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Prostate Cancer in the Older Man

Prostate Cancer in the Older Man

There are few topics that generate as much controversy as the
screening, detection, and treatment of prostate cancer, especially in elderly
men. The article by Drs. Ko and Bubley does a good job of reviewing the major
relevant topics but leaves the reader without much definitive advice. For this
reason, 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 patients
with a first-degree relative diagnosed at an early age). Screening combined with
early curative treatment has resulted in decreased mortality despite the aging
of the population.[1] Since survival advantages only become apparent
10 years after treatment, screening has generally been reserved for those
men with a life expectancy of at least 10 years. This is a prudent
guideline to follow.

In order to garner an increase in life span, physicians must detect prostate
cancer early and give definitive local therapy. Prostate-specific antigen (PSA)-detected
prostate cancer is usually significant prostate cancer; it can only be ignored
if outcome can be ignored. Failure to recommend screening, detection, and
treatment to individuals over 50 (with 10 years of life to protect) is not
advisable. Thus, the following discussions are relevant only in relation to
those therapies capable of rendering cure for local disease: radiation and
surgery.

Hormonal Therapy

There appears to be a real advantage in giving hormonal treatment before
radiation therapy. There also appears to be a real advantage to treating minimal
lymphatic metastasis with radical prostatectomy, regional lymphadenectomy, and
postoperative hormonal therapy.[2] Even acknowledging these minor exceptions,
more than 55 years of experience with hormonal therapy shows there is no other
evidence (despite the concerted efforts of the pharmaceutical industry) that
hormonal therapy prolongs life, and, therefore, it should be regarded as
palliative.

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

Brachytherapy

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