Prostate Cancer In Elderly Men Research Articles

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We read with great interest the editorial comment regarding our recent publication RL after RP. We, along with other investigators who have examine the postoperative outcomes using similar cohorts, 1 Hu J.C. Gu X. Lipsitz S.R. et al. Comparative effectiveness of minimally invasive vs open radical prostatectomy. JAMA. 2009; 302: 1557-1564 Crossref PubMed Scopus (654) Google Scholar , 2 Wong Y.N. Mitra N. Hudes G. et al. Survival associated with treatment vs observation of localized prostate cancer in elderly men. JAMA. 2006; 296: 2683-2693 Crossref PubMed Scopus (243) Google Scholar , 3 Hollenbeck B.K. Ye Z. Dunn R.L. et al. Provider treatment intensity and outcomes for patients with early-stage bladder cancer. J Natl Cancer Inst. 2009; 101: 571-580 Crossref PubMed Scopus (74) Google Scholar , 4 Davies B.J. Allareddy V. Konety B.R. Effect of postcystectomy infectious complications on cost, length of stay, and mortality. Urology. 2009; 73: 598-602 Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar , 5 Lowrance W.T. Elkin E.B. Jacks L.M. et al. Comparative effectiveness of prostate cancer surgical treatments: a population based analysis of postoperative outcomes. J Urol. 2010; 183: 1366-1372 Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar recognize the inherent limitations of retrospective observational cohorts. However, one should wonder why, despite such limitations, numerous well-designed systematic studies using large population-based cohorts exist? Are all such studies without any clinical value? On the contrary, population-based cohorts come with a number of advantages that institutional databases lack. For one, population-based cohorts generally benefit from a larger number of patients than institutional cohorts. Also, population-based cohorts are composed of a more heterogeneous group of individuals who come from many different hospitals, which can include both teaching and nonteaching centers, situated at various regions throughout the United States. Such characteristics allow clinicians and research scientists to attest whether the findings of select referral centers also apply to the general population. In that regard, studies relying on population-based cohorts play an important role in systematic research, which seeks to address a specific research topic and to test a hypothesis. As such, findings that originate only from population-based cohorts are also insufficient. In fact, both observational and institutional studies, along with prospective randomized trials, are needed to establish the generalizability and validity of any findings. Editorial CommentUrologyVol. 79Issue 4PreviewThe authors present a population-based analysis of the relationship between the annual surgical volume and RL rates in >36 000 RPs during a 10-year period in Florida, a state that captures medical record information from admission to discharge from approximately 80% of in-state hospitals. As secondary endpoints, the authors also examined the effect of RL on LOS, hospital charges, and in-hospital mortality. They found that high-volume RP surgeons had a decreased likelihood of RL and that patients with an RL were more likely to have a prolonged LOS and increased hospital charges, even though <8% underwent diverting colostomy. Full-Text PDF

Treating Prostate Cancer in Elderly Men: How Does Aging Affect the Outcome?

Prostate Cancer (PCa) is the second most common cancer in United States and remains the second leading cause of death in the Western world. Because the median age of diagnosis for men with prostate cancer is greater than 75years, PCa can be considered a disease of the elderly. Several disease-specific factors (e.g., stage, tumor grade, prostate-specific antigen (PSA) level) and patient-specific factors (e.g., age, co-morbidity, and functional status) need to be considered in the decision-making process. In an attempt to incorporate these important factors to select optimal treatment for older individuals, several decision models have been published, yet their utility in clinical practice remains poorly understood. Current guidelines for the management of patients with PCa do not make specific recommendations for the elderly. Clearly there is a need to improve our understanding of the complex interrelationships between old age, co-morbidities, and their impact on expected outcomes.

