Data Source And Patient Cohort
The National Cancer Instituteâs Surveillance, Epidemiology, and End Results program is an epidemiologic surveillance system collecting demographic information , clinical and tumor characteristics , and vital status for all individuals diagnosed with cancer and residing within 1 of the 18 SEER regions, which currently covers 28% of the population in United States.15,16 The SEER-Medicare data are an electronic linkage of persons in SEER with their Medicare enrollment and claims data.16 Medicare Part A and B claims data provide information on medical services delivered in the inpatient and outpatient settings, including service dates, diagnoses, procedures, and treatments delivered during medical encounters. Furthermore, using Medicare data in the 12 months prior to prostate cancer diagnosis, we calculated Klabunde indexâa validated modified Charlson comorbidity measure.17 The Klabunde index is a refined comorbidity measurement algorithm appropriate for analyses of commonly occurring cancers when using administrative claims databases.17 The study was approved by the University of North Carolina at Chapel Hill institutional review board, waiving written informed consent for deidentified retrospective data.
Watchful Waiting And Active Surveillance
Watchful waiting is an adequate approach in patients who are at low risk of death from prostate cancer because of their limited life expectancy due to severe comorbidities.26,27 Watchful waiting resulted in similar overall survival when compared with radical prostatectomy, but disease-specific survival was better in patients who had undergone surgery.26 For some patients it turns out to be hard to persist on a watchful waiting policy, and many men drop out and seek active treatment within several years, mostly when PSA elevation is noted.
Active surveillance is a novel and fascinating approach to distinguish between patients who are at higher risk and need active therapy and patients who are at low risk for disease progression.27,28 This approach avoids the risks of therapy while allowing early detection of those patients who are prone to progress. In these high-risk individuals, delayed active treatment is offered. Periodic monitoring of the PSA serum level, digital rectal exam, and repeated prostate biopsies are performed in patients who are on active surveillance, and active therapy is started when predefined threshold values are reached. This concept makes it possible to offer curative treatment to individuals who are at high risk for disease progression as indicated by active surveillance parameters.
Epidemiological Data From Germany
More than 58 000 men are given the diagnosis of prostate cancer in Germany each year . This figure corresponds to 25.4% of the new cancer diagnoses in men prostate cancer is thus the most common form of cancer in men. The mean age at diagnosis is 69 years. The annual incidence is 720 per 100 000 per year in the 70-to-74-year-old age group and peaks at approximately 750 per 100 000 per year in men aged 75 to 79. The relative 5-year survival rate of patients with prostate cancer is currently 87% . These epidemiological figures reveal the importance of an appropriate choice of initial therapy.
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Staging Of Prostate Cancer
Doctors will use the results of your prostate examination, biopsy and scans to identify the stage of your prostate cancer .
The stage of the cancer will determine which types of treatments will be necessary.
If prostate cancer is diagnosed at an early stage, the chances of survival are generally good.
$451 Million Spent On Seniors With Gleason Score Of 6 Or Lower
Each year, the diagnosis of prostate cancer in men ages 70 and older led to Medicare costs in excess of $1.2 billion over the ensuing 3 years, the lion’s share of that going toward treatment, the first analysis of its kind has shown.
Switching patients with lower-risk disease from “low value” treatment to conservative approaches such as active surveillance would potentially yield $320 million in savings over that 3-year period, Ronald Chen, MD, MPH, of the University of North Carolina at Chapel Hill, and colleagues reported.
“Elderly patients, especially those with comorbidities, are unlikely to die of prostate cancer or benefit from screening,” Chen’s group wrote in JAMA Oncology. “Reducing detection of localized prostate cancer in elderly patients represents a potential source of significant cost savings for the U.S. Medicare program.”
They noted that among all diagnosed patients with the typically slow-growing disease, the 15-year relative survival runs as high as 95%.
The retrospective study included 49,692 elderly men diagnosed with non-metastatic prostate cancer from 2004 to 2007. The median cost per patient within 3 years of diagnosis was $14,453 , with treatment costs of $10,558 accounting for most of it .
Included in the overall cost of $1.2 billion was $451 million spent on men with a Gleason score of 6 or lower.
Disclosures
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Help Getting Through Cancer Treatment
People with cancer need support and information, no matter what stage of illness they may be in. Knowing all of your options and finding the resources you need will help you make informed decisions about your care.
