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Prostate Cancer in Older Adults: Risk of Clinically Meaningful Disease, the Role of Screening and Special Considerations

  • Geriatric Oncology (L Balducci, Section Editor)
  • Published:
Current Oncology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Prostate cancer is the second most common cancer in men in the USA and several studies suggest more aggressive disease in older patients. However, screening remains controversial, especially in the older patient population.

Recent Findings

Aggressive prostate cancers are more common in older men. Screening trial results are conflicting but data suggest an improvement in prostate cancer mortality and increased detection of metastatic disease with screening. When PSA is utilized with multiparametric MRI and biomarker assays, patients at significant risk of clinically meaningful prostate cancer can be appropriately selected for biopsy.

Summary

A thoughtful and individualized approach is central when considering prostate cancer screening in older men. This approach includes life expectancy estimation, use of appropriate geriatric assessment tools, use of multiparametric MRI and biomarkers in addition to PSA, and most importantly shared decision-making with patients.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Cancer Stat Facts: Prostate Cancer. Available from: https://seer.cancer.gov/statfacts/html/prost.html.

  2. Howlader N, N.A., Krapcho M, Miller D, Brest A, Yu M, Ruhl J, Tatalovich Z, Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds), SEER cancer statistics review, 1975–2017. April 2020.

  3. Grossman DC, et al. Screening for prostate cancer: US Preventive Services Task Force recommendation statement. JAMA. 2018;319(18):1901–13.

    Article  Google Scholar 

  4. Social Security Actuarial Life Table. [cited 2021; Available from: https://www.ssa.gov/OACT/STATS/table4c6.html.

  5. World Health Organization Life Tables by Country. [cited 2021; Available from: https://apps.who.int/gho/data/view.main.60000?lang=en.

  6. Memorial Sloan Kettering Cancer Center Male Life Expectancy Survey [cited 2021; Available from: https://webcore.mskcc.org/survey/surveyform.aspx?preview=true&excelsurveylistid=4.

  7. NCCN Clincal Practice Guidelines in Oncology (NCCN Guidelines). Prostate cancer, Version 1.2021 2021; Available from: NCCN.org.

  8. Epstein JI, et al. The 2014 International Society of Urological Pathology (ISUP) consensus conference on Gleason grading of prostatic carcinoma. Am J Surg Pathol. 2016;40(2):244–52.

    Article  Google Scholar 

  9. Epstein JI, et al. A contemporary prostate cancer grading system: a validated alternative to the Gleason score. Eur Urol. 2016;69(3):428–35.

    Article  Google Scholar 

  10. Gleason DF, Mellinger GT. Prediction of prognosis for prostatic adenocarcinoma by combined histological grading and clinical staging. J Urol. 1974;111(1):58–64.

    Article  CAS  Google Scholar 

  11. Amin MB, Edge SB, Greene, FL et al (Eds.), ed. AJCC Cancer Staging Manual. 8th ed. 2017, Springer: New York.

  12. Rider JR, et al. Long-term outcomes among noncuratively treated men according to prostate cancer risk category in a nationwide, population-based study. Eur Urol. 2013;63(1):88–96.

    Article  Google Scholar 

  13. Prostate cancer recent trends in SEER age-adjusted incidence rates, 2000–2017. Available from: https://seer.cancer.gov/explorer/application.html?site=66&data_type=1&graph_type=2&compareBy=stage&chk_stage_104=104&chk_stage_105=105&chk_stage_106=106&hdn_sex=2&race=1&age_range=160&hdn_rate_type=1&advopt_precision=1&advopt_display=2.

  14. Jemal A et al. Prostate cancer incidence 5 years after US Preventive Services Task Force recommendations against screening. JNCI: Journal of the National Cancer Institute, 2021. 113(1): 64–71.

  15. Brassell SA, et al. Prostate cancer in men 70 years old or older, indolent or aggressive: clinicopathological analysis and outcomes. J Urol. 2011;185(1):132–7.

    Article  Google Scholar 

  16. Pepe P, Pennisi M. Gleason score stratification according to age at diagnosis in 1028 men. Contemp Oncol (Pozn). 2015;19(6):471–3.

    Google Scholar 

  17. Sun L, et al. Men older than 70 years have higher risk prostate cancer and poorer survival in the early and late prostate specific antigen eras. J Urol. 2009;182(5):2242–8.

    Article  CAS  Google Scholar 

  18. Richstone L, et al. Radical prostatectomy in men aged >or=70 years: effect of age on upgrading, upstaging, and the accuracy of a preoperative nomogram. BJU Int. 2008;101(5):541–6.