Prostate Cancer in Men 70 Years Old or Older, Indolent or Aggressive: Clinicopathological Analysis and Outcomes

Currently there is a lack of consensus on screening recommendations for prostate cancer with minimal guidance on the cessation of screening in older men. We defined the clinicopathological features and outcomes for men 70 years old or older who were diagnosed with prostate cancer. The Center for Prostate Disease Research database was queried for all men diagnosed with prostate cancer from 1989 to 2009. The patients were stratified into age quartiles and by race. Cox proportional hazard models were used to compare clinicopathological features across patient stratifications. Kaplan-Meier analysis was used to compare biochemical recurrence-free, prostate cancer specific and overall survival. Of the 12,081 men evaluated 3,650 (30.2%) were 70 years old or older. These men had a statistically significant higher clinical stage, biopsy grade and prediagnosis prostate specific antigen velocity (p < 0.0001). For those patients who underwent prostatectomy, pathological stage, grade and surgical margin status were all significantly higher in men 70 years old or older. Biochemical recurrence and secondary treatment were also more common in this age group (p < 0.0001). Multivariate analysis revealed age 70 years or older as a significant predictor of biochemical recurrence after prostatectomy (HR 1.45, p = 0.0054). Overall survival was lowest in men age 70 years or older who had surgery, but interestingly the mean time to death was comparable regardless of age. Our findings indicate that as men age, parameters consistent with more aggressive disease become more prevalent. The etiology of this trend is unknown. However, these data may have implications for current screening and treatment recommendations.

Apport du PSA et de sa densité dans le diagnostic et le dépistage du cancer de la prostate

Owing to the fact that prostate cancer is the second cause of death behind lung cancer, several diagnostic strategies have been introduced in the past years. Among these prostate specific antigen is widely acknowledged to be the simplest and routine clinical parameter the purpose of this study is to reveal the contribution of the prostate specific antigen (PSA) in the diagnosis and tracking of prostate cancer compared to the PSA density (PSAD). 182 unrelated Tunisian men divided in two groups were considered by this study. The first, formed of 116 patients, comprised 91 subjects with a prostate benign hyperplasia (HBP) and 25 patients developing a prostate cancer (CaP). The second included 66 men without symptomatology of prostate pathologies. The serum prostate specific antigen values are measured in all the cases by immunoenzymatic method. However, the clinical characteristics of all subjects of the first group were determined by recourse to Gleason score, digital rectal examination and prostate echography. Nevertheless, those of the second group were given just for 7 subjects with PSA>4 ng/mL by making a biopsy. The present study shows, on the one hand, a clear correlation between PSA level and prostate pathology frequencies in a Tunisian population, on the other, it demonstrates a considerable relationship between the pathologic PSA level and patient age especially in the 7th decade. Besides, it points out to the contribution of additional parameters essentially the PSAD. PSA measurement can be considered as a reliable tool for early detection, staging, and monitoring of prostate cancer in elderly men even in the absence of clinical signs only for remarkable high levels (>20 ng/mL). Conversely, it cannot be in case of moderate levels (4≤PSA≥20 ng/mL) from where, the need of its combination to other complementary parameters specifically the PSAD which is very beneficial for early diagnosis of the prostate cancer. In fact, when compared to the result of pathological analysis of prostate biopsies, sensibility, specificity, diagnostic efficacy, positive and negative predictive values and the like hood ratio of total PSA were respectively, 100%, 71%, 77%, 0.49, 1.0 and 2.5; those of PSA density respectively 100%, 92%, 95%, 0.86, 1.0 and 12.25.

253 PATHOLOGICAL CHARACTERISTICS AND MANGANESE SUPEROXIDE DISMUTASE GENETIC POLYMORPHISM OF PROSTATE CANCER IN MEN 70 YEARS OR OLDER: AN AUTOPSY STUDY