Whether you are thinking about treatment, getting treatment, or not being treated at all, you can still get supportive care to help with pain or other symptoms. Communicating with your cancer care team is important so you understand your diagnosis, what treatment is recommended, and ways to maintain or improve your quality of life.
Different types of programs and support services may be helpful, and can be an important part of your care. These might include nursing or social work services, financial aid, nutritional advice, rehab, or spiritual help.
The American Cancer Society also has programs and services including rides to treatment, lodging, and more to help you get through treatment. Call our National Cancer Information Center at 1-800-227-2345 and speak with one of our trained specialists.
Comparison Between Definitive And Non
The outcome of the patients with localized prostate cancer was compared between those treated definitively and those treated non-definitively. The 5- and 10-year overall survival rates for the definitively treated group were 78 and 25%, and those for the non-definitively treated group were 58 and 15%, respectively. There was no significant difference between the two groups . Since the mean age of the patients treated non-definitively was higher than those treated definitively , the relative survival rates were calculated for each group. As shown in , the overall survival curves of the patients treated definitively and those treated non-definitively were both in line with the corresponding expected survival curves, and the relative survival rates were similar for both groups .
Overall survival curves for the patients with stage A2-B and the expected survival curves of the age-matched male population: patients treated definitively patients treated non-definitively .
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Treatments For Prostate Cancer
If you have prostate cancer, your healthcare team will create a treatment plan just for you. It will be based on your health and specific information about the cancer. When deciding which treatments to offer for prostate cancer, your healthcare team will consider:
- the type and stage of the cancer
- the grade or Gleason score
- prostate-specific antigen levels
- the risk group
- possible side effects of treatments
- your personal preferences
- your overall health and any existing medical conditions
- your age and life expectancy
- whether you have symptoms
Prostate cancer treatments can seriously affect your quality of life and cause side effects such as erectile dysfunction and incontinence . Many prostate cancers grow slowly and cause no symptoms or problems.
Common Urinary Problems In Elderly Men
These problems are not cancer. Acute prostatitis is an infection of the prostate caused by bacteria. It usually starts all of a sudden. It can cause fever, chills, or pain in the lower back and between the legs. It can cause pain when your aging dad urinates. If your father has these symptoms, see your doctor right away. Antibiotic drugs can kill the bacteria and help him feel better.
Chronic prostatitis is an infection of the prostate that keeps coming back time after time. This problem can be hard to treat. Sometimes, taking antibiotics for a long time may work. Talk with your doctor about other things you can do to help your elderly father feel better.
Benign prostatic hyperplasia, or BPH, is very common in older men. The prostate is enlarged, but it is not cancerous. Over time, an enlarged prostate may press against the urethra, making it hard to urinate. It may cause dribbling after an elder urinates or a need to urinate often, especially at night. Your doctor will do a rectal exam to check for BPH. And your elderly father may need to have special x-rays or scans to check his urethra, prostate, and bladder.
Treatments for BPH include:
Usually, men have surgery only if medicine hasn’t worked. Surgery does not protect against prostate cancer. Regular check-ups are important after BPH surgery. Talk with your doctor about this treatment choice. There are three kinds of surgery. All are done with anesthesia:
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Treating Advanced Prostate Cancer
If the cancer has reached an advanced stage, it’s no longer possible to cure it. But it may be possible to slow its progression, prolong your life and relieve symptoms.
Treatment options include:
- hormone treatment
- chemotherapy
If the cancer has spread to your bones, medicines called bisphosphonates may be used. Bisphosphonates help reduce bone pain and bone loss.
Continuous Versus Intermittent Hormonal Therapy
The disadvantages of continuous androgen withdrawal are its side effects and its cost. In patients over age 70 with asymptomatic prostate cancer, the side effects are very bothersome . Numerous phase II trials have shown that, the longer patients are treated with intermittent androgen withdrawal, the shorter the intervals between treatments become.
The PSA nadir after the initiation of androgen withdrawal is prognostically significant for progression and survival time. A PSA nadir below 0.2 ng/mL is prognostically favorable . The interim evaluation of the phase III trial of the South European Uroncological Group, presented by Calais da Silva et al. at the 2006 ASCO meeting , revealed no difference between continuous and intermittent hormonal therapy with respect to progression. The patients quality of life was better with intermittent treatment, e.g., hot flashes were considerably rarer. In the single randomized phase III trial that has been completed to date involving the treatment of patients with locally advanced or metastatic prostate cancer with goserelin and bicalutamide, the progression-free interval was found to be longer with intermittent than with continuous therapy. These results were presented by Miller et al. at the 2007 ASCO meeting . The side effects were the same in both arms of the trial.
