Prostate Cancer in the Older Man

There are few topics that generate as much controversy as thescreening, detection, and treatment of prostate cancer, especially in elderlymen. The article by Drs. Ko and Bubley does a good job of reviewing the majorrelevant topics but leaves the reader without much definitive advice. For thisreason, it is instructive to review what we know to be true.

Prostate cancer kills more than 31,000 men in the United States each year,and there are identified high-risk groups (ie, African-Americans and patientswith a first-degree relative diagnosed at an early age). Screening combined withearly curative treatment has resulted in decreased mortality despite the agingof the population.[1] Since survival advantages only become apparent10 years after treatment, screening has generally been reserved for thosemen with a life expectancy of at least 10 years. This is a prudentguideline to follow.

In order to garner an increase in life span, physicians must detect prostatecancer early and give definitive local therapy. Prostate-specific antigen (PSA)-detectedprostate cancer is usually significant prostate cancer; it can only be ignoredif outcome can be ignored. Failure to recommend screening, detection, andtreatment to individuals over 50 (with 10 years of life to protect) is notadvisable. Thus, the following discussions are relevant only in relation tothose therapies capable of rendering cure for local disease: radiation andsurgery.

Hormonal Therapy

There appears to be a real advantage in giving hormonal treatment beforeradiation therapy. There also appears to be a real advantage to treating minimallymphatic metastasis with radical prostatectomy, regional lymphadenectomy, andpostoperative hormonal therapy.[2] Even acknowledging these minor exceptions,more than 55 years of experience with hormonal therapy shows there is no otherevidence (despite the concerted efforts of the pharmaceutical industry) thathormonal therapy prolongs life, and, therefore, it should be regarded aspalliative.

In a palliative context, hormonal therapy, spot radiotherapy, andtransurethral resection of a malignant prostate can all be effective; palliativechemotherapy also works in rare instances. Because hormonal therapy ispalliative and has adverse effects, it should not be recommended in asymptomaticpatients. There are some exceptions, however, as previously discussed.Similarly, there is no compelling evidence that combined hormonal therapy ismore effective than orchiectomy.

Brachytherapy

I differ with the authors regarding their opinion of brachytherapy. While itcan be performed in a single session, brachytherapy, unlike external-beamradiation, involves general anesthesia. Also, the 5-year relapse-free survivaldata cited by the authors are not meaningful. It was definitively proven thatthe 5- and 10-year data were significantly misleading in the long-term follow-upof brachytherapy performed in the 1970s and 1980s.[3]

More worrisome is the debilitating perineal pain that can occur (albeitrarely) with brachytherapy for prostate cancer. This pain can be refractory totreatment, producing a disastrous outcome that is not seen with either radicalprostatectomy or external-beam therapy. The outcomes of external-beamradiotherapy are at least as good as, if not better than, brachytherapy andavoid this serious complication. For this reason, I recommend three-dimensionalconformal external-beam therapy delivered with modern equipment by anexperienced prostate radiotherapist for patients who need radiotherapy.

Individualized Approach to Treatment and Prevention

The management of prostate cancer demands an individualized approach to everypatient. Elderly prostate cancer patients can no more be classified into ahomogeneous group than young patients, black patients, or white patients. Ourobligation, as clinical practitioners, is to provide accurate information,experienced advice, and careful attention to our patients in order to help themmake appropriate treatment choices. A 70-year-old man who only cares aboutsurviving the next 2 years so that he can take care of a dying, disabled spouseshould not be subjected to treatments that may disable the only caretaker. A70-year-old (with a likely 10-year life expectancy) who wants to live to see hisgreat-great-grandchildren should be given the option of definitive therapy.Physicians must ask these types of questions and actively (but quietly) listento the answers.

In the final paragraph of their article, Drs. Ko and Bubley state, "Forolder men, even a significant delay in diagnosis could be of significantbenefit." There is no benefit to delaying a diagnosis. There is, however, adistinct benefit to delaying the onset of disease. An effective preventivetherapy would provide the greatest benefit to the greatest number of people forthe longest period of time. Currently, there is sufficient evidence to recommendsmoking cessation and selenium supplementation to smokers. There is insufficientevidence to recommend other preventive agents. Everyone should consume moderatelevels of fat, exercise regularly, and stop smoking.

Conclusions

Overall, the Ko/Bubley article is well written and serves as an excellentreference for practitioners who are not familiar with the diagnosis andtreatment of prostate cancer. The lasting message of the article should be thatscreening combined with early definitive treatment of prostate cancer reducesprostate cancer mortality. Screening and definitive therapy should be pursuedfor individuals over age 50 (or 45, if in a high-risk group)[1] with at least a10-year life expectancy, for whom reduction in mortality from prostate cancer isa desirable outcome.

References:

1. Smith RA, von Eschenbach AC, Wender R, et al: American Cancer Societyguidelines for the early detection of cancer: Update of early detectionguidelines for prostate, colorectal, and endometrial cancers. CA Cancer J Clin51(1):38-75, 2001.

2. Messing EM, Manola J, Sarosdy M, et al: Immediate hormonal therapycompared with observation after radical prostatectomy and pelvic lymphadenectomyin men with node-positive prostate cancer. N Engl J Med 341(24):1781-1788, 1999.

3. Zelefsky MJ, Whitmore WF Jr: Long-term results of retropubic permanentiodine-125 implantation of the prostate for clinically localized prostaticcancer. J Urol 158(1):23-29, 1997.