Treatment By Stage Of Prostate Cancer
Different treatments may be recommended for each stage of prostate cancer. Your doctor will work with you to develop a specific treatment plan based on the cancers stage and other factors. Detailed descriptions of each type of treatment are provided earlier on this same page. Clinical trials may also be a treatment option for each stage.
Early-stage prostate cancer
Early-stage prostate cancer usually grows very slowly and may take years to cause any symptoms or other health problems, if it ever does at all. As a result, active surveillance or watchful waiting may be recommended. Radiation therapy or surgery may also be suggested, as well as treatment in clinical trials. For those with a higher Gleason score, the cancer may be faster growing, so radical prostatectomy and radiation therapy are often recommended. Your doctor will consider your age and general health before recommending a treatment plan.
ASCO, the American Urological Association, American Society of Radiation Oncology, and the Society of Urologic Oncology recommend that patients with high-risk early-stage prostate cancer that has not spread to other areas of the body should receive radical prostatectomy or radiation therapy with hormonal therapy as standard treatment options.
Locally advanced prostate cancer
Watchful waiting may be considered for older adults who are not expected to live for a long time and whose cancer is not causing symptoms or for those who have another, more serious illness.
Senior Cancer Treatment Options
As mentioned, doctors may not have a full understanding of how threatening a mans prostate cancer may be which can make it difficult to recommend treatment. Often times, these treatments done through surgery and/or radiation can negatively affect various aspects of normal living, especially for older men. Many health communities tend to agree that screening for older men may not be greatly beneficial since they are more likely to die from other conditions, should they exist.
That is not to say that prostate cancer does not pose a threat. While treatment may potentially be more harmful than the cancer itself, its not to be taken lightly. If your aging loved one is concerned about his prostate and unsure about screening, its important to begin the discussion with his doctor and to see what the best course of action is, given factors such as age and health. Screening/treatment should always be mutually agreed upon by both your loved one and his doctor.
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The Suitability Of Patients Over Age 70 For Hormonal Therapy
It is agreed by all that hormonal therapy is indicated for an increasing percentage of patients with increasing age, but the only entirely uncontroversial indication for it is symptomatic, metastatic prostate cancer . Irritative and obstructive urinary symptoms can also be treated hormonally .
The patients chronological age is less important than his biological age and life expectancy. In one study, the tumor-specific survival rates of patients with local prostate cancer were no different at age 60 and at age 80 if the patients were given hormonal treatment only in case of progression of their prostate cancer. In this age group, it was the Gleason scorea tumor-associated, rather than patient-associated, factorthat shortened metastasis-free 10-year survival: The figure for highly differentiated prostate cancer was 81%, while that for poorly differentiated prostate cancer was 26% .
The case studies mentioned above yielded survival figures based on the patients chronological age. One may suspect, however, that the treating physicians were also influenced by their patients comorbidities when choosing the therapy to be given to each. In a population-based study in the Netherlands, only 8% of the patients under age 69 had two or more comorbidities, as compared to 27% of patients aged 80 .
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Prostate Cancer In The Older Man
John A. Petros, MDOncology
Most men diagnosed with prostate cancer are more than 65 years of age. Therefore, a discussion of the issues surrounding the diagnosis, prevention, and treatment of prostate cancer in older men is, in many ways, a review of
There are few topics that generate as much controversy as thescreening, detection, and treatment of prostate cancer, especially in elderlymen. The article by Drs. Ko and Bubley does a good job of reviewing the majorrelevant topics but leaves the reader without much definitive advice. For thisreason, 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 . Screening combined withearly curative treatment has resulted in decreased mortality despite the agingof the population. Since survival advantages only become apparent10 years after treatment, screening has generally been reserved for thosemen with a life expectancy of at least 10 years. This is a prudentguideline to follow.
Individualized Approach to Treatment and Prevention
Are Older Men Undertreated
Schwartz and colleagues44 reviewed the treatment decisions and factors influencing them in a cohort of men with localized prostate cancer. Age, comorbidity, and Gleason score were found to be independent predictors of suboptimal treatment. It was concluded that most men older than 70 years with moderately or poorly differentiated tumors and no to mild comorbidity were given suboptimal treatment. Most of these men were undertreated, receiving watchful waiting therapy when potentially curative therapy could have been applied. With optimal treatment, clinical outcomes could have been improved.
Thompson and colleagues46 investigated otherwise healthy octogenarians diagnosed with prostate cancer who underwent radical prostatectomy. At the last follow-up visit, 10 patients had survived more than a decade after surgery, and 3 patients had died within 10 years of surgery. The remaining 6 patients were alive at less than 10 years of follow-up. Seventy-four percent of patients were continent. No patient had died of prostate cancer, and the 10-year, all-cause survival rate was similar to that observed in healthy patients 60 to 79 years old undergoing radical prostatectomy. These findings indicate that careful selection of patients even older than 80 years can achieve satisfactory oncologic and functional outcomes after surgery. It is important to note, however, that the rate of urinary incontinence after surgery exceeds that of younger counterparts.
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A Biopsy Is Done To Diagnose Prostate Cancer And Find Out The Grade Of The Cancer
A transrectal biopsy is used to diagnose prostate cancer. A transrectal biopsy is the removal of tissue from the prostate by inserting a thin needle through the rectum and into the prostate. This procedure may be done using transrectal ultrasound or transrectal MRI to help guide where samples of tissue are taken from. A pathologist views the tissue under a microscope to look for cancer cells.
Sometimes a biopsy is done using a sample of tissue that was removed during a transurethral resection of the prostate to treat benign prostatic hyperplasia.
If cancer is found, the pathologist will give the cancer a grade. The grade of the cancer describes how abnormal the cancer cells look under a microscope and how quickly the cancer is likely to grow and spread. The grade of the cancer is called the Gleason score.
To give the cancer a grade, the pathologist checks the prostate tissue samples to see how much the tumor tissue is like the normal prostate tissue and to find the two main cell patterns. The primary pattern describes the most common tissue pattern, and the secondary pattern describes the next most common pattern. Each pattern is given a grade from 3 to 5, with grade 3 looking the most like normal prostate tissue and grade 5 looking the most abnormal. The two grades are then added to get a Gleason score.
Active Surveillance And Watchful Waiting
If prostate cancer is in an early stage, is growing slowly, and treating the cancer would cause more problems than the disease itself, a doctor may recommend active surveillance or watchful waiting.
Active surveillance. Prostate cancer treatments may seriously affect a person’s quality of life. These treatments can cause side effects, such as erectile dysfunction, which is when someone is unable to get and maintain an erection, and incontinence, which is when a person cannot control their urine flow or bowel function. In addition, many prostate cancers grow slowly and cause no symptoms or problems. For this reason, many people may consider delaying cancer treatment rather than starting treatment right away. This is called active surveillance. During active surveillance, the cancer is closely monitored for signs that it is worsening. If the cancer is found to be worsening, treatment will begin.
ASCO encourages the following testing schedule for active surveillance:
A PSA test every 3 to 6 months
A DRE at least once every year
Another prostate biopsy within 6 to 12 months, then a biopsy at least every 2 to 5 years
Treatment should begin if the results of the tests done during active surveillance show signs of the cancer becoming more aggressive or spreading, if the cancer causes pain, or if the cancer blocks the urinary tract.
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Quality Of Life With Advanced Stage Prostate Cancer
Since Huggins and Hodges won a Nobel Prize in 1966 for their work describing the relationship between testosterone and prostate cancer, androgen deprivation has continued to be an important component in the treatment of advanced prostate cancer. It is associated, however, with significant cost in terms of morbidity as well as economics. Side effects of androgen deprivation therapy include hot flashes, osteoporosis, loss of libido or impotence, and psychological effects such as depression, memory difficulties, or emotional lability. Recently Harle and colleagues55 reported insulin resistance, hyperglycemia, metabolic syndrome, and metabolic complications being associated with castration and thus being responsible for increased cardiovascular mortality in this population.
Because of the palliative nature of androgen ablation, quality of life is an important component of evaluating competing therapies. Intermittent androgen deprivation is one approach to hormonal therapy that has been developed with the aim of minimizing the negative effects of therapy while maximizing clinical benefits and the patients quality of life. It can be used in any clinical situation where continuous androgen deprivation treatment could be applied.56
Remission And The Chance Of Recurrence
A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having no evidence of disease or NED.
A remission can be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. Although there are treatments to help prevent a recurrence, such as hormonal therapy and radiation therapy, it is important to talk with your doctor about the possibility of the cancer returning. There are tools your doctor can use, called nomograms, to estimate someone’s risk of recurrence. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.
In general, following surgery or radiation therapy, the PSA level in the blood usually drops. If the PSA level starts to rise again, it may be a sign that the cancer has come back. If the cancer returns after the original treatment, it is called recurrent cancer.
When this occurs, a new cycle of testing will begin again to learn as much as possible about the recurrence, including where the recurrence is located. The cancer may come back in the prostate , in the tissues or lymph nodes near the prostate , or in another part of the body, such as the bones, lungs, or liver . Sometimes the doctor cannot find a tumor even though the PSA level has increased. This is known as a PSA recurrence or biochemical recurrence.
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Prostate Cancer: A Guide For Aging Men
Prostate cancer is one of the most frequently diagnosed cancers in the world, despite it only being diagnosed in males . In fact, more than 70 percent of men over the age of 80 have some quantity of cancer cells in their prostate.
