Management of elderly men with low- and very low-risk prostate cancer

In a newly published article in the American Journal of Clinical Oncology, Mishra et al. have attempted to assess the application of immediate, first-line treatment among older men with favorable-risk prostate cancer.

We know today that we are diagnosing many older men today, men of 70 and more years of age with low- and very low-risk disease, who may well do just as well (if not better) on some form of active monitoring as they will if they are given immediate, first-line, invasive therapy of any type. Mishra et al. were able to use the Surveillance, Epidemiology, and End Results (SEER) database to identify 15,108 men, all ≥ 70 years of age, who were diagnosed with with favorable risk prostate cancer between 2004 and 2008.

Here is what the research team learned about their management:

  • Of the entire group of 15,108 men
    • 2.6 percent were treated by radical prostatectomy
    • 59 percent were treated by some form of radiation therapy
  • When analyzed by age groups
    • 66.5 percent of men aged 70 to 74 years were advised to undergo radiation therapy.
    • 59.0 percent of men aged 75 to 79 years were advised to undergo radiation therapy.
    • 36.6 percent of men aged 80 to 84 years were advised to undergo radiation therapy.
    • 15.8 percent of men aged ≥ 85 years were advised to undergo radiation therapy.
  • Multiple, factors were significantly associated with the recommendation for the patients to undergo immediate treatment, including
    • Younger age
    • White race
    • A Gleason score of 6 (as opposed to a Gleason score of ≤ 5)
    • Married marital status
    • No history of prior malignancy
  • There was significant geographic variation in patterns of application of immediate, first-line treatment.

Now let’s remember that diagnosis and treatment of these men did pre-date the change in the guideline from the National Comprehensive Cancer Network to recommend active surveillance as first-line management for a very high proportion of men ≥ 70 years of age with low- and very low-risk prostate cancer, so we shouldn’t be overly surprised at this high degree of immediate, first-line therapy.

On the other hand, The “New” Prostate Cancer InfoLink is in full agreement with the conclusion drawn by Mishra et al. that a very high percentage of elderly men seem to be undergoing (potentially unnecessary and harmful) immediate, first-line treatment for favorable-risk, localized prostate cancer. Specifically the authors note that “Future research should be performed to identify barriers to patient and physician acceptance of active surveillance.”

It is worth considering the idea that many of those men might be making wiser decisions if they were to spend an hour being walked through a decision aid of the type recently tested by av Tol-Geerdink et al. (compared to spending the best part of 2 months undergoing external beam radiation therapy which may well provide no clinically significant benefit).

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