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Feb 16,2009
Lifelong Health: Prostate cancer treatment inconclusive for older men
by Dr. David Lipschitz

Prostate cancer affects millions of American men, with one in six being diagnosed with the disease during his life. But, thanks to early detection and sophisticated therapy, only one in 35 will die from it.

Awareness of prostate cancer has risen dramatically in the last decade, and more than ever before, average American men are taking steps to detect the disease. Unfortunately, for the medical community, determining the appropriate screening and treatment process for prostate cancer has become highly contentious. In recent weeks, a new published report shows that for older men, aggressive treatment may not be warranted. What's more, the cancer may not need treatment at all.

At a recent genitourinary cancer conference, Dr. Grace Lu-Yao of the Robert Wood Johnson Medical School in New Jersey reported that for older adults, therapy does not necessarily lead to longer life expectancy. Researchers followed 9,000 older men (average age, 77) who were diagnosed with localized prostate cancer, but elected not to receive treatment. A decade later, less than 10 percent had died from the disease. And the average life expectancy of those who did receive treatment was more than 10 years.

The bottom line: Treatment or not, the end result was very similar. Based upon this observation, the researchers now recommend older men to not rush to treatment if prostate cancer is diagnosed.

Despite all this information, many men continue to screen for prostate cancer well into their 80s, having an annual digital rectal examination to evaluate the prostate and measuring the "prostate-specific antigen," or PSA level, in the blood. If a nodule is felt on the prostate or the PSA is elevated, an urologist biopsies the prostate to identify possible cancer. If cancer is diagnosed, it is treated with surgery, radiotherapy, or both. Many are treated with medications to eradicate circulating testosterone to slow the rate of growth of the cancer.

Unfortunately, treatment is not without complications and can greatly impair quality of life, especially for older men. Urinary incontinence and erectile dysfunction are quite common. Irradiation can lead to chronic inflammation of the bladder and the bowel, and the anti-testosterone therapy causes loss of muscle, fatigue and deconditioning. Additionally, it can interfere with memory. When therapy neither prolongs nor improves the quality of life, it is time to discuss other options.

Knowing when and how to be screened and treated for prostate cancer can be quite confusing. The traditional screening tools of PSA testing and digital rectal exams are controversial. Unfortunately, the PSA test is riddled with problems of false positives. For 12 with elevated PSAs, biopsies identify only three with prostate cancer. And even when prostate cancer is diagnosed, aggressive therapy may not be warranted.

The U.S. Preventive Services Task Force, the definitive screening group for preventing disease, states that "the evidence is insufficient to recommend for or against routine screening for prostate cancer using PSA testing or digital rectal examination." With the many mixed messages on screening and treatment, it is important to be an empowered consumer of health care at every age.

For all of my male patients, these are my recommendations: Between the ages of 50 and 70, a PSA and digital rectal examination should be done annually. If you have a strong family history of cancer, or your ethnicity is black, you may need to be screened from age 40 and on. If the PSA is only modestly elevated, the test should be repeated three and six months later. If no real change is noted, then further aggressive care is not warranted. If the PSA rises rapidly, further testing must be done.

After the age of 75, I do not recommend PSA measurements, but the prostate should be examined by a digital rectal examination. Only if a large nodule is felt should further work-up be considered. And if you are determined to have a PSA, see an urologist only if the value is very high or rises rapidly.

In the near future, newer and more sensitive tests should become available that will not only identify prostate cancer, but also recognize those that are aggressive and warrant treatment. Until that time, be wary of treatment if the benefits are not definite.

Dr. David Lipschitz is the author of the book "Breaking the Rules of Aging."

Copyright 2009 Creators Syndicate, Inc.
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