Survival advantage with surgery for elderly patients with prostate cancer?
| Conclusions This study suggests a survival advantage is associated with active treatment for low- and intermediate-risk prostate cancer in elderly men aged 65 to 80 years. Because observational data cannot completely adjust for potential selection bias and confounding, these results must be validated in randomized controlled trials of alternative management strategies in elderly men with localized prostate cancer. |
An important paper was recently published in JAMA that concluded that men between 65 and 80 may do better with surgery or radiation than with watchful waiting.
The authors did a good job with this observational study. They looked at all men with prostate cancer and compared those who had treatment with radiation or surgery and compared them to men who did not receive therapy for at least 6 months after diagnosis.
They found that there was a 30% lower mortality in the men that had therapy. The authors made an effort to compare the men with regard to other medical conditions and pointed out that without a randomized trial, there may be a selection bias since most urologists counsel men with good 10 year life expectancies to undergo therapy and men with poor life expectancies to have watchful waiting.
This is one study that I can use to help guide patients, but not an absolute decision maker in my opinion.
I reviewed my patients to see how many men I did robotic prostatectomies on. Over my first 200 robotic prostatectomies I operated on 19 men that were 70 or older:
5 were 70
11 were 71-74
1 was 76,78, and 80
I typically counsel them based on their health, the aggressiveness of their cancer and tell these men they will likely be equally cured with surgery or radiation.
12 of the 19 went home in 1 day, 6 in 2 days, and 1 in 3 days. The only medical problem I had was one patient who was re-hospitalized with a pulmonary embolus (blood clot in lung) a few days after going home and did well on blood thinners.
I do feel that these men often have significant BPH symptoms that is greatly helped by surgery. They do seem to have more incontinence in the short run, but they have done well. 9 of the prostates were big (larger than 50 grams), 5 were very big (greater than 75 gms), and 1 was huge (123 grams).
As for continence, 8 of the 15 that I have data on had 1 pad or less incontinence at 1 month, and 8 of 11 had 1 pad or less incontinence at 3 months, and 7 of 7 were in 1 pad or less at 6 months.
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Comments
Can you give us the results from your robotic patients aged 65 thru 69 years old. Thanks.
Posted by: alan newman | December 15, 2006 9:02 PM
Reviewing the 65-69 year old men:
36 total patients.
28 went home in 1 day (28 of the last 32 went home in 1 day).
6 in 2 days.
2 in 3 days.
Some of these men were earlier on when we used to routinely keep people in the hospital for 2 days (4 of them, 2 2 days and 2 3 days).
I haven't had any major complications in these patients.
18 of the prostates were big (larger than 50 grams), 10 were very big (greater than 75 gms), and 5 were huge (100 to 175 gms). It is interesting that these men have larger prostates than the older men. I think the main reason why is that men with larger prostates are more difficult and have more short term urinary problems. Men over 70 likely opt for radiation with larger prostates. I have also operated on several of these patients that found me after other robotic centers thought their prostates were too big which would lead to a referral bias.
As for continence, 16 of the 27 that I have data on had 1 pad or less incontinence at 1 month, and 15 of 21 had 1 pad or less incontinence at 3 months, and 13 of 14 were in 1 pad or less at 6 months (10 in 0 pads).
I think the urinary numbers are skewed by the larger prostates in this group.
6 of these patients are having intercourse, which doesn't sound like much, but I do not have a good denominator for this. Only 6 had normal erection and both nerves spared, 2 had normal erections and 1 nerve spared. I also don't have all the followup for these guys and not that many are at 1 year yet.
Posted by: Domenico Savatta, MD | December 16, 2006 9:51 AM
Way back as a medical student I remember overhearing urology faculty discussing the age at which they would no longer consider operating for prostate cancer and at that time some argued for 65, others 70. Since then 70 has become more generally accepted and some are using a cutoff of 75. Given the slow growth of most prostate cancers many surgeons say that a patient should have a life expectancy of 10 years to be considered for surgery. Otherwise something else is likely to be the cause of death and prostate cancer treatment would be of no benefit. If we had a crystal ball, patient selection for treatment could be easy!
Average life expectancy for a male (all races) has gone from 70 in 1980 to about 75 now. But that isn't the number we should be looking at. The life expectancy of a male age 75 today is probably close to 11 years. And that is the average. A thin, healthy, non-smoker might expect to live 15 or more years.
http://www.cdc.gov/nchs/data/hus/hus05.pdf#027
So what to do about prostate cancer in those patients 70+ or even 75+ years of age? This paper suggests that there may indeed be a benefit to treatment at an age that often is offered only watchful waiting or hormonal control. If we can operate with reduced morbidity, as I believe we can with the da Vinci, then I think the argument for treatment in older patients becomes stronger. As the article pointed out there are several randomized trials that will be reported out over the next 3-5 years that will give us better information, but in an imperfect world this article may give us all some guidance.
Posted by: Dale Russell MD | December 17, 2006 8:29 PM
I seem to be getting more of these older patients asking about robotic prostatectomy. I think this is something we are going to have to re-think. I pondered this recently in my new blog, http://www.UroCanswer.com
http://urocanswer.com/?p=6
In fact, i've even had elderly patients come for consultation, without a diagnosis of prostate cancer. But, they want their prostate removed robotically.. pre-emptively. (almost like the gallbladder?!)
Drs. Savatta & Russell.. Would either of you ever consider doing a robotic prostatectomy for non-cancer indications, like BPH alone?
An interesting thought...
-Dr. Jay Yew
Posted by: Jay Yew, MD | August 28, 2007 3:24 AM