    Article  Google Scholar 

  19. Delongchamps NB, et al. Pathological characteristics of prostate cancer in elderly men. J Urol. 2009;182(3):927–30.

    Article  Google Scholar 

  20. Scosyrev E, et al. Prostate cancer in the elderly: frequency of advanced disease at presentation and disease-specific mortality. Cancer. 2012;118(12):3062–70.

    Article  Google Scholar 

  21. Zeng C, et al. Disparities by race, age, and sex in the improvement of survival for major cancers: results from the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Program in the United States, 1990 to 2010. JAMA Oncol. 2015;1(1):88–96.

    Article  Google Scholar 

  22. Andriole GL, et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med. 2009;360(13):1310–9.

    Article  CAS  Google Scholar 

  23. Schröder FH, et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med. 2009;360(13):1320–8.

    Article  Google Scholar 

  24. • Hugosson J. et al. A 16-yr Follow-up of the European randomized study of screening for prostate cancer. European urology, 2019;76(1): 43–51. (The European Randomized Study of Screening for Prostate Cancer (ERSPC) randomized over 160,000 patients ages 55–69 years old to PSA screening. In this 16-year follow-up study, the NNI and NND to prevent one prostate cancer death were 570 and 18, respectively.)

  25. Godtman RA, et al. Opportunistic testing versus organized prostate-specific antigen screening: outcome after 18 years in the Göteborg randomized population-based prostate cancer screening trial. Eur Urol. 2015;68(3):354–60.

    Article  Google Scholar 

  26. • Pinsky PF et al. Extended mortality results for prostate cancer screening in the PLCO trial with median follow‐up of 15 years. Cancer. 2017; 123(4): 592–599. (The PLCO trial enrolled over 75,000 patients 55 to 74 years old across 10 centers in the USA between 1993 and 2001. Extended follow-up of nearly 19 years reported in this reference did not demonstrate an improvement in mortality with organized PSA screening. However, as discussed in the review, nearly 46% of patients in the control group underwent PSA screening at some point in the trial, potentially confounding the results.)

  27. Martin RM, et al. Effect of a low-intensity PSA-based screening intervention on prostate cancer mortality: the CAP randomized clinical trial. JAMA. 2018;319(9):883–95.

    Article  Google Scholar 

  28. Moyer VA. Screening for prostate cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(2):120–34.

    Article  Google Scholar 

  29. Eapen RS, et al. Impact of the United States Preventive Services Task Force “D” recommendation on prostate cancer screening and staging. Curr Opin Urol. 2017;27(3):205–9.

    Article  Google Scholar 

  30. Fenton JJ, et al. Prostate-specific antigen-based screening for prostate cancer: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2018;319(18):1914–31.

    Article  Google Scholar 

  31. Tsodikov A, et al. Reconciling the effects of screening on prostate cancer mortality in the ERSPC and PLCO Trials. Ann Intern Med. 2017;167(7):449–55.

    Article  Google Scholar 

  32. Heijnsdijk EA, et al. Quality-of-life effects of prostate-specific antigen screening. N Engl J Med. 2012;367(7):595–605.

    Article  CAS  Google Scholar 

  33. • Ahmed HU et al. Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. Lancet; 2017(389);10071: 815–822. (The PROMIS trial was a multicenter study designed to test the diagnostic accuracy of mpMRI. The negative predictive value of mpMRI for clinically significant prostate cancer was 89%. In this study, incorporation of mpMRI could potentially allow 27% of men with elevated PSA to avoid a primary biopsy.)

  34. Kasivisvanathan V, et al. MRI-targeted or standard biopsy for prostate-cancer diagnosis. N Engl J Med. 2018;378(19):1767–77.

    Article  Google Scholar 

  35. Klotz L. et al. Comparison of multiparametric magnetic resonance imaging-targeted biopsy with systematic transrectal ultrasonography biopsy for biopsy-naive men at risk for prostate cancer: a phase 3 randomized clinical trial. JAMA Oncol, 2021.

  36. Bhattu AS, et al. A 4Kscore cut-off of 7.5% for prostate biopsy decisions provides high sensitivity and negative predictive value for significant prostate cancer. Urology. 2021;148:53–8.

    Article  Google Scholar 

  37. Catalona WJ, et al. Serum pro-prostate specific antigen preferentially detects aggressive prostate cancers in men with 2 to 4 ng/ml prostate specific antigen. J Urol. 2004;171(6 Pt 1):2239–44.

    Article  Google Scholar 

  38. de la Calle C, et al. Multicenter evaluation of the prostate health index to detect aggressive prostate cancer in biopsy naive men. J Urol. 2015;194(1):65–72.

    Article  Google Scholar 

  39. Loeb S, et al. Prostate Health Index improves multivariable risk prediction of aggressive prostate cancer. BJU Int. 2017;120(1):61–8.