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Demographic Characteristics Of The Patients
Stage, histologic grade, treatment and follow-up period of the patients are shown in . There was no significant difference for the age at diagnosis among the three groups with different clinical stages. A positive correlation was observed between stage and histologic grade . The percentage of non-definitive treatment was higher in more advanced stages.
Design Setting And Participants
This nationwide, population-based, retrospective cohort study uses the Surveillance, Epidemiology, and End Results -Medicare linked database to identify men 70 years or older diagnosed with localized prostate cancer between 2004 and 2007 and to ascertain Medicare costs associated with diagnosis and workup, treatment, follow-up, and morbidity management of the disease. National Medicare costs were estimated using per-person costs, stage-adjusted prostate cancer incidence rates by age from SEER 2007 through 2011, and 2010 Census population estimates by age.
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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:
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A PSA test every 3 to 6 months
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A DRE at least once every year
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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.
Definitions Of Target Volumes And Critical Structures
Indications for seminal vesicle irradiation included positive biopsy, disease invasion by medical imaging, and a calculated risk of > 5% based on Roachs formula. Indications for whole pelvis RT included seminal vesicle involvement identified by medical imaging, a calculated risk of lymph node involvement that was > 15% based on Roachs formula, and high-risk disease. Of the 371 patients meeting these criteria, 324 received WPRT. We did not prescribe WPRT to 39 patients indicated considering their comorbidities. Eight indicated patients did not receive WPRT due to poor performance status.
Following the International Commission on Radiation Units and Measurements 50 recommendations, clinical target volume was delineated on individual axial CT slices in all patients by our radiation oncologist and reviewed by another. For those not receiving WPRT, CTV2 included the prostate and bilateral seminal vesicles. For patients treated with WPRT, the CTV2 consisted of the prostate, bilateral seminal vesicles, and bilateral common iliac, proximal external iliac, hypogastric, and obturator lymph nodes.
CTV1 for patients receiving irradiation of seminal vesicles included the prostate and bilateral seminal vesicles. Otherwise, only prostate and proximal seminal vesicles were included in CTV1.
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Good Prostate Cancer Care
Your MDT will be able to recommend what they feel are the best treatment options, but ultimately the decision is yours.
You should be able to talk with a named specialist nurse about treatment options and possible side effects to help you make a decision.
You should also be told about any clinical trials you may be eligible for.
If you have side effects from treatment, you should be referred to specialist services to help stop or ease these side effects.
If Treatment Does Not Work
Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.
This diagnosis is stressful, and for some people, advanced cancer may be difficult to discuss. However, it is important to have open and honest conversations with your health care team to express your feelings, preferences, and concerns. The health care team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported is extremely important.
People who have advanced cancer and who are expected to live less than 6 months may want to consider hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment, including a hospital bed, can make staying at home a workable option for many families. Learn more about advanced cancer care planning.
After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.
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Considering Complementary And Alternative Methods
You may hear about alternative or complementary methods that your doctor hasnt mentioned to treat your cancer or relieve symptoms. These methods can include vitamins, herbs, and special diets, or other methods such as acupuncture or massage, to name a few.
Complementary methods refer to treatments that are used along with your regular medical care. Alternative treatments are used instead of a doctors medical treatment. Although some of these methods might be helpful in relieving symptoms or helping you feel better, many have not been proven to work. Some might even be harmful.
Be sure to talk to your cancer care team about any method you are thinking about using. They can help you learn what is known about the method, which can help you make an informed decision.
Treating Prostate Cancer In Elderly Men
There are many ways to treat prostate cancer. The choice of treatment depends on the stage of the cancer . It also depends on your father’s age and general health. How you feel about the benefits and side effects of the various treatments is also very important.
The following are three standard treatment choices for cancer that has not spread beyond the prostate:
In addition, after radiation therapy, some men are treated with hormone therapy. This is used when chances are high that the cancer will come back. Hormone therapy is also used for prostate cancer that has spread beyond the prostate. Side effects of hormone treatments include hot flashes, loss of sexual function, and loss of desire for sex.
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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.