You have accessJournal of UrologyProstate Cancer: Epidemiology and Natural History II1 Apr 2010253 PATHOLOGICAL CHARACTERISTICS AND MANGANESE SUPEROXIDE DISMUTASE GENETIC POLYMORPHISM OF PROSTATE CANCER IN MEN 70 YEARS OR OLDER: AN AUTOPSY STUDY Taro Iguchi, Ching Wang, Nicolas Delongchamps, Gustavo de la Roza, Yujiro Nitta, Toshihide Naganuma, Katsuyuki Kuratsukuri, Junji Uchida, Hidenori Kawashima, Gabriel Haas, and Tatsuya Nakatani Taro IguchiTaro Iguchi Osaka, Japan More articles by this author , Ching WangChing Wang Syracuse, NY More articles by this author , Nicolas DelongchampsNicolas Delongchamps Paris, France More articles by this author , Gustavo de la RozaGustavo de la Roza Syracuse, NY More articles by this author , Yujiro NittaYujiro Nitta Osaka, Japan More articles by this author , Toshihide NaganumaToshihide Naganuma Osaka, Japan More articles by this author , Katsuyuki KuratsukuriKatsuyuki Kuratsukuri Osaka, Japan More articles by this author , Junji UchidaJunji Uchida Osaka, Japan More articles by this author , Hidenori KawashimaHidenori Kawashima Osaka, Japan More articles by this author , Gabriel HaasGabriel Haas Syracuse, NY More articles by this author , and Tatsuya NakataniTatsuya Nakatani Osaka, Japan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.312AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Increased life expectancy and the availability of less invasive treatment methods have led to an interest in the characterization of prostate cancer (PCa) in elderly men. Manganese superoxide dismutase (MnSOD) is an enzyme involved with oxidative stress. A polymorphism encoding for either valine (V) or alanine (A) at codon 16 of human MnSOD gene has been described. We previously reported that MnSOD AA genotypes were associated with PCa. We now investigated whether MnSOD genotypes are associated with clinically aggressive PCa in elderly men by using autopsy prostates where we can certainly account for all cancers present. METHODS A total of 194 prostates were from deceased men (age range 46-92 years) who have not been diagnosed with PCa in their lifetime were eligible for analysis. Prostates were processed whole-mounted at 5-mm intervals. Cancers were defined as clinically “significant” or “insignificant” based on established histological criteria. Genomic DNA was extracted from normal area of the prostate and MnSOD genotyping was performed using PCR restriction fragment length polymorphism analysis. RESULTS Fifty-seven out of 194 prostates had histological evidence of PCa. Thirty-three out of 74 prostates (45%) from men older than 69 had histological evidence of PCa. Twenty-six out of 137 (19%) from men younger than 70 had PCa. Clinically significant PCa were more common in old than in young men (64% vs 23%, p<0.05). MnSOD AA genotype was not associated with PCa (OR=1.90, 95%CI: 0.97-3.71, adjusted for age). In elderly men MnSOD AA genotype was strongly associated with “significant” PCa, but not in younger group (Table). On the other hand, MnSOD AA genotype was not associated with “insignificant” PCa regardless of age (Table). CONCLUSIONS Men older than 69 are more likely to have larger, higher grade, and clinically significant PCa as compared to younger men. MnSOD polymorphism is associated with aggressive PCa risk in elderly men. These results suggest that oxidative stress may be involved in the progression of PCa. Autopsy studies provide important information regarding the prevalence and genetic characteristics of PCa in SPECIFIC age groups. © 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e99-e100 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Taro Iguchi Osaka, Japan More articles by this author Ching Wang Syracuse, NY More articles by this author Nicolas Delongchamps Paris, France More articles by this author Gustavo de la Roza Syracuse, NY More articles by this author Yujiro Nitta Osaka, Japan More articles by this author Toshihide Naganuma Osaka, Japan More articles by this author Katsuyuki Kuratsukuri Osaka, Japan More articles by this author Junji Uchida Osaka, Japan More articles by this author Hidenori Kawashima Osaka, Japan More articles by this author Gabriel Haas Syracuse, NY More articles by this author Tatsuya Nakatani Osaka, Japan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Androgens and male aging: current evidence of safety and efficacy