Its so common that it sometimes doesnt go diagnosed until autopsies are performed, though that doesnt mean the cancer is the cause of death. On the contrary, the overall prognosis for men diagnosed with prostate cancer is as positive as you can get when talking about the dreaded c word. The five-year survival rates for the disease are close to 100 percent, especially when talking about prostate cancer that is caught early on in the processbefore it spreads.
The five-year survival rates for the disease are close to 100 percent, especially when talking about prostate cancer that is caught early on in the processbefore it spreads.
Nevertheless, prostate cancer is serious business, and the best way to handle a diagnosis is to be informed. Lets take a look at the frequency at which its diagnosed, how youre tested for it, how it can affect your daily life, and what we can do to try and prevent the disease.
Average Age of Prostate Cancer Diagnosis
Comorbidities And Life Expectancy
In general, older people have more comorbidities. A precise estimation of life expectancy is important in the decision whom to screen, whom to treat, and when choosing between different options. Patients with a long life expectancy may be offered aggressive treatment, whereas those with short life expectancy because of underlying disease may be advised to follow a conservative approach. Health status can be assessed by many different indices, for example the WHO status, the Charlson comorbidity index, and the Total Illness Burden Index for prostate cancer. To assess competing risks, Daskivich et al. used Charlson scores in a retrospective study of 1482 men diagnosed with nonmetastatic prostate cancer from 1997 to 2004. The study had a mean follow-up of 6 years. Older men and those managed by primary androgen deprivation therapy had higher Charlson scores, which in turn were associated with greater non-PCa mortality. Ten years after treatment, men with Charlson scores of 0 had a non-PCa mortality rate of 17 %, while men with Charlson scores of 3+ had a non-PCa mortality rate of 74 %. During the observation period, 32 % of men died, of which 3 % died from PCa and 25 % died from other causes. Prostate cancer mortality was extremely rare in the low-risk and intermediate-risk groups, independent of the treatment received. Tewari et al. also calculated a probability of 10-year overall survival in men with and without prostate cancer using Charlson scores.
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How Does Treatment Differ When Youre Older
As you get older, your odds of developing chronic diseases such as heart disease and diabetes go up. That can make treatment decisions difficult. For example, hormone deprivation therapy is commonly used to slow the growth of prostate cancer. Itâs not a cure, but can keep the cancer from getting worse, at least for a while.
The problem: Some, though not all, studies show that it increases your risk of high blood pressure , diabetes, heart disease, and stroke. It may even up your odds of dying from heart disease. Hormone deprivation therapy raises other concerns as well. It can weaken your bones , which makes fractures more likely. It also can lead to problems with thinking. You and your doctor will have to weigh the risks of treatment against its potential benefits.
A 2008 study looked at more than 200,000 men with prostate cancer from ages 65 to 84. The researchers found that only men with the most advanced cases of prostate cancer were more likely to die of their cancer than another cause. Men in the study had a much greater chance of dying of heart failure than from late-stage prostate cancer.
If youâve been diagnosed with prostate cancer, you should have a thorough discussion about the risks and benefits of watchful waiting or active surveillance with your doctor.
Diminution Of Muscular Strength
A mans muscular strength is reduced by 12% to 66% as the result of androgen deprivation. Moreover, muscle mass declines by 20% to 30% by age 70 . Because androgen deprivation reduces the amount of protein synthesis and the non-lipid body mass, obesity results. Thus, elderly patients should actively work against the loss of muscle by directed strength-training exercises .
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Metabolic And Body Composition
Patients may experience changes in metabolic parameters and body composition, such as bone mineral density loss and sarcopenic obesity. These changes occur naturally through the aging process and are accelerated with the use of ADT. The risk of osteoporosis development is important to keep in mind because geriatric syndromes can predispose patients to osteoporotic fractures. Men who suffer an osteoporotic fracture have a higher mortality risk compared with women. As such, preventing bone mineral density loss may in turn prevent a fracture and the associated morbidity and mortality risk of such an event. In order to modify this risk, all patients on ADT should take a daily vitamin D and calcium supplement and engage in weight-bearing exercise.
New Research More Options
But more aggressive treatment may be warranted: A recent study in the Journal of Clinical Oncology has found that adding radiation therapy to ADT leads to better outcomes in older men with locally advanced prostate cancer or aggressive tumors . The results support those found in other studies.
What does this mean? “In many patients older than 75, simple hormone treatment for aggressive prostate cancer may not be the best treatment,” Kristo says. “If patients are otherwise healthy, they should have a thorough discussion with their physician about receiving radiation treatment as well.”
Blaine Kristo, MD, reviewed this article.
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