Rethinking Prostate Cancer in Older Men
FRIDAY Oct. 17, 2008 -- With increasing life expectancies, improved surgical tools, and better information on patient results, many older men diagnosed with early prostate cancer are taking a pass on the traditional advice to hold off on treatment for a period of time.
So-called "watchful waiting" -- or closely monitoring the cancer's progression -- is still a viable option. But many experts now believe that aggressive treatment -- even for older men -- may be the better way to go.
"We're pushing the limits on the upper end," said Dr. Edouard J. Trabulsi, assistant professor in the department of urology at Jefferson Medical College and co-director of the Jefferson Prostate Diagnostic Center in Philadelphia.
A study published recently in the Journal of the American Medical Association helped shake up the conventional wisdom. The study, which involved some 44,000 men, found that the death risk for those who received prostate cancer treatment was nearly one-third lower than for men who received no treatment. And that was true across all age categories, including the oldest men in the study, aged 75 to 80.
"We often think of prostate cancer as an indolent disease, and it is for many men, which is why observation is a very reasonable treatment option for patients with low and intermediate risk disease," said the study's lead author, Dr. Yu-Ning Wong, a medical oncologist at the Fox Chase Cancer Center in Philadelphia.
"However, the life expectancy for a 70-year-old man is about 13 years, and patients who are otherwise healthy should recognize that if they live long enough, they may be at risk of developing complications from prostate cancer," she added.
Prostate cancer is the second most common type of cancer in American men, after skin cancer. In 2008, about 186,320 new cases of the disease will be diagnosed, and about 28,660 men will die from it, according to the American Cancer Society.
Because prostate cancer is generally a slow-growing cancer, some men may never need treatment. And for many older men without symptoms, watchful waiting has been recommended, because it was believed they would die from other causes before their cancer advanced.
But as men's life expectancy creeps higher and new robotic techniques improve the precision of surgery, the decision is becoming more complicated.
"Patients should understand the risks and benefits of all their treatment options -- radiation, surgery and observation," Wong noted. "If they choose observation, they should be committed to careful follow-up with their physicians."
Watchful waiting does not mean watching someone die. Many oncologists today prefer the term "active surveillance," Trabulsi said, because it more accurately describes the diligent approach to monitoring these patients, including the use of PSA blood tests, digital rectal exams and biopsies of the prostate to detect changes in the cancer.
Still, determining the best course of treatment is difficult, because there isn't good data to help guide patients and their families on the effectiveness and harms of treatments for clinically localized prostate cancer, according to a recent literature review prepared for the federal Agency for Healthcare Research and Quality.
But oncologists hope to have better information on the benefits and risks of active surveillance, also known as "expectant management," compared with treatment, by late next year. The National Cancer Institute and the Department of Veterans Affairs are co-sponsoring a study, called the Prostate Cancer Intervention Versus Observation Trial, to compare radical prostatectomy -- which is removal of the gland -- and expectant management on patient survival and overall quality of life.
For now, Wong advises: "They [patients] should place the potential benefit of treatment found in our study in the context of the potential side effects of treating the patient's other medical problems."
Posted: October 2008