Radiation Therapy in the Management of Low and Intermediate Risk Prostate Cancer in the Geriatric Population

Add to Favorites
Collapse All

Radiation Therapy in the Management of Low and Intermediate Risk Prostate Cancer in the Geriatric Population - #49

Take Quiz

Understand the course of treatment for patients with low and intermediate risk prostate cancer.

Assessment

Treatment decisions for men who present with low to intermediate risk prostate cancer need to consider risk of morbidity and mortality of the disease, morbidity of treatment, and patient life expectancy based on co-morbid conditions and geriatric assessments.

  • Intermediate risk disease and life expectancy greater than 10 years, treatment with either
  1. Prostatectomy or
  2. Definitive radiation therapy with either external beam irradiation or brachytherapy as the preferred treatment

Primary androgen depravation therapy in this patient population is discouraged.

  • Low and intermediate risk disease and a life expectancy of less than 10 years, the preferred treatment is active surveillance or observation
    • One algorithm for active surveillance suggests PSA and digital rectal exam every 3 months for the first two years, then every 6 months if the PSA is stable.
    • Biopsy should be repeated 12 months after diagnosis, and then every 3-5 years until age 80.
    • Transition to definitive therapy include detection of Gleason 7 disease or higher
    • increased volume of disease based on greater number of biopsy cores involved or greater percentage of tissue involvement, or PSA doubling time <3 years.

Context

Prostate cancer risk increases with age and balancing the risks of treatment with the risks of disease progression presents challenges for providers treating patients with this disease.

Action

Determine best course of treatment for patients with low and intermediate risk prostate cancer

Incidence / Prevalence

Increasing age is a risk for the development of prostate cancer. Most cases occur in men over age 65 and prostate cancer deaths occur disproportionately in the elderly, owing to the long natural history of the disease.

Underlying Sciences

Albertsen et.al.  published outcomes of a cohort of patients with clinically localized prostate cancer diagnosed between 1971 through 1984. None of the patients were treated with definitive therapy and were either observed or treated with androgen depravation.

Patients diagnosed at ages 65-75 with Gleason 6 disease, the risk of prostate cancer mortality was less than 20% over a 10 year time period, while the risk of all-cause mortality was 50-70% with variation in age

Patients with Gleason 7 disease, the risk of prostate cancer mortality over 10 years jumped to 30-40%

However, data from the SEER database suggests that co-morbidities may provide a better tool to evaluate and balance the risk of prostate cancer related mortality with other competing risks for mortality. The society for geriatric oncology has recommended that healthy geriatric patients be treated the same as their younger counterparts. Patients with mild comorbidities should be treated similarly with the exception of prostatectomy.

Prostatectomy over age 70 may have a higher risk of complications related to anastamotic stricture, urinary incontinence and sexual dysfunction compared with younger patients. Some series have suggested that the complication rates from radiotherapy in older men are comparable to rates in younger men. This has led some to suggest definitive radiation therapy as the treatment modality of choice in this age group.

Science Principles

Impaired homeostasis
Post-mitotic tissue and age related degeneration

Objectives

Describe the role of radiation therapy in the management of Low and Intermediate risk prostate cancer for geriatric patients

Keywords/Tags

References

Ries, LAG, Melbert, D, Krapcho, M, et al. SEER Cancer Statistics Review, 1975–2005. Bethesda, MD: National Cancer Institute, 2008. Available at: http://seer.cancer.gov/csr/1975-2005/

NCCN guidelines on prostate cancer, version 2.2014

Klotz L  Semin Radiat Oncol 2008 19:2-6

Thompson I, Thrasher JB, Aus G, et.al. J of Urol  2007 177:2106-2131

Albertsen PC, Hanley JA, Fine J. JAMA 2005 293(17): 2095-2101

Daskivich TJ, Fan KH, Koyama T, et.al. Ann Intern Med 2013;158(10):709-718

Droz JP, Balducci L, Bolla M, et.al.  Brit J of Urol International 2010  106:462-469

Kundu SD, Roehl KA, Eggener SE  J Urol 2004  172:2227-2231

Mohamad BA, Marszalek M, Brossner C  Eur Urol 2007:684-689

This GFF ___ my competence in geriatrics.

Authors

Adam Currey, MD, Colleen Lawton, MD, and Steve Denson, MD

Author Affiliation

Medical College of Wisconsin, Milwaukee WI

Copyright

Collapse All
Report a problem about this Fast Fact