Many signs of aging, such as sexual dysfunction, visceral obesity, impaired bone and muscle strength, bear a close resemblance to features of hypogonadism in younger men. The statistical decline of serum testosterone in aging men is solidly documented. It has been presumed that the above features of aging are related to the concurrent decline of androgens, and that correction of the lower-than-normal circulating levels of testosterone will lead to improvement of symptoms of aging. But in essence, the pivotal question whether the age-related decline of testosterone must be viewed as hypogonadism, in the best case reversed by testosterone treatment, has not been definitively resolved. Studies in elderly men with lower-than-normal testosterone report improvement of features of the metabolic syndrome, bone mineral density, of mood and of sexual functioning. But as yet there is no definitive proof of the beneficial effects of restoring testosterone levels to normal in elderly men on clinical parameters. Few of these studies meet as yet rigorous standards of scientific enquiry: double-blind, placebo-controlled design of the study. The above applies also to the assessment of safety of testosterone administration to elderly men. There is so far no convincing evidence that testosterone is a main factor in the development of prostate cancer in elderly men and guidelines for monitoring the development of prostate disease have been developed. It is of note that there are presently no long-term safety data with regard to the prostate. Polycythemia is another potential complication of testosterone treatment. It is dose dependent and can be managed with dose adjustment.

Pathological Characteristics of Prostate Cancer in Elderly Men

Recent guidelines recommend that men older than 75 years should not be screened for prostate cancer. However, increased life expectancy and the development of less invasive treatments have led to an interest in characterizing prostate cancer in elderly men. We determined how prostate cancer pathological characteristics differ in men older vs younger than 70 years. We studied differences in prostate cancer pathological characteristics in autopsied glands from men 70 years old or older and compared findings to those in men younger than 70 years. All men died of causes unrelated to prostate cancer. Prostates were whole mounted at 4 mm intervals. Histological analysis was done to identify and characterize each cancer focus observed. Tumor volume was measured by computerized planimetry. Cancer was defined as clinically significant or insignificant based on established histological characteristics. Of 211 prostates evaluated 74 were from men 70 years old or older. We identified cancer in 33 men (45%) in this age group vs in 26 of 137 (19%) younger than 70 years (p <0.001). Men older than 70 years had significantly larger cancer and more clinically significant cancer (64% vs 23%, p <0.005). Older men had more advanced stage cancer and greater Gleason scores (p <0.001). In an autopsy study of men with no history of prostate cancer those older than 70 years were more likely to have larger and higher grade prostate cancer than younger men.

Predictors of prostate cancer-specific mortality in elderly men with intermediate-risk prostate cancer treated with radiation therapy

9543 Background: To identify clinical factors associated with prostate cancer-specific mortality (PCSM), adjusting for co-morbidity, in elderly men with intermediate-risk prostate cancer treated with brachytherapy alone or in conjunction with external beam radiation therapy (EBRT). Methods: The study cohort comprised 1,978 men of median age 71 (interquartile range [IQR], 66–75) years with intermediate-risk prostate cancer (Gleason score 7 with PSA 20 ng/mL or less and tumor category T2c or less). Fine and Gray's multivariable competing risks regression was used to assess whether presence of cardiovascular disease (CVD), age, treatment, year of brachytherapy, PSA level, or tumor category were associated with the risk of PCSM. Results: After a median follow up of 3.2 (IQR, 1.7 - 5.4) years, 15 men were observed to experience PCSM. The presence of CVD was significantly associated with a decreased risk of PCSM (AHR 0.20, 95% CI 0.04 - 0.99, P = 0.05), whereas an increasing PSA level was significantly associated with an increased risk of PCSM (AHR 1.14, 95% CI 1.02 - 1.27, P = 0.02). In the absence of CVD, cumulative incidence estimates of PCSM were higher (P = 0.03) in men with PSA levels above as compared to the median PSA level (7.3 ng/mL) or less; however, in the setting of CVD there was no difference (P = 0.27) in these estimates stratified by the median PSA level (6.9 ng/mL). Conclusions: Detection of intermediate-risk prostate cancer in elderly men without CVD at lower PSA levels is associated with a lower risk of PCSM; this risk reduction is not observed in men with known CVD. [Table: see text] No significant financial relationships to disclose.

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Editorial Comment

The authors are to be commended for their grass roots efforts to affect the practice patterns regarding prostate cancer in elderly men. In Iowa, as in the rest of the United States, the prostate cancer screening efforts used by primary care doctors and urologists are inconsistent and not well standardized in the elderly population. The authors previously attempted to inform physicians and patients in Iowa about the risks and benefits of screening for prostate cancer in elderly men using local media, continuing medical education, direct mail, and focus groups.

