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Managing Localized Prostate Cancer in a Septuagenarian With Dementia
Despite exhaustive efforts in prostate cancer screening and treatment options, the management of localized prostate cancer remains a challenge for patients and physicians, particularly in elders. This article focuses on a review of the American Urological Association’s (AUA) Guideline for the Management of Clinically Localized Prostate Cancer,1 which was updated in 2007 and validated in 2011. A case presentation illustrates how to apply these clinical practice guidelines in an elderly man with diminished decision-making capacity. The approach involves his family and considers his age, comorbidities, and stated requests before he developed moderate dementia.
Case Presentation
A 74-year-old black man with moderate dementia had lived in a long-term care facility for 1 year. His daughter, who had power of attorney and was the decision maker for his medical conditions, insisted that he be screened for prostate cancer annually using prostate-specific antigen (PSA) testing. His cognitive deficits had impaired his ability to contribute to this decision, but his daughter said he had always feared getting prostate cancer because of a strong family history of the disease. She also explained that before her father developed dementia, he had requested that his primary care physician conduct a PSA test at every annual physical examination. This routine surveillance for the disease showed that his PSA level had remained stable over many years.
A comprehensive geriatrics assessment was done, which showed no subjective or objective symptoms of prostate cancer. Comorbidities included chronic hypertension, type 2 diabetes mellitus controlled with insulin, mild renal insufficiency, and peripheral neuropathy. After a discussion with the patient’s daughter about the risks and benefits of testing for prostate cancer, the decision was made to test his PSA level and perform a digital rectal examination (DRE). The PSA level was 8.8 ng/mL, which was markedly elevated from a year earlier, when it was below 5 ng/mL. The rest of the physical examination, including the DRE, was negative for an enlarged prostate or nodules. The urinalysis showed no abnormalities. When the PSA was repeated and the abnormal results were confirmed, the patient was referred to a urologist, who performed a transrectal biopsy of the prostate. Histopathology showed a Gleason score of 6, with moderate differentiation. To clinically stage his disease, an abdominal and pelvic computed tomography scan and a total bone scan were undertaken. Results were negative for metastatic disease and the tumor was staged T1cNXM0.
Discussion
Prostate cancer is the second leading cause of cancer-related death among men.2 The lifetime risk of prostate cancer is 1 in 6 among all American men, and 1 in 36 will die from this malignancy.3,4 Although mortality from prostate cancer has declined because of early detection and burgeoning treatment options, the incidence of the disease and the rate of death from prostate cancer remains much higher in blacks than in whites.3,5
The natural history of prostate cancer ranges from a quiescent disease to a highly aggressive cancer. Established risk factors are age older than 60 years, black race, and family history.6 Other factors influencing the prognosis of a patient with prostate cancer are the tumor characteristics, including histological appearance (Gleason score), clinical stage, and the PSA level at the time of the initial clinical presentation.7 The patient’s life expectancy and comorbid conditions are important considerations for developing a management plan and for predicting prognosis.3,7
Guidelines
The International Society of Geriatric Oncology recommends performing a comprehensive geriatric assessment in the elderly population, including identifying comorbidities, functional status (dependent or independent performance in activities of daily living), nutritional status, cognitive and psychological status, and overall quality of life.8 A discussion of the risks versus the benefits of oncology therapy or active surveillance is an important part of any management plan.
More recently, after a review of the current screening literature, the United States Preventive Services Task Force (USPSTF) concluded that the benefits of screening for prostate cancer are uncertain for men younger than age 75 years, with the balance of benefits and harms being unclear in this population; however, there was moderate certainty that the harms of screening for prostate cancer outweigh the benefits for men 75 years and older.9,10 Based on these findings, the USPSTF recommends against screening men 75 years and older.9 Most medical organizations, including the American Cancer Society, American Medical Association, American Urological Association, American College of Physicians, among others, generally recommend that screening is conducted only in individuals age 50 years and older who have a life expectancy of
at least 10 years.9
The Prostate Cancer Clinical Guideline Update Panel of the AUA has developed specific guidelines for clinically localized prostate cancer1 that can serve as a clinical tool for physicians and specialists. The recommendations were developed using a literature search and data collection from PubMed and a Cochrane review of articles published between 1991 and early 2004. After applying selection criteria to a total of 13,888 articles that were identified on PubMed, only 436 were accepted. The guidelines comprise expert opinion based on this systematic review. A meta-analysis was not performed because of limitations in the data; however, some recommendations are based on randomized controlled trials. The rating system for the strength of each recommendation is standard, recommended, or optional, depending on the panel consensus (Table 1). These labels are used throughout this article as the guidelines are summarized, appearing after each recommendation in parentheses. A summary of the identified patient risk categories is shown in Table 2. The guidelines were subjected to internal and external peer review before publication. The final AUA recommendations were developed for men with clinically localized prostate cancer stage T1 to T2 N0-NXM0 without regional or distant metastases. Major outcomes considered in the guidelines were patient survival, disease-free survival, and progression to metastatic disease. Other important aspects of the outcomes include patient quality of life and the severity of adverse effects from the selected therapy, particularly bowel problems, erectile dysfunction (ED), and urinary incontinence.
Common Recommendations for All Risk Groups
The AUA guidelines recommend detailed discussion and counseling of all available treatment options with the patients in all risk groups (standard). Treatment options include watchful waiting, active surveillance, brachytherapy, external beam radiation therapy (EBRT), hormonal therapy, and radical prostatectomy (an option in all risk groups; Figure 1).
Based on patient preference, any choice is an appropriate treatment option in all risk groups of patients with localized prostate cancer; however, combination therapy is advised in the intermediate- and high-risk groups (standard). Special consideration should be given to possible adverse outcomes involving the genitourinary (GU) and gastrointestinal tract ([GI] standard). Benefits of therapy and adverse effects of the treatment choices should always be reviewed in discussions with patients (standard).
Active surveillance can be used as first-line therapy in any risk group. It is considered as expectant management or postponement of immediate therapy. Defining the frequency and type of monitoring during surveillance is crucial (standard). It is also important to establish and document the goals of second-line treatment in such situations, clarifying whether the selected therapy would be curative or palliative (standard). Active surveillance may be the choice for patients with localized and well-
differentiated cancers. Active surveillance is also acceptable for patients with comorbidities, compromised functional status, and cognitive and psychological deficits. Treatment-related options may cause more complications and compromise quality of life.1,8 Androgen deprivation therapy (ADT) should not be used as first-line curative therapy. Evidence indicates that primary ADT does not improve prostate cancer–specific mortality and can have negative effects on quality of life.11
Newer forms of therapy, such as focal therapy, cryotherapy, and combination therapy with ADT are undergoing clinical trials.12 The guidelines highly recommend encouraging patients with localized prostate cancer to enroll in clinical trials for newer forms of therapy. Figure 2 summarizes treatment management for all risk groups.
Treatment of Low-Risk Patients. Monotherapy may be an appropriate option for this group, as they have a lower risk of recurrence (standard). The randomized controlled trials that were reviewed to construct the AUA guidelines suggest that higher-dose radiation with EBRT and radical prostatectomy are superior to watchful waiting (standard). These options may lower the risk of cancer recurrence, extend the disease-free period, and enhance survival. Complications of the treatments include sexual dysfunction, urinary hesitancy or urgency, incontinence, dysuria, rectal urgency or frequency, and, rarely, prostatorectal fistula. Patients undergoing EBRT had a lower incidence of urinary incontinence or sexual dysfunction but higher rates of GI symptoms compared with those undergoing radical prostatectomy.13,14
Brachytherapy as a monotherapy is also a reasonable option for men with low-risk disease.1 ED is one of the more bothersome complications of this treatment. The use of agents such as phosphodiesterase inhibitors may play a positive role in treating ED in patients who develop this disorder after radiation therapy.15
Treatment of Intermediate-Risk Patients. High-dose EBRT is associated with better outcomes (standard) than conventional doses in this risk group. Patients who decide to have EBRT with conventional doses should receive concurrent hormonal therapy for at least 6 months (standard). Evidence suggests that this approach improves survival and disease-free progression.1 Radical prostatectomy has improved outcomes regarding disease-free progression, recurrence rates, and cancer-related death (standard).1
Treatment of High-Risk Patients. Maintaining a balance between life-prolonging therapies and better quality of life is a major consideration in this risk group. The evidence favors combination therapy over monotherapy, as monotherapy has a higher rate of cancer recurrence (standard). Radical prostatectomy is also prefered in this group of patients (standard) compared with watchful waiting, adjuvant ADT with EBRT, or brachytherapy.
Potential Benefits and Harms of Treatment Approaches
Benefits of therapy include prolonging life and decreasing the risk of cancer recurrences or cancer-related death. When watchful waiting is the option, the stigma of living with cancer can have a negative impact on the patient’s quality of life. In contrast, each treatment carries its own adverse effects. Hematuria is commonly seen with brachtherapy and EBRT. Urinary incontinence, irritative and obstructive urinary symptoms, ED, GI toxicity, and proctopathy are commonly reported with all treatment options except watchful waiting and active surveillance. Surveys suggest that the health-related quality of life may be slightly better in patients who opt for EBRT or brachytherapy compared with radical prostatectomy.15 Available data are insufficient to recommend any form of treatment over any other in such patients.10
Case Outcome and Resolution
The case presentation illustrates the application of the AUA guidelines for localized prostate cancer, after a complete geriatric assessment of the patient as recommended by the International Society of Geriatric Oncology. This patient’s Gleason score was 6, indicating that he was in the low-risk group. Clinical staging was T1cNXM0. His stable PