Mayo Clinic Cancer Center researchers have found that a radical prostatectomy can be a viable option for select octogenarian patients. The findings, which run counter the conventional practice of generally avoiding surgeries for individuals over 80 years old solely based on age, are available today in Urology.
"Increased life expectancy and generally higher levels of wellness, as well as safer forms of anesthesia and less-invasive surgical techniques, have made it possible for older adults to safely and effectively have surgeries traditionally not offered over a certain age," says Michael Lieber, M.D., Mayo Clinic urologist and the study's senior investigator. "We didn't think that using age as the deciding factor was a valid argument for not performing a radical prostatectomy, and we proved that it is a safe option for some men."
One in six men will eventually be diagnosed with prostate cancer, reports the American Cancer Society, and more than 27,000 men will die from prostate cancer this year in the United States. A variety of treatment options exist for this traditionally slow-growing cancer, including hormone therapy, chemotherapy, radiation therapy, cryotherapy, surgery and expectant management ("watchful waiting"). JAMA reported in 2000 that urologists typically offer a radical prostatectomy to patients with more than 10 years of life expectancy, and do not offer this surgical option to patients older than age 70 to 75. Another study, published in The New England Journal of Medicine in 2005, showed that radical prostatectomy significantly reduces overall mortality, local disease progression, and distant metastases; and is associated with less hormone treatment and palliative radiation.
In the Mayo study, Dr. Lieber's team reviewed records for the 19 patients age 80 or older who underwent radical prostatectomy at Mayo Clinic from 1986 to 2003. They found that while reasons for the radical prostatectomy varied, usually the patients requested or even demanded the surgery. At the time of surgery, the average patient age was 81 (range was 80 to 84), the average prostate-specific antigen (PSA) level was 10.2 nanograms per milliliter (normal is 0 to 4 ng/ml), and the average American Society of Anesthesiologists score (relates general health and risk of death) was 2.4 out of five (worst).
Thirteen had pathological stage pT3 (pT4 being the worst) disease or a Gleason score (tumor aggressiveness measurement system) of seven or more (out of 10). "These were patients with very aggressive forms of prostate cancer," says R. Houston Thompson, M.D., the study's primary author. "Had our surgeons not removed the cancer, risk of death or need for palliative care (radiation, hormones, etc.) certainly could have become an issue."
The researchers say the decision to perform a radical prostatectomy for each man was reasonable, and the data agree. Of the 19 patients, 14 remained continent, none died within a year of surgery or from prostate cancer, and the 10-year survival rate was similar to that observed in healthy patients 60 to 79 years old undergoing a radical prostatectomy. Only three of the 19 died from any cause within 10 years of the surgery.
"Aging is a highly individualized process," says Dr. Lieber. "Decisions should be made on a case-by-case basis, but we feel surgery can be offered to very healthy, active octogenarians with localized prostate cancer with satisfactory results."