Abstract
There is significant controversy on how aggressively to treat older men with prostate cancer. We identified 1082 patients diagnosed with prostate cancer from 1998-2008 with Gleason score ≥ 7 on biopsy or prostatectomy pathology in the South Texas Veteran’s Healthcare System. Prostate specific antigen (PSA) values, pathology, treatment and response to treatment were analyzed. Mean follow up was 4.99 years. Patients > 74 years had significantly higher pretreatment PSA, higher grade disease, and were received hormone therapy more often. Unadjusted hazard ratios for metastasis and cancer related death were 2.15 (95% CI 1.02, 4.52; p = 0.04) and 2.66 (95% CI 1.18, 6; p = 0.02), respectively. However, after controlling for treatment, Gleason score and pre-treatment PSA, there was no significant difference in cancer specific survival (CSS) by age group. In the patients > 74 years, there was also no significant difference in overall survival (OS) or CSS among patients treated with surgery, radiation or hormones after controlling for Gleason score and pre-treatment PSA. Our oldest patients have worse cancer presumably to later diagnosis, but they do just as well as younger patients with any given treatment modality. Most importantly, they have similar cancer specific survival with hormone therapy as they do with radiation or surgery.
Highlights
Prostate cancer is still the most common cancer, excluding cutaneous malignancies, diagnosed in men
The widespread use of prostate specific antigen (PSA) screening has allowed for both younger age and earlier stage of diagnosis, the vast majority of cases are still diagnosed in men older than 65 years, and approximately 25% of cases are diagnosed in men older than 75 years [2]
Primary treatment was radical prostatectomy (RP) in 585, radiation therapy (RT) in 253, and hormone therapy (HT) in 244 for a total of 1082 patients included for analysis
Summary
Prostate cancer is still the most common cancer, excluding cutaneous malignancies, diagnosed in men. If the patient is expected to live 10 years or more, the recommendation is to treat these high risk tumors aggressively with radical prostatectomy (RP) or radiation therapy (RT) ± short term hormone therapy (HT) ± brachytherapy. For patients with clinically localized Gleason 8 - 10 prostate cancer, treatment with either RT + long term HT, RT + brachytherapy ± short term HT, or RP is indicated regardless of age or life expectancy [5]. We have two discordant recommendations; one is not to screen men under the age of 75 and the other is to treat men older than 75 with higher risk cancer aggressively if they are in good health. The concern is that some older men with high risk cancer will suffer adversely from not receiving definitive treatment
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