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Elderly men, African-Americans at increased risk for aggressive prostate cancer
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A substantial number of elderly or African-American men with PSA-detected, stage T1cN0M0 prostate cancer have high-risk disease at diagnosis, according to results of a retrospective study presented at the Genitourinary Cancers Symposium.
Stage T1cN0M0 tumors cause no symptoms, and they cannot be felt during physical exams nor detected via imaging. They can only be detected through PSA testing. Yet, the US Preventive Services Task Force (USPSTF) recently recommended against PSA screening for healthy men, regardless of age, due to concerns about the harms caused by overtreatment.
“If we stop PSA screening altogether, we have no other way to detect [stage T1cN0M0] prostate cancer sufficiently early to have the best chance of helping this group of high-risk patients,” Hong Zhang, MD, PhD, associate professor of radiation oncology at the University of Rochester, said in a press release.
Zhang and colleagues determined the frequency of risks of stage T1cN0M0 prostate cancer based on patient characteristics and PSA levels.
Researchers used the SEER database to identify 70,345 men in the United States with stage T1cN0M0 disease diagnosed between Jan. 1, 2004 and Dec. 31, 2008.
“This is the largest analysis exclusively consisting of PSA-detected stage T1cN0M0 prostate cancer in the United States in an era of widespread PSA testing,” Zhang said during a press conference held prior to the symposium.
Of the identified patients, 47.6% had low-risk disease, 35.9% had intermediate disease and 16.5% had high-risk disease.
Study results showed men aged 75 years or older were nine times more likely to present with high-risk disease compared with men aged younger than 50 years (OR=9.39; 95% CI, 7.25-12.16).
African-American men of all ages were nearly twice as likely as white men to present with high-risk disease (OR=1.84; 95% CI, 1.72-19.97).
The results suggest that a significant number of elderly men and African-Americans may have an aggressive form of prostate cancer diagnosed because of PSA testing.
“The findings of this study will help physicians and certain patients make more informed decisions [about whether] they want to proceed with PSA testing,” Zhang said. “More research and longer follow-up is needed to determine the effect of early detection and intervention on outcome in these high risk patients.”
For more information:
Zhang H. Abstract #50. Presented at: Genitourinary Cancers Symposium; Feb. 14-16, 2013; Orlando.
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Bruce J. Roth, MD
We have heard recommendations all over the map in the last couple of years regarding PSA screening, from everyone should get screened above the age of 50 to the USPSTF recommendations that no one should be screened. The answer is somewhere in between. This gives us information regarding the concept that older patients diagnosed with prostate cancer are destined to die of something else. That is not necessarily true. We see a significant percentage of people with intermediate- and high-risk disease in this patient population. What this ultimately means is that a numeric age probably is not a great determinant of who should and who should not receive PSA screening. This just adds to the complexity of the issue. A number of institutions have said the life expectancy of a patient in a particular age group could warrant a discussion with the patient’s physician about whether PSA screening should be undertaken.
Perspective
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Donald L. Trump, MD, FACP
Zhang and colleagues presented an important retrospective study in which they evaluated a large cohort of 70,345 men with T1C prostate cancer drawn from the SEER database. These men were diagnosed between 2004 and 2008. Of these men, 16.5% had high-risk disease (PSA >20 ng/mL and/or Gleason >8). Almost half of (40%) of this high-risk group were men aged older than 75 years, and such men had almost a 10-fold greater chance of being diagnosed with high-risk prostate cancer compared with men aged younger than 50 years. African-American men were almost twice as likely to develop high-risk disease as white men.
These are striking data, confirming again what has been known for some time — African-American men are at greater risk of poor-prognosis prostate cancer compared with white men — and emphasizing that older men with asymptomatic, localized disease (T1C) are at considerable risk of poor outcome because their disease is often poor prognosis, too.
In many studies, men with high-risk T1C disease have <10% PFS at 10 years. The authors make the important point that the only way to diagnosis high-risk T1C disease is through measurement of the PSA. While we are still challenged to prove that making the diagnosis of prostate cancer through PSA measurement — whether high- or intermediate-risk disease — leads to improved survival, this large, carefully done study emphasizes the importance of physicians discussing with their patients their risk of having poor-prognosis prostate cancer, and the approaches that might be employed to diagnose and begin treating the disease earlier.
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