International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationSurvival Following Radiation and Androgen Suppression Therapy for Prostate Cancer in Healthy Older Men: Implications for Screening Recommendations
Introduction
In August 2008, the U.S. Preventive Services Task force recommended that men over the age of 75 should not be screened for prostate cancer (1). The rationale was that the benefit of screening, if any, is likely to be small in this older age group with a typical life expectancy of less than 10 years, and given the risk of physical and psychological harm due to screening and overtreatment, it was concluded that “there is at least moderate certainty that the harms of screening for prostate cancer in men age 75 years or older outweigh the benefits.”
The task force recommendation for when to stop screening is based on age and does not take into account the patient's overall health status. However, it is known that at any given age, patients with multiple medical comorbidities will have a shorter life expectancy than those who are generally healthy and have no or few medical comorbidities 2, 3, 4. Therefore, it is possible that there are many men older than 75 who are healthy enough and have relatively long life expectancies who may benefit from screening as younger men would.
To provide some evidence for this hypothesis, we performed a postrandomization analysis of a randomized trial (DFCI 95-096) that had assigned 206 men with intermediate- to high-risk prostate cancer to treatment with either external beam radiation (RT) alone or RT plus androgen suppression therapy (AST) and found that RT+AST decreased all-cause mortality (ACM) (5). The goal of the current study was to determine whether older healthy men also derived a survival benefit from aggressive treatment, which would raise the possibility that healthy older men should also be given the same opportunity to be screened and diagnosed as younger men.
Section snippets
Patient population and treatment
At academic (Dana-Farber Cancer Institute, Brigham and Women's Hospital, and Beth Israel Deaconess Medical Center) and community-based (St Anne's Hospital, Metrowest Medical Center, and Suburban Oncology Center) medical centers in Massachusetts, between December 1, 1995, and April 15, 2001, 206 men (median age, 72.5 years; range, 49–82 years) with 1992 American Joint Commission on Cancer (AJCC) Clinical Stage T1b to T2bN0M0 adenocarcinoma of the prostate and at least one unfavorable prognostic
Baseline characteristics stratified by comorbidity
Of the 206 participants, there were 157 men with mild or no comorbidity (healthy men), and 49 men with moderate to severe comorbidity. The patient baseline characteristics, stratified by comorbidity, are shown in Table 1. The median age of the healthy men was 72.4 years, whereas the median age for those with moderate or severe comorbidity was 73 years. For those older than the respective medians, baseline characteristics including T-category, PSA, Gleason score, and age, were not significantly
Discussion
In this study, we performed a postrandomization analysis and found that among older healthy men, aggressive treatment of prostate cancer with RT+AST seemed to decrease ACM compared with treatment with RT alone. Conversely, we found that among older men with moderate or severe comorbidity, the addition of 6 months of AST to RT did not reduce ACM.
The clinical implications of these findings are threefold. First, they imply that a patient's level of comorbidity can affect whether he derives a
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Irradiation of localized prostate cancer in the elderly: A systematic literature review
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2022, Clinical and Translational Radiation OncologyCitation Excerpt :HDR-BT boost was mostly delivered in a single fraction of 14/15 Gy (79%), with median V100 and median D90 of 98 % [79–100] and 110% [78–140] respectively (Table 1 & e-Table Supplementary data). ADT was used in 302 pts (79.4%; ≤ 70 y (73.4%) vs. > 70 y (84.7%); p = 0.01) for a median time of 18 months [3 –41] (IR: 6 months [5 –33]; HR: 19 months [3 –41]). With a median follow-up (MFU) of 73.6 months [67.4 – 83.4] for the whole cohort, 5-year oncological outcomes were: 5-y bRFS: 88% [CI95%: 85–92], 5-y lRFS: 97% [CI95%: 95–99], 5-y rRFS: 99% [CI95%: 98 – 100] and 5-y mRFS: 96% [CI95%: 94–98].
A systematic review of randomised controlled trials of radiotherapy for localised prostate cancer
2015, European Journal of CancerHormone and Radiotherapy versus Hormone or Radiotherapy Alone for Non-metastatic Prostate Cancer: A Systematic Review with Meta-analyses
2014, Clinical OncologyCitation Excerpt :Figure 4 shows the results of all the individual studies (data used from the 6 month hormone treatment group from TROG 96.01 [17,18]) and their meta-analysis, which showed that biochemical disease-free survival was longer in the patients who received combination therapy compared with those receiving only radiotherapy (hazard ratio = 1.65; 95% confidence interval 1.48–1.83; P < 0.00001; I2 = 0%). Figure 4 shows the results of the two studies (D'Amico et al. [23–27], L-101 [19] data included for the group receiving 10 months of hormone therapy) that reported this outcome together with their meta-analysis, which all showed that also in the case of biochemical disease-free survival is combination treatment associated with a more favourable outcome than treatment with radiotherapy alone (hazard ratio = 2.53; 95% confidence interval 1.75–3.67; P < 0.00001; I2 = 0%). Although the consistent finding that combination therapy is associated with longer biochemical disease-free survival than radiotherapy treatment alone was confirmed when the results of all the studies that compared radiotherapy alone with combination therapy were meta-analysed, this analysis should be interpreted with caution because there was substantial between-study heterogeneity and the data from the radiotherapy-alone group in L-101 [19] is entered twice as a comparator for the two combination treatment groups (hazard ratio = 1.67; 95% confidence interval 1.54–1.82; P < 0.00001; I2 = 54%).
Low risk prostate cancer in men ≥ 70 years old: To treat or not to treat
2013, Urologic Oncology: Seminars and Original InvestigationsCitation Excerpt :According to the results of one study by Konety et al., older men are less likely to receive curative treatment regardless of comorbidities [6]. Other investigators have demonstrated that healthy older men who receive aggressive treatment for localized CaP in the form of external beam radiation therapy (EBRT) plus androgen suppression have better outcomes than those treated with radiation alone [9]. Furthermore, healthy older men with CaP have been shown to have better overall and CaP-specific survival following radical prostatectomy (RP) [10].
Management of prostate cancer in elderly men
2013, Seminars in Radiation OncologyCitation Excerpt :Adjuvant ADT therapy in addition to EBRT or brachytherapy has been shown to be superior to RT alone in select elderly populations. In a post-hoc analysis of the Dana Farber Cancer Institute (DFCI) randomized trial comparing EBRT plus 6 months of ADT with EBRT alone for intermediate- to high-risk PrCa, combined therapy was associated with a decrease in all-cause mortality from 41% to 17% in older men with no or minimal comorbidity.23 Similarly, in a large retrospective trial of men with high-risk PrCa, brachytherapy plus ADT showed improved PrCa-specific mortality compared with brachytherapy alone in men without active cardiovascular disease.24
Conflict of interest: none.