Conservative vs Aggressive Treatment in Older Prostate Cancer Patients

A new cohort study says older men with prostate cancer who have other health conditions that put them at risk of mortality within 10 years should consider their prostate cancer treatment options carefully. Survival data of prostate cancer patients 70 and older show that those with three or more comorbidities and low- or intermediate-risk prostate cancer are less likely to die from prostate cancer than another health issue. But, those with aggressive, high-risk disease are more likely to die from their prostate cancer. The multicenter study is published in Annals of Internal Medicine and was led by researchers at the University of California, Los Angeles, and Vanderbilt University in Nashville, Tennessee.

The population cohort study followed 3,183 men initially diagnosed with non-metastatic prostate cancer between 1994 and 1995 for 14 years. Men completed surveys within 6 months of their diagnosis, self-reporting comorbidities. Survival outcomes were analyzed using data on the cohort from the Surveillance, Epidemiology, and End Results database.

An increase in comorbidities increased the non–prostate cancer cumulative mortality rates in these men: those with zero, one, two, or three comorbidities had mortality rates of 24%, 33%, 46%, and 57%, respectively. Older age increased the 10-year non–prostate cancer cause mortality of those men with three or more comorbidities from 26% for men age 60 or younger, to 71% for those aged 75 or older at diagnosis.

The number of comorbidities did not greatly affect non–prostate cancer mortality rates in those men with high-risk disease. These men had non–prostate cancer mortality rates of 10% to 11% and were more likely to die from their prostate cancer than from another health problem. Men with high-risk prostate cancer had an 18% risk of death from prostate cancer over the 14-year study period. The analysis found men with low- and intermediate-risk prostate cancer had a relatively low risk of dying of their prostate cancer, 3% and 7%, respectively.

“For men with low- to intermediate-risk disease, prostate cancer is an indolent disease that doesn't pose a major risk to survival,” said lead author Timothy Daskivich, MD, department of urology, University of California, Los Angeles, in a statement. “The take home point from this study is that older men with multiple underlying health problems should carefully consider whether they should treat these tumors aggressively, because that treatment comes with a price.”

The study provides data for the ongoing discussion of how to best tailor treatment of prostate cancer that may not be life threatening. Aggressive treatments such as radiation, surgery, and chemotherapy can lower quality of life as it can lead to urinary incontinence, erectile dysfunction, and bowel dysfunction, but does not necessarily boost overall survival over an 8- to 10-year timeframe.

Which prostate cancers require treatment is still an open question that research is attempting to address. Not all diagnosed, early-stage prostate tumors are aggressive and threaten the life of the patient in the short-term or midterm. Treating these tumors may only increase morbidity but will not benefit the patient in the long-term. The current study suggests that factors such as prostate cancer stage and aggressiveness along with age and other health issues need to be well considered when a clinician and patient decide on either treatment or active surveillance.

In fact, the US Preventive Services Task Force no longer recommends prostate cancer screening using the prostate specific antigen (PSA) level test for men 75 and older. But studies, including this one, suggest that age alone is not the only factor that needs to be considered for either screening or management of prostate cancer. An international study from the International Society of Geriatric Oncology showed that not only age, but also other health issues influence long-term survival of patients.

“It seems that 3 fundamental variables must be considered to identify the best management strategy for prostate cancer in elderly men: age, tumor characteristics, and comorbid conditions,” state Lazzaro Repetto, MD, of the Sanremo Hospital, Department of Oncology in Sanremo, Italy, and colleagues in an editorial accompanying the study.

“The challenge for the physician is to accurately evaluate the life expectancy of a patient in order to balance the risk for prostate cancer mortality with that of other-cause mortality,” the editorial states.