Radical
Prostatectomy for octogenarians: How old is too
old?
Newswise — There is no
defined recommendation for when to stop prostate
cancer (CaP) screening, except when the life
expectancy decreases to less than 10 years. In
the United States, it is relatively uncommon for
a man to undergo radical prostatectomy (RP) as
definitive therapy beyond the age of 75 years.
Yet life expectancy for a
man in his upper 70s is about 10 years. Some men
older than age 80 are fit and demand definitive
therapy in the form of RP. Dr. Thompson and
colleagues at the Mayo Clinic, Rochester MN
identified a group of 19 men over age 80 who
underwent RP and report on their outcomes in the
November issue of Urology.
From 1986 to 2003, 13,154
men were treated with RP at the Mayo Clinic. Of
these, 19 (0.4%) were 80 years or older at
surgery.
Overall, their database revealed that
876 men were diagnosed with localized CaP during
this time period. The clinical, pathological,
oncologic and functional outcomes were
retrospectively assessed.
Mean patient age was 81
years, median pre-operative PSA was 10.2ng/ml,
all men had clinical T1-2 disease and no patient
had known metastasis.
The mean American Society
of Anesthesiologists score was 2.4. Records
indicated that 5 patients specifically demanded
RP and were opposed to age discrimination and in
addition, 5 patients were physicians. On
pathology, 13 (68%) had organ-confined disease,
2 had pT3a, 4 had pT3b, and 3 had a positive
surgical margin. Gleason score was 7 or greater
in 11 men (58%) and all had a negative pelvic lymphadenectomy.
While no peri-operative
complications occurred and 3 received a blood
transfusion, but these men all had surgery prior
to 1992. Median follow-up was 10.5 years and no
patient died within the first year after RP.
Three men died less than 10 years after RP and
no patient died from CaP. Ten patients survived
more than 10 years, with 7 alive at a mean
follow-up of 12.8 years. No overall survival
difference was found comparing the survival of
these patients (79%) with patients 60-69 years
old (84%) and 70-79 years olds (75%) from the
Mayo database during the same time period. Four
men experienced a biochemical recurrence of PSA
level 0.4ng/ml or greater. One patient with a
positive surgical margin received adjuvant
radiotherapy.
Regarding functional
outcomes, one year after RP, 14 patients (74%)
were using less than 1 pad/day for incontinence,
2 used 1 pad/day, 2 needed 2 pads/day or more
and 1 required an artificial urinary sphincter.
Nerve sparing was not performed in these men.
To the authors' knowledge,
this is the first report of RP in octogenarians.
While their data supports that RP can be
performed safely in these men with good
outcomes, it does not answer the question
whether it is necessary. Other non-definitive
modalities such as active surveillance and
delayed androgen deprivation might give
comparable results but were not compared in this
study.
Thompson RH, Slezak JM,
Webster WS, Lieber MM
Urology
2006; 685(5):1042-45
By Christopher P. Evans, MD
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