Large Study Shows
Elderly and African-American Men at Increased Risk of Having Aggressive
This cancer only found
by PSA testing but not known if early detection and treatment can be
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
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
All aggressive therapies for prostate cancer have
significant side effects and perhaps these data make an argument for
active surveillance (avoiding aggressive treatment and closely following
the cancer) in certain cases
"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
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
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.
two schemes commonly used to stage prostate cancer. The most
common is promulgated by the American Joint Committee on Cancer,
and is known
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
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
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
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.
included Lois B. Travis, Edward M. Messing, Ollivier Hyrien, Rui Chen,
Michael T. Milano, Ralph Anthony Brasacchio and Yuhchyau Chen
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.
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,
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
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.
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