Prostate brachytherapy in men greater than or equal to 75 years of age

16069 Background: The management of prostate cancer in elderly men remains controversial. In this study, we evaluated cause- specific survival (CSS), biochemical progression-free survival (bPFS) and overall survival (OS) in prostate cancer patients ≥ 75 years of age undergoing brachytherapy with or without supplemental therapies. Methods: Between April 1995 and August 2004, 145 consecutive patients ≥ 75 years of age underwent permanent prostate brachytherapy. Median follow-up was 5.8 years. bPFS was defined by a PSA ≤ 0.40 ng/mL after nadir. Patients with metastatic prostate cancer or hormone refractory disease without obvious metastases who died of any cause were classified as dead of prostate cancer. All other deaths were attributed to the immediate cause of death. Multiple clinical, treatment and dosimetric parameters were evaluated for impact on survival. Results: Nine-year CSS, bPFS and OS for the entire cohort were 99.3%, 97.1% and 64.5%, respectively. None of the evaluated parameters predicted for CSS, while bPFS was most closely to percent positive biopsies. Overall survival and non-cancer deaths were best predicted by tobacco status. Androgen deprivation therapy did not influence survival. Thirty-seven patients have died with 83.8% of the deaths due to cardiovascular disease (22 patients) or second malignancies (9 patients). To date, only 1 patient (0.7%) has died of metastatic prostate cancer. Conclusions: Following brachytherapy, high rates of cause-specific and biochemical progression-free survival are noted in elderly prostate cancer patients. Overall, approximately 65% of patients are alive at 9 years with survival most closely related to tobacco status. Androgen deprivation therapy did not influence survival. We believe our results support an aggressive locoregional approach in appropriately selected elderly patients. No significant financial relationships to disclose.

Prostate brachytherapy in men ≥75 years of age

Purpose: The management of prostate cancer in elderly men remains controversial. In this study, we evaluated cause-specific survival (CSS), biochemical progression-free survival (bPFS) and overall survival (OS) in prostate cancer patients ≥75 years of age undergoing brachytherapy with or without supplemental therapies.

Patterns of Primary and Secondary Therapy for Prostate Cancer in Elderly Men: Analysis of Data From CaPSURE ®

We examined patterns of primary treatment for prostate cancer in men 75 years or older. Data were obtained from the multi-institutional CaPSURE database on the type of primary therapy performed in men younger than 75, or 75 years old or older. Primary therapy was defined as watchful waiting, radical prostatectomy, brachytherapy, brachytherapy plus external beam radiotherapy, external beam radiotherapy or primary androgen deprivation therapy. The chi-square test and multinomial logistic regression analysis were performed to identify predictors of the type of primary therapy and outcomes. A greater proportion of patients 75 years or older were white, single, had multiple comorbidities, low income and low education, and were classified as being at high risk compared to those younger than 75 years (43% vs 25%). On multivariate analysis adjusted for sociodemographic factors, diagnostic risk category and the number of comorbidities at diagnosis patients 75 years or older were less likely to be treated with primary therapy than with watchful waiting regardless of the risk category or comorbidity level. Older patients with high risk cancer are far more likely to be observed regardless of the burden of comorbidity. A more tailored approach to prostate cancer therapy that considers comorbidity and functional level to determine primary therapy may be more appropriate. Well selected older patients with high risk disease, particularly those with low comorbidity levels, may derive survival benefit from a primary therapy other than watchful waiting. Alternatively elderly patients with low risk disease may be better treated with watchful waiting.

Screening and Management of Prostate Cancer in Elderly Men: The Iowa Prostate Cancer Consensus

