to this field of study.
A 84-year-old retired professor was referred for second opinion regarding management of prostate cancer. He had been relatively healthy, with a history of hyperlipidemia and gout. He was a widower, and lived with his daughter and her family. He maintained an active lifestyle that included weekly golf and occasionally tennis (doubles). He used no tobacco products, but enjoyed one or two glasses of wine daily. Medications included simvastatin 20 mg and aspirin 82 mg daily. Physical exam, other than that mentioned below, was unremarkable. His hemoglobin was 12.6 g/dL and his complete blood count was normal. Chemistry survey revealed a serum creatinine of 1.0 mg/dL, and normal alkaline phosphatase and liver function tests were normal.
His tumor was discovered as an incidental finding when his primary care physician obtained a screening PSA and found it to be 14 ng/mL. At the time, he had complained of nocturia x2, but this had been a problem for the past several years without significant change. He was referred to a urologist, and digital exam revealed a diffusely enlarged prostate gland. Ultrasound identified a tumor mass occupying approximately one-half of a slightly enlarged prostate, and biopsies were positive for an undifferentiatled adenocarcinoma, Gleason score 8. The tumor was confined to the prostate, and there was no lymphadenopathy apparent on imaging studies. Bone scan and serum chemistries were negative. Thus, his prostate cancer was classified Stage IIB; pT2cNoMo.
This case brings to light some of the controversy with regard to prostate cancer in the elderly. The U.S. Preventive Services Task Force recommends against screening men age 75 years or older,1 although this is a general comment extrapolating from studies of men younger than 75, and does not take into account the presence or absence of comorbidities, functional status, and the considerable physiological heterogeneity existing among the elderly. It is true, as was concluded in a recently published meta-analysis of six randomized, controlled trials of screening involving close to 400,000 participants,2 that the existing evidence does not support the routine use of PSA screening for prostate cancer, as such screening does not have a significant impact on overall mortality or death from prostate cancer. The argument, particularly in the elderly, is that although screening helps to diagnose prostate cancer at an earlier stage, the risk of over-treatment and downstream adverse effects would likely counter any added benefit among individuals with existing comorbidities. There also is the added suspicion that such tumors are likely to exhibit indolent patterns of growth and spread. This stated, and despite the published guidelines, there remains controversy on this topic, and PSA screening remains common among many practicing physicians.3 In the current case, PSA screening led to the diagnosis of an undifferentiated tumor confined to the prostate gland, without extension beyond the capsule or to lymph nodes, a clinical setting which, in younger patients, would lead to aggressive primary local therapy, either radical prostatectomy or definitive radiation therapy.4
a.recent report by Bechis and colleagues on behalf of the Cancer of the Prostate Strategic Urologic Research Endeavor (CapSURE) registry5 described a high level of variability in treatment provided to patients 75 years and older who had high-risk disease. In their assessment, they used the Cancer of the Prostate Risk Assessment instrument,6 which allows stratification into low, intermediate, or high risk based upon a number of prognostic factors. Of men in this age group, 26% presented with high-risk disease, and unlike the disease occurring in younger men, the majority were treated with primary androgen ablation therapy. The majority of younger men (< 55, 56-65, 66-75) with similar risk scores were treated with radical prostatectomy, brachytherapy, or external-beam radiotherapy. The authors speculated that the underuse of potentially curative local therapy among older men with high-risk disease might contribute to the observed differences in cancer-specific survival with advancing age.
Returning to the case presented, we have an 84-year-old man with minimal comorbidity but with high-grade, high-risk prostate cancer. Keeping in mind that the average survival for men at this age is approximately 7 years,7 and thus, aiming for a cure is reasonable, I would favor recommending definitive local treatment rather than primary androgen ablation. The choice between surgery (radical prostatectomy) or radiation would be based upon local expertise. However, either brachy- or external-beam radiation might be favored, avoiding a major surgical procedure and the inherent anesthesia risk in this age group.
1. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2008;149:185-191.
2. Djulbegovic M, et al. Screening for prostate cancer: Systematic review and meta-analysis of randomised controlled trials. BMJ. 2010;341:c4543.
3. Baade PD, et al. International epidemiology of prostate cancer: Geographical distribution and secular trends. Mol Nutr Food Res. 2009;53:171-184.
4. Mohler J, et al. NCCN clinical practice guidelines in oncology: prostate cancer. J Natl Compr Canc Netw. 2010;8:162-200.
5. Bechis SK, et al. Impact of age at diagnosis on prostate cancer treatment and survival. J Clin Oncol. 2011;29:235-241.
6. Cooperberg MR, et al. Risk assessment for prostate cancer metastasis and mortality at the time of diagnosis. J Natl Cancer Inst. 2009;101:878-887.
7. Minino AM, Smith BL. Deaths: Preliminary data for 2000. National Vital Statistics Reports, Vol 49, No. 12. Hyattsville, MD, National Center for Health Statisitcs, 2001, pp 1-40. http://www.cdc.gov/nchs/data/nvsr/nvsr49/nvsr49_12.pdf.