Post-treatment mortality of elderly men with high-risk prostate cancer

New data from a series of > 700 elderly patients with high-risk prostate cancer suggests that aggressive combination therapy for such men is associated with a reduced risk for prostate cancer-specific mortality.

This study by Hoffman et al. is a retrospective analysis of data from 764 men of at least 65 years of age treated at the Chicago Prostate Cancer Center or at a 21st Century Oncology facility. All patients had high-risk prostate cancer according to the D’Amico criteria (clinical stage T3 or T4N0M0, a PSA level > 20 ng/ml, and/or Gleason score 8-10). They were treated either with brachytherapy alone (n = 206) or with CMT (a combination of brachytherapy, external-beam radiation to the prostate and seminal vesicles, and androgen deprivation therapy; n = 558). In addition, the patients either had no history of myocardial infarction (MI) or had a history of MI treated with a stent or surgical intervention.

The results of this study show that:

  • The median age of the patients was 73 years.
  • After a median follow-up of 4.9 years, 25/764 men (3.3 percent) had died of prostate cancer.
  • After adjusting for age and prostate cancer prognostic factors, the risk of prostate cancer-specific mortality was significantly reduced (hazard ratio = 0.29) for men who received CMT by comparison with men who received brachytherapy alone.
  • A Gleason score of 8 to 10 was associated with a significant increase in risk for prostate cancer-specific mortality.

The authors conclude that elderly men with high-risk prostate cancer and with no history of cardiovascular disease or with surgically corrected cardiovascular disease had a lower risk of prostate cancer-specific death when treated with CMT than when treated with brachytherapy alone.

Another on-line commentary on this article has suggested that these results are surprising, but this analysis appears to be highly flawed for a variety of reasons. The “New” Prostate Cancer InfoLink does not feel that this result is in the slightest bit surprising. Even elderly men diagnosed with high-risk prostate cancer and a life expectancy of 10+ years are at relatively high risk from prostate cancer-specific mortality, especially if they have a Gleason score of 8-10. We also know that for patients with progressive prostate cancer the combination of external beam radiation and androgen deprivation therapy will definitively extend patient survival.

What the current study does is further confirm the idea that men with high risk disease will probably benefit from more aggressive forms of treatment, at least in the relatively short term (i.e., about 5 years). What this study does not tell us (at least based on the abstract) is what percentage of these men were able to avoid progressive disease altogther if they stopped the androgen deprivation therapy at the normal time of 3 years after initial treatment.

Aggressive treatment of older men with high-risk disease needs to take careful account of the relative benefit of lowering risk for prostate cancer-specific mortality and the potential harms of treatment. It is of considerable interest that, at least in this study, the men with a recognized history of (effectively managed) cardiovascular disease appeared to tolerate androgen deprivation just as well as the men with no history of cardiovascular disease.

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