The issue of prostate cancer screening and management is likely to assume greater importance with progressive aging of the population. Because there are no currently established guidelines for screening and management of prostate cancer in elderly men (older than 75 years), a multidisciplinary panel was convened to develop consensus recommendations. The panel consisted of experts in urology, internal medicine/geriatrics, medical oncology, radiation oncology, family practice, law, patient advocacy and physician assistants. Four internationally known experts on prostate cancer served as external advisors. Relevant literature was reviewed and consensus was developed based on expert opinion, given the lack of level I evidence regarding most aspects of prostate cancer diagnosis and management in men older than 75 years of age. On the basis of the opinions of the expert panel, recommendations for screening and management of prostate cancer in elderly men older than 75 years of age was developed. In general, there was support for using greater discretion in screening for prostate cancer in elderly men. The lack of adequate patient education tools to facilitate discussion with patients was recognized. There was also agreement on the need for greater and renewed patient counseling regarding benefits and risks of prostate cancer screening beyond age 75. It is possible to build consensus around a standardized approach to prostate cancer screening and management in older men. Promulgation of such consensus recommendations and their widespread adoption may help engender a tailored approach to managing prostate cancer in older men, thereby decreasing health care costs and morbidity while limiting unnecessary therapy.

Docetaxel treatment in the elderly patient with hormone refractory prostate cancer.

Docetaxel is an anti-microtubular agent in the family of the taxanes, now FDA approved as first line chemotherapy for the treatment of hormone refractory metastatic prostate cancer. Recent data from two large randomized Phase III trials showed a survival advantage in hormone refractory prostate cancer patients treated with docetaxel. This discovery changed the perceptions about utilization of chemotherapy for this devastating disease and introduced a new paradigm/standard of care treatment for this patient population. The management of elderly patients with metastatic prostate cancer is an important issue because according to data from the Surveillance, Epidemiology, and End Results (SEER) program, the American Cancer Society, and the United Nations, the incidence of prostate cancer in elderly men is expected to increase since people are living longer. In this paper we will review the results of trials evaluating docetaxel in hormone refractory prostate cancer and the implications of these trials as they relate to diagnosis and management of this disease in the elderly man.

Validity of the CAPRA Score to Predict Biochemical Recurrence-Free Survival After Radical Prostatectomy. Results From a European Multicenter Survey of 1,296 Patients

The CAPRA (Cancer of the Prostate Risk Assessment) score from the University of California, San Francisco provides a new statistical model to predict recurrence-free survival and pathological tumor stage after radical prostatectomy. It was originally developed using data from the CaPSURE (Cancer of the Prostate Strategic Urologic Research Endeavor) registry. To calculate the score, which ranges from 0 to 10, 5 clinical variables are needed, ie prostate specific antigen, Gleason sum, clinical tumor grade, percentage of positive biopsies and patient age. To date, the only external validation of the CAPRA score has been conducted using the SEARCH (Shared Equal Access Regional Cancer Hospital) database. The present study uses a German database to contribute to existing validation work and to test transferability of the CAPRA score to a sample that differs fundamentally from the SEARCH sample in terms of clinical features. Data from 1,296 German patients after radical prostatectomy were used for validation. Mean followup was 56.5 (+/-35.4) months. Accuracy of prediction of recurrence-free survival and pathological tumor stage with the CAPRA score was analyzed using Kaplan-Meier analysis, proportional hazards regression, logistic regression and graphic representation. For the external validation of the CAPRA score, the underlying clinical variables of our study group were unfavorable compared to the original cohort from the CaPSURE data set. The recurrence-free survival rate decreased after 3 and 5 years from 100% to 97%, respectively, in the CAPRA score 0 to 1 group, and from 44% to 31%, respectively, in the CAPRA score of 7 or higher group. The hazard ratios of a biochemical recurrence per 1-group increase were 1.50 (95% CI 1.43-1.56) for the CAPRA sum score, 1.62 (95% CI 1.53-1.71) for the 7-group CAPRA score and 3.52 (95% CI 3.00-4.12) for the 3-group CAPRA score. Concordance indices between 0.78 and 0.81 suggested good predictive accuracy. Of the 5 CAPRA constituents 4 independently predicted recurrence-free survival, ie prostate specific antigen, Gleason sum, cT stage and percent of positive biopsies. Positive margins occurred in 13.1% of patients with a CAPRA score of 0 to 1 vs 62% of patients with a score of 7 to 10 (p <0.001). Organ confined tumors were present in 97.7% of patients with a CAPRA score of 0 to 1 vs 19.3% of those with a score of 7 to 10 (p <0.001). Despite different clinical features in the present patient cohort and the CaPSURE data set, the accuracy of the CAPRA nomogram in predicting recurrence-free survival was high. These results underscore the effectiveness and the clinical applicability of the CAPRA score which, in addition to patient counseling, may also be used for risk stratification in clinical studies.

