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Health & Medicine for Senior Citizens

Large Study Shows Elderly and African-American Men at Increased Risk of Having Aggressive Prostate Cancer

This cancer only found by PSA testing but not known if early detection and treatment can be beneficial

Feb. 13, 2013 – A significant number of elderly men (age 75 and older) and African-Americans may have an aggressive form of prostate cancer that is only diagnosed by PSA testing, according to a large retrospective study. These men have high to intermediate risk prostate cancer staged as T1cN0M0.

T1cN0M0 stage prostate cancer can only be detected through PSA testing, as the tumor causes no symptoms, cannot be felt during a physical exam and is not seen during imaging. The study indicates PSA testing may be warranted but more research is needed to verify that early detection and intervention is beneficial for those patients.

"If we stop PSA screening altogether, we have no other way to detect this form of prostate cancer sufficiently early to have the best chance of helping this group of high-risk patients," said lead author Hong Zhang, MD, PhD, Associate Professor of Radiation Oncology at the University of Rochester.

 

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"The findings of this study will help physicians and certain patients make more informed decisions on whether or not they want to proceed with PSA testing, although more research (and longer follow-up) is needed to determine the effect of early detection and intervention on outcome in these high-risk patients."

There is convincing evidence that a substantial proportion of men who have asymptomatic, PSA-detected prostate cancer will remain asymptomatic throughout their life and have good outcomes even without treatment.

Given the harms associated with "over treatment," the U.S. Preventative Services Task Force (USPSTF) recommended against PSA screening for men in the general U.S. population. While at any given time, the percentage of all men who have either intermediate- or high-risk prostate cancer diagnosed exclusively because of PSA is small (about 1 in 8000 men), for those patients, early diagnosis and treatment might be life-saving, particularly if they have a life expectancy of more than 10 years.

About T1cN0M0 Staging

Prostate cancer staging is the process by which physicians categorize the risk of cancer having spread beyond the prostate, or equivalently, the probability of being cured with local therapies such as surgery or radiation. Once patients are placed in prognostic categories, this information can contribute to the selection of an optimal approach to treatment.

There are two schemes commonly used to stage prostate cancer. The most common is promulgated by the American Joint Committee on Cancer, and is known as the TNM system, which evaluates the size of the tumor, the extent of involved lymph nodes, and any metastasis (distant spread) and also takes into account cancer grade.

T1: tumor present, but not detectable clinically or with imaging
      T1c: tumor was found in a needle biopsy performed due to an elevated serum PSA
N0: there has been no spread to the regional lymph nodes
M0: there is no distant metastasis

See Prostate cancer staging, Wikipedia

Among the 70,345 U.S. men with T1cN0M0 prostate cancer evaluated in the study, 47.6 percent, 35.9 percent, and 16.5 percent had low-, intermediate-, and high-risk disease, respectively.

Men older than 75 years accounted for 40 percent of all patients with high-risk disease. Patients aged 75 and older had a 4.4-fold higher probability of developing intermediate-risk disease and 9.4-fold higher probability of developing high-risk disease compared with patients younger than 50.

In addition, African Americans of all ages had a 1.8-fold higher likelihood of developing high-risk disease compared with white men.

The present study identifies two subpopulations of patients – men older than 75 years and African Americans – in which the potential benefit of PSA screening may need further investigation. The population-based study included 70,345 men with AJCC stage T1cN0M0 disease.

Prior research has shown that over 50 percent of deaths due to prostate cancer occur in men initially diagnosed when older than 75 years and that African Americans of all ages are twice as likely to die of prostate cancer compared with other men in the United States. The USPSTF did not have enough evidence to assess the ratio of potential benefits and harms of PSA screening in the African American population specifically.

Since the release of the USPSTF recommendations, there has been a decline in PSA screening for all age groups. ASCO issued guidance in 2012 recommending that physicians discuss the benefits and risks of PSA screening with their asymptomatic male patients who have a life expectancy of more than 10 years.

ASCO recommended against screening for men expected to live less than 10 years because the harms appear to outweigh potential benefits. Physicians should therefore assess life expectancy before offering PSA screening to their elderly patients. ASCO's decision aid for patients explains available data and important considerations about PSA testing in lay language.

The average 10-year survival rates are 91 percent for low-risk, 84 percent for intermediate-risk and 80 percent for high-risk disease.

The risk levels are defined based on clinical stage, PSA level and Gleason score. Patients have different treatment options depending on the aggressiveness of their cancer. For example, while active surveillance is appropriate for low-risk disease, intermediate- and high-risk patients are typically offered radiation, surgery, and/or androgen deprivation therapy.

Other authors included Lois B. Travis, Edward M. Messing, Ollivier Hyrien, Rui Chen, Michael T. Milano, Ralph Anthony Brasacchio and Yuhchyau Chen

Background

The U.S. Preventive Services Task Force (USPSTF) recently recommended against prostate-specific antigen (PSA)-based screening for prostate cancer. This recommendation has heightened the debate about risks and benefits of prostate cancer screening, and underscored our limited understanding of PSA-detected prostate cancer. The purpose of this study was to determine the frequency of various risks of prostate cancer based on patient characteristics and PSA levels.

Methods

This population-based study used the Surveillance, Epidemiology, and End Results (SEER) program to identify men with AJCC stage T1cN0M0 disease diagnosed between 1/2004 and 12/2008. Multivariate logistic regression was conducted to model the probability of developing low (PSA <10 mg/L and Gleason score ≤6), intermediate (PSA between 10 mg/L to 20 mg/L and/or Gleason score 7), and high risk diseases (PSA ≥20 mg/L, and/or Gleason score ≥8). Results:

A total of 70,345 men with PSA-detected T1cN0M0 prostate cancer were evaluated. Among them, 47.6%, 35.9% and16.5% had low, intermediate, or high risk disease, respectively.

