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Prostate Cancer in the Older Man

Prostate Cancer in the Older Man

A discussion of prostate cancer and the elderly is a microcosm
of the overall debate regarding the screening, detection, and treatment of
localized prostate cancer for all men, irrespective of age. Drs. Ko and Bubley
are correct, however, in pointing out that elderly patients present unique
challenges given the indolent natural history of the cancer, the high incidence
of clinically insignificant tumor, and the presence of comorbid disease that
competitively causes symptoms or death. Their excellent review nicely captures
some of the complexity of the debate, although I believe there are three
questions that remain to be answered.

Is It Appropriate to Check Men Over Age 75 for Prostate Cancer?

An important distinction here is the difference between cancer screening and
cancer detection. While most men diagnosed with prostate cancer are more than 65
years of age, many of these men were evaluated because of urinary symptoms (ie,
retention, hematuria, or incontinence) or systemic symptoms from metastatic
disease (ie, weight loss, bone pain, or azotemia). Early diagnosis and treatment
is clearly indicated for men who have symptomatic or advanced prostate cancer,
since treatment can alleviate symptoms and potentially prolong life.

In contrast, the importance of prostate cancer detection in the asymptomatic
elderly patient is unknown. It is still unproven that population-based prostate
cancer screening significantly decreases morbidity and mortality.[1] Prostate
cancer has a prolonged natural history, and more men will die with prostate
cancer than from prostate cancer. Prostate cancer can take 10 to 20 years to run
its course, and it often occurs in older men with other, more immediate threats
to longevity.

While almost 65% of 70-year-old men harbor microscopic foci of prostate
cancer on autopsy, there is only a 20% lifetime probability that a clinically
apparent tumor will occur.[2] Applying cancer screening programs to older men
has the potential for detecting many of these biologically indolent tumors (pseudodisease),
subsequently increasing health-care costs and morbidity caused by pseudodisease
and side effects from treatment, yet doing nothing to improve overall quantity
or quality of life.[3] Although the scientific evidence to date suggests that
PSA-based screening programs do not detect these clinically insignificant
tumors, the broad application of screening to the elderly will probably result
in the treatment of some men who otherwise would never develop symptoms or die
from prostate cancer.

So, should we be checking asymptomatic men over the age of 75 for prostate
cancer? At this time, there is some evidence that screening and treatment in
asymptomatic men who have more than a 10-year life expectancy can reduce
cause-specific mortality.[4] In addition, improvements in the treatment of both
localized and advanced disease mean fewer side effects and better preservation
of quality of life, which makes treatment more acceptable to the elderly
male.[5] Finally, average life span itself represents a moving target, with
progressive increases expected to occur into the middle of the next century.[6]
Strict cutoffs based on age should not be used, since average life span does not
predict a specific individual’s risk of dying. A screening decision based on
an individualized, quantitative estimate of life expectancy seems more
reasonable.[7]

Since there is no strong scientific evidence that shows a benefit for
prostate cancer screening, the best suggestion at this time is to offer PSA
testing on an individual basis—based on a conceptual framework that reviews
the individual patient’s comorbidity, life expectancy, family history, fear of
disability from cancer, and cognitive state.[7,8] Because of time constraints, a
specific discussion of the risks and benefits of screening can be difficult in
the primary care setting, but there are many helpful brochures for patient
education such as those produced by the American Foundation for Urologic Disease
or the American Academy of Family Practice.[9,10]

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