(UroToday.com) The 2023 American Urological Association (AUA) annual meeting held in Chicago, was host to the International Prostate Forum, with Dr. Samuel Washington III discussing how to select appropriate candidates in their seventies for PSA screening and curative treatment versus observation strategies.
The current NCCN guidelines for the early detection of prostate cancer emphasize the importance of considering baseline risk factors (i.e., race, family history, known/suspected germline mutations) and patient age (<75 vs >75) when considering early screening/diagnostic evaluation of men.
Among men subsequently diagnosed with prostate cancer, risk assessment and estimated life expectancy are key features to consider for treatment decision-making. For very low-risk patients with a >20-year life expectancy, active surveillance, external beam radiotherapy, and radical prostatectomy are all reasonable options, per the latest NCCN guidelines. Conversely, for very low-risk patients with a <10 year life expectancy, observation alone is recommended.
The importance of life expectancy in the treatment-decision making process is also highlighted for low-risk prostate cancer patients, with those having a >10-year life expectancy recommended active surveillance or definitive therapy. Conversely, for those with a <10-year life expectancy, observation alone is recommended.
For favorable intermediate risk patients, active surveillance or definitive therapy (RP or XRT alone) remain recommended options for patients with a life expectancy of >10 years. However, as opposed to the <10-year life expectancy cut-off recommended for very low- and low-risk patients, observation alone may be considered for patients with an expected survival of 5-10 years.
In patients with unfavorable intermediate risk disease and a life expectancy of >10 years, both RP and radiotherapy + ADT (4-6 months) are recommended. Conversely, for patients with a limited life expectancy of 5-10 years, both radiotherapy and observation are reasonable in this setting.
For high- or very-high risk groups, the NCCN guidelines recommend considering both life expectancy and patient symptomatology for initial treatment decision-making, as summarized below. Even among patients with a limited life expectancy of <5 years and who are symptomatic, radical therapy +/- systemic therapy may be considered in the appropriate setting as summarized below.
A similar management paradigm is recommended for patients with nodal disease, again emphasizing the importance of considering life expectancy and patient symptomatology.
At this point, Dr. Washington highlighted the concerns with PSA screening in older men:
- Testing after 75 years of age should be done only in very healthy people with little or no comorbidities
- Widespread testing would substantially increase over-detection rates and is not recommended
- Individuals >75 years of age with a PSA <3.0 ng/ml have very low risks of prostate cancer metastases during their lifetime
Dr. Washington emphasized that life expectancy estimation is critical to informed decision-making in early detection and treatment. He acknowledged that estimation of life expectancy can be challenging, and highlighted the following available resources:
- The Social Security Administration tables (www.ssa.gov/OACT/STATS/table4c6.html)
- The WHO’s Life Tables by country (http://apps.who.int/gho/data/view.main.60000?lang=en)
- The Memorial Sloan Kettering Male Life Expectancy tool https://www.mskcc.org/nomograms/prostate
With regard to quality of life and shared decision-making, Dr. Washington concluded his presentation by noting that::
- Baseline urinary, sexual, and bowel function are strongly associated with functional outcomes after treatment
- We need to consider the risks of cure, recurrence, disease progression, and disease- specific mortality of each management option, including disease severity and competing risks
- We should discuss the side effects of each treatment and predict their impact on quality of life, including urinary, sexual, and bowel function
- Patient preferences should be elicited and should be incorporated into the management decision
Presented by: Samuel L. Washington III, MD, MAS, Assistant Professor, Department of Urology, University of California in San Francisco, San Francisco, CA
Written by: Rashid K. Sayyid, MD, MSc – Society of Urologic Oncology (SUO) Clinical Fellow at The University of Toronto, @rksayyid on Twitter during the 2023 American Urological Association (AUA) Annual Meeting, Chicago, IL, April 27 – May 1, 2023
Related Content:
Improving Primary Prostate Cancer Diagnosis Through Risk Stratified Screening: a European Perspective - Sigrid Carlsson