Odds ratios (OR) of having intermediate or high risk disease in patients ≥75 years old were 4.47 (95% confidence interval (CI) 3.81 to 5.26, p<0.01) and 9.39 (95% CI 7.25 to 12.16, p<0.01), respectively, when compared with patients aged <50.

Also, black men had increased ORs for intermediate and high risk disease compared with white men (OR 1.50, 95% CI 1.42 to 1.58, p<0.01 for intermediate risk disease; OR 1.84, 95% CI 1.72 to 19.97, p<0.01 for high risk disease).

While men aged >75 accounted for 11.8% of the population at risk, they accounted for 24.3% of intermediate and 26.1% of high risk disease.

Links to More Archived Stories on Prostate Cancer

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Interpretation of PSA Tests May Be More Meaningful with DNA Study

May reduce risk of men being treated for prostate cancer unnecessarily

Oct. 30, 2012

Pricey New Prostate Cancer Proton Therapy Raises Questions About Safety, Cost

Proton therapy targets more precisely, should minimize damage to nerves and tissue; hope is it translates into fewer side effects, but has become center of intense debate

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Contrast-Enhanced Ultrasound Detects High-Grade Prostate Cancer Using Less Biopsies

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Oct. 1, 2012

Prostate Cancer Survival Rates Improved After Introduction of PSA Screening

Growing evidence that questions U.S. Preventative Services Task Force recommendation against PSA screening in all men - Aug. 23, 2012

No PSA Testing May Triple Cases of Advanced Prostate Cancer, Spread

Data very clear: not doing PSA will result in many men with far more advanced prostate cancer spread to other parts of the body

July 30, 2012

Debate About Recommendation Against PSA Test for Prostate Cancer to Continue

The recommendation by U.S. Preventive Services Task Force against PSA screening for men of any age for prostate cancer stirs swirl of controversy: says special report in NCI Cancer Bulletin

By Carmen Phillips, National Cancer Institute - June 5, 2012

Four New Drugs Will Change Prostate Cancer Care, Colorado Expert Says

Hope this will lead to making prostate cancer a disease a patient is more likely to die with than from

By Garth Sundem - Feb. 16, 2012

Researchers Find Possibility of Heart Disease Causing Prostate Cancer

Duke researchers find evidence linking prostate cancer and coronary artery disease - Feb. 8, 2012

Why Observing Prostate Cancer Gaining Ground On Surgery: NIH Panel Says Not Cancer

‘Some think these tumors should be rebranded as something else, such as idle tumors’

By Richard Knox, NPR’s Shots blog - Dec. 9, 2011

Delay of Treatment for Low-Risk Prostate Cancer Gets Nod from NIH Panel

Recommends active monitoring but details of strategies not determined, Dec. 8, 2011

Cardiovascular Deaths Not Linked with ADT for Prostate Cancer but Lower All- Death Risk May Be

Study should be 'generally reassuring' to most men with unfavorable-risk prostate cancer considering ADT, because it was associated with improved survival  - Dec. 7, 2011

Prostate Cancer Patients Considering Suicide May Find Help in New Concept

Patients who have these negative thoughts before surgery are more likely to have a lower perceived quality of life 3 months afterwards

Oct. 31, 2011

Influential Panel Giving Thumbs Down To Routine PSA Test for Prostate Cancer

See links to other comments and reports on this recommendation

By Scott Hensley, NPR News, Oct. 10, 2011

New Models Predict Likelihood of Erectile Function Return After Prostate Cancer Treatment

Problem still there but it helps men make better informed decisions with realistic expectations - watch video report

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New Surgery-Free Treatment for Enlarged Prostate Avoids Sexual Dysfunction

Prostatic artery embolization as effective as popular TURP surgical method; more than half of senior men have enlarged prostate; also silodosin a new treatment for prostatitis

May 18, 2011

Ten Ways to Improve Communications, Make Better Decisions About Your Cancer Care

Michigan researchers outline how to improve communication about the risk

Sept. 20, 2011

Concern Is Growing That the Elderly Get Too Many Medical Tests; Little Benefit

Growing skepticism about widespread, routine screening for cancer and other ailments of people in their 70s, 80s and 90s

By Sandra G. Boodman, Kaiser Health News

Sept. 13, 2011

Prostate Cancer Patients Live Much Longer with Hormone Therapy Added to Radiation

Larger graphs of prostate cancer cases and deaths 1987-2007 below story

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July 15, 2011

Medicare Bites Bullet to Cover Expensive Provenge, Prostate Cancer Drug for Bad Cases

CMS also to continue expensive breast cancer drug, Avastin; Sipuleucel-T activates immune system to defend against prostate cancer; first approved autologus cellular immunotherapy

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Cancer Death Rates Continue Decline That Began in Early 1930s Says Cancer Society

Cancer Statistics 2011 shows among men the reduction in lung, prostate, and colorectal cancers is nearly 80% of decline; among women, almost 60% of decrease in breast and colorectal - see chances of seniors getting cancer - June 17, 2011

Drug Approved to Treat Nail Fungus Found to Delay Chemo in Advanced Prostate Cancer

Itraconzole slows prostate cancer progression but has potential of serious side effects - June 3, 2011

Rising PSA Levels May Sometimes Lead to Negative Biopsies But Usually Means Cancer

News study shows nearly 70 percent with rising PSA eventually get prostate cancer - May 18, 2011

 

 

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