Survival associated with treatment vs. observation of localized prostate cancer in elderly men: Wong YN, Mitra N, Hudes G, Localio R, Schwartz JS, Wan F, Montagnet C, Armstrong K, Division of Population Science, Fox Chase Cancer Center, Philadelphia, PA

Prostate-specific antigen screening has led to an increase in the diagnosis and treatment of localized prostate cancer. However, the role of active treatment of low- and intermediate-risk disease in elderly men is controversial. To estimate the association between treatment (with radiation therapy or radical prostatectomy) compared with observation and overall survival in men with low- and intermediate-risk prostate cancer. Observational US cohort from Surveillance, Epidemiology, and End Results Medicare data. At total of 44,630 men aged 65 to 80 years who were diagnosed between 1991 and 1999 with organ-confined, well- or moderately differentiated prostate cancer and who had survived more than a year past diagnosis. Patients were followed up until death or study end (December 31, 2002). Patients were classified as having received treatment (n = 32,022) if they had claims for radical prostatectomy or radiation therapy during the first 6 months after diagnosis. They were classified as having received observation (n = 12,608) if they did not have claims for radical prostatectomy, radiation, or hormonal therapy. Patients who received only hormonal therapy were excluded. Overall survival. At the end of the 12-year study period, 4,663 men (37%) in the observational group and 7,639 men (23.8%) in the treatment group had died. The treatment group had longer 5- and 10-year survival than the observation group. After using propensity scores to adjust for potential confounders (tumor characteristics, demographics, and comorbidities), there was a statistically significant survival advantage associated with treatment (hazard ratio, 0.69; 95% confidence interval, 0.66–0.72). A benefit associated with treatment was seen in all subgroups examined, including older men (aged 75–80 years at diagnosis), black men, and men with low-risk disease. This study suggests a survival advantage is associated with active treatment for low- and intermediate-risk prostate cancer in elderly men aged 65 to 80 years. Because observational data cannot completely adjust for potential selection bias and confounding, these results must be validated in randomized controlled trials of alternative management strategies in elderly men with localized prostate cancer.

Under Diagnosis and Over Diagnosis of Prostate Cancer

We quantified the rates of over and under diagnosis of prostate cancer in 2 large patient cohorts during the last 15 years. A total of 2,126 men with clinical stage T1c prostate cancer were treated with radical prostatectomy during 1 of the 3 periods 1989 to 1995, 1995 to 2001 and 2001 to 2005. The respective proportions of men with a tumor that met our criteria for over diagnosis (0.5 cm3 or less, confined to the prostate with clear surgical margins and no Gleason pattern 4 or 5) and under diagnosis (nonorgan confined, pathological stage T3 or greater, or positive surgical margins) were examined. The proportion of men with an over diagnosed tumor was 1.3% to 7.1%. The proportion with prostate cancer that was under diagnosed was 25% to 30%. An ancillary finding was that decreasing the prostate specific antigen threshold for biopsy from 4.0 to 2.5 ng/ml in the screened population resulted in a lower rate of under diagnosis from 30% to 26%, a higher rate of over diagnosis from 1.3% to 7.1% and an increase in the 5-year progression-free survival rate from 85% to 92%. Men who were 55 years or younger were significantly more likely to meet our criteria for over diagnosed cancer. Under diagnosis of prostate cancer continues to occur more frequently than over diagnosis. Lowering the prostate specific antigen threshold for recommending biopsy to 2.5 ng/ml resulted in a lower rate of under diagnosis and a higher progression-free survival rate.

Outcomes of Treatment vs Observation of Localized Prostate Cancer in Elderly Men

Outcomes of Treatment vs Observation of Localized Prostate Cancer in Elderly Men

Outcomes of Treatment vs Observation of Localized Prostate Cancer in Elderly Men—Reply

Outcomes of Treatment vs Observation of Localized Prostate Cancer in Elderly Men—Reply