We evaluated clinical outcomes in elderly subjects newly diagnosed with an early stage prostate cancer.  We compared quality of life and mortality outcomes between men undergoing aggressive treatment (radical prostatectomy or radiation therapy) and those who were conservatively managed (androgen deprivation therapy or watchful waiting).  Subjects were participants in the population-based Prostate Cancer Outcomes Study who were age 75 to 84 at the time of diagnosis.  We used surveys to collect baseline and follow-up information on quality of life measures, including urinary, sexual, and bowel function, as well as general health.  We also used vital statistics data to determine overall and prostate-cancer specific mortality.  We used a propensity score analysis to adjust for selection bias in undergoing aggressive treatment--these men were generally younger and healthier than men who were conservatively managed.   We were able to follow 344 subjects for 2 years.  We found that aggressively treated men were significantly more likely to report daily urinary leakage (odds ratio [OR] = 2.9, 95% confidence interval [CI] 1.2-7.0), and to be bothered by urinary problems (OR = 5.1, 95% CI 1.3-9.1) and sexual problems (OR = 2.8, 95% CI 1.2-6.3).  The adjusted overall mortality rate was lower in men receiving aggressive treatment (hazard ratio [HR] = 0.67, 95% CI 0.44-1.03).  The adjusted disease-specific mortality rate was also lower in men receiving aggressive treatment, HR = 0.43, 95% CI 0.15-1.28.  However, the latter difference was not statistically different and the absolute disease-specific survival difference was only 6%.

We concluded that aggressive treatment was associated with declines in disease-specific quality of life measures for older men with early-stage cancer.  Although mortality was less with aggressive treatment, this was likely confounded by selection bias that could not be adequately adjusted by our statistical analysis.  To put our findings in perspective, prostate cancer is often slow-growing and most men diagnosed with the disease die from other causes.  There is currently no evidence that men older than 65 will benefit from aggressive treatment for early-stage cancer, and no evidence that screening improves survival or reduces disease complications for men of any age.   However, there is a substantially increased risk of complications with aggressive treatment for older men and, as we demonstrated in our study, declines in quality of life.   Given that most early-stage cancers are detected through screening, this suggests that  primary care providers should be very cautious about offering prostate cancer screening to their elderly patients.  If screening is eventually proven to be effective in randomized trials, the benefits are likely to be seen for only the healthiest older patients--those with at least a 10- to 15-year life expectancy.  Providers need to educate their elderly patients about the uncertain benefits and potential harms of finding and aggressively treating an early-stage prostate cancer.

 

Bibliographical reference:

Hoffman RM et al.: "Health outcomes in older men with localized prostate cancer: results from the Prostate Cancer Outcomes Study",
Am J Med. 2006 May;119(5):418-25

 

Richard M. Hoffman

New Mexico VA Health Care System, Albuquerque, NM, USA