Excess deaths among some older men with prostate cancer

A population-based analysis of mortality data for men diagnosed with prostate cancer from three European nations suggests that “a small but important group of older patients” initially present with late stage prostate cancer and die rapidly as a consequence.

The study by Holmberg et al., published in Cancer Epidemiology, was designed to compare patterns of survival among men with prostate cancer from England, Norway, and Sweden between 2001 and 2004, taking account of the ages of the patients and the length of follow-up.

The study included data from 179,112 men in England, 23,192 in Norway and 59,697 in Sweden. All study data were based on information available from the national cancer registries for the three countries involved. Estimates of the “excess mortality” among men with prostate cancer were calculated using a period approach for relative survival.

The results of the study showed that:

  • The overall, age-standardized 5-year survival was
    • 76.4 percent for English patients
    • 80.3 percent for Norwegian patients
    • 83.0 percent for Swedish patients
  • English patients had
    • The lowest overall survival
    • The lowest overall survival among men aged ≥ 80 years in particular
  • The majority of the excess deaths in England were confined to the first year of follow-up.

In their conclusion, the authors suggest that the early demise of the “small but important group of older patients” may be because (a) they first present with late stage disease and (b) they have severe concomitant comorbidities in addition to their prostate cancer. It is clear that this problem is more common in England than in Norway or Sweden, which may reflect male health-related behavior patterns in the UK by comparison with Scandinavian countries.

11 Responses

  1. It means our health programme is worse than Scandinavia. We must do what it takes to improve it.

  2. From what I am hearing from several patients or their caregivers in the UK, the treatment available to many is far from sufficient and too often not even totally appropriate. For example, a patient diagnosed Gleason 9, with mets, with pain, with hot flashes from Zoladex, and a slowly elevating PSA has been told that he is not experiencing a failure of the Zoladex monotherapy, that he does not have advanced prostate cancer, that he doesn’t need Casodex or its generic, that his doctor doesn’t believe in combination medications in androgen deprivation therapy, that he doesn’t need Zometa, he doesn’t need his 25-hydroxy vitamin D checked, that his doctor refuses to refer him to an oncologist, and as to his hot flashes …”put up with it!” No wonder men apparently are dying more rapidly in the UK when diagnosed with advanced prostate cancer when there are heartless and obviously inexperienced physicians like this one practicing medicine. … This one isn’t even “practicing!”

  3. Surely this is an argument in favor of more widespread testing — even for older men.

    BTW, can someone explain what is meant by age-standardized 5-year survival? How should this be contrasted to the US experience that is close to 100% survival … or am I mixing apples and oranges?

  4. For an introduction to age-standardization, click here.

    With respect to comparison to the rates in the USA, you are comparing apples to oranges. The 100% 5-year survival in the USA is for men largely being diagnosed today, i.e., with early stage, localized prostate cancer, at any age. This study focuses on men being diagnosed between 2001 and 2004 in countries where the use of the PSA test was still not widespread at that time, and who were therefore almost inevitably being diagnosed with more advanced forms of prostate cancer more comparable to the situation in the USA in the early 1990s.

  5. But Mike, isn’t that the case of the 45% or so of 50-year-olds and older men who have never had a PSA test here in the US? Aren’t those apples too?

  6. Chuck’s observation is pretty close! Many doctors in the UK seem to have no idea of what prostate cancer entails. A few urologists and oncologists are switched on. The rest are “painting by numbers.”

    I was diagnosed over 15 years ago with advanced disease yet still find it difficult to get meaningful treatment, at the right time, and consistent with my disease status.


  7. Ralph:

    I don’t know if 45% is the right number … but my point is that if it is 45% in the USA it is more likely to be 75-80% in the UK. In other words, it is not just about apples and oranges but also about the numbers of apples and the numbers of oranges. It is, after all, just an exercise in statistical analysis.

  8. Mike:

    As you point out, PSA testing was not that widespread in these countries at the turn of the millenium … and I am not sure how prevalent is is today. I think we can all agree that with widespread testing we can improve the survival rate; as previously stated, this is a good argument for widespread testing.

  9. Rick:

    I do think, however, that there are some major differences of opinion about what people mean by “widespread” testing. As you will know, for example, I do not personally believe that annual PSA tests for every man under the Sun are either necessary or a particularly good idea. Individual risk factors need to be carefully accounted for in making the decision about who to test and how often. And a much better type of test would help to resolve many of the key issues.

  10. As a person 68 years old with T3b, Gleason 8, who got PSA tests done every year under a company medical scheme, since I was in my 30s, I dread to think what might have happened if it had not been detected at that stage. I would be dead by now, I honestly believe. As it is, after EBRT and HDBT + 2 years treatment via Prostap 3, I now have a PSA of 0.3 mcg/l over my last four tests (3-monthly). I have no problems with incontinence and my libido has returned since the last Prostap 3 injection 15 months ago.

    I know I haven’t reached the 60 months marker yet but the way things are going I am pretty confident I will reach that point and hopefully a lot longer. In my opinion PSA tests save lives in the longer term and at the moment it is the best test we have until a better one is found. Who in their right mind would suggest that regular breast checks for women was a bad thing, and yet the mortality for prostate cancer is equal to that of breast cancer in women.

  11. Dear Mr. Bermingham:

    Something seems a little odd about your statement immediately above. The PSA test only became commercially available in the very late 1980s. I know of no way that someone of 68 years of age today could have been getting PSA tests since they were in their 30s. Indeed widespread use of PSA testing as amethod for screeing for prostate cacner was only initiated in about 1992 — just 19 years ago, when you would have been 49 years of age.

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