    Article  CAS  Google Scholar 

  40. Parekh DJ, et al. A multi-institutional prospective trial in the USA confirms that the 4Kscore accurately identifies men with high-grade prostate cancer. Eur Urol. 2015;68(3):464–70.

    Article  Google Scholar 

  41. Punnen S, et al. A multi-institutional prospective trial confirms noninvasive blood test maintains predictive value in African American men. J Urol. 2018;199(6):1459–63.

    Article  Google Scholar 

  42. Haese A, et al. Multicenter optimization and validation of a 2-gene mRNA urine test for detection of clinically significant prostate cancer before initial prostate biopsy. J Urol. 2019;202(2):256–63.

    Article  Google Scholar 

  43. McKiernan J, et al. A prospective adaptive utility trial to validate performance of a novel urine exosome gene expression assay to predict high-grade prostate cancer in patients with prostate-specific antigen 2–10ng/ml at initial biopsy. Eur Urol. 2018;74(6):731–8.

    Article  CAS  Google Scholar 

  44. McKiernan J, et al. A novel urine exosome gene expression assay to predict high-grade prostate cancer at initial biopsy. JAMA Oncol. 2016;2(7):882–9.

    Article  Google Scholar 

  45. Van Neste L, et al. Detection of high-grade prostate cancer using a urinary molecular biomarker-based risk score. Eur Urol. 2016;70(5):740–8.

    Article  Google Scholar 

  46. Dearnaley D, et al. Conventional versus hypofractionated high-dose intensity-modulated radiotherapy for prostate cancer: 5-year outcomes of the randomised, non-inferiority, phase 3 CHHiP trial. Lancet Oncol. 2016;17(8):1047–60.

    Article  Google Scholar 

  47. Hoffman KE, et al. Randomized trial of hypofractionated, dose-escalated, intensity-modulated radiation therapy (IMRT) versus conventionally fractionated IMRT for localized prostate cancer. J Clin Oncol. 2018;36(29):2943.

    Article  CAS  Google Scholar 

  48. Jackson WC, et al. Stereotactic body radiation therapy for localized prostate cancer: a systematic review and meta-analysis of over 6,000 patients treated on prospective studies. International Journal of Radiation Oncology Biology Physics. 2019;104(4):778–89.

    Article  Google Scholar 

  49. Lee WR, et al. Randomized phase III noninferiority study comparing two radiotherapy fractionation schedules in patients with low-risk prostate cancer. J Clin Oncol. 2016;34(20):2325.

    Article  Google Scholar 

  50. Mottet N. et al. EAU-ESTRO-SIOG guidelines on prostate cancer. Part 1: screening, diagnosis, and local treatment with curative intent. European urology, 2017;71(4): 618–629.

  51. •• Boyle H. et al. Updated recommendations of the International Society of Geriatric Oncology on prostate cancer management in older patients. European Journal of Cancer, 2019;116: 116–136. (These are the updated guidelines from the International Society of Geriatric Oncology (SIOG) on the management of prostate cancer in older patients. This reference serves as a comprehensive resource on this topic—the authors emphasize that treatment decisions should be based on global health status not only chronologic age, and discuss the importance of using appropriate geriatric assessments and screening tools for cognitive impairment in older patients.)

  52. NCCN Clincal Practice Guidelines in Oncology (NCCN Guidelines). Prostate Cancer Early Detection, Version 1.2021 2021; Available from: NCCN.org.

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Authors and Affiliations

  1. Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA

    Tyler P. Robin

  2. Division of Medical Oncology, University of Colorado School of Medicine, Aurora, CO, USA

    Christopher L. Geiger, Eryn B. Callihan & Elizabeth R. Kessler

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  1. Tyler P. Robin
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  2. Christopher L. Geiger
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  4. Elizabeth R. Kessler
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Correspondence to Tyler P. Robin.

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Conflict of Interest

Tyler P. Robin declares that he has no conflict of interest.

Christopher L. Geiger declares that he has no conflict of interest.

Eryn B. Callihan declares that she has no conflict of interest.

Elizabeth R. Kessler has received research funding from Astellas for an investigator-initiated clinical trial; is the site principal investigator for clinical trials funded by Merck, Bristol-Myers Squibb, and Pfizer; and is a voting member for the ClinicalPath Genitourinary Medical Oncology Committee.

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Robin, T.P., Geiger, C.L., Callihan, E.B. et al. Prostate Cancer in Older Adults: Risk of Clinically Meaningful Disease, the Role of Screening and Special Considerations. Curr Oncol Rep 23, 130 (2021). https://doi.org/10.1007/s11912-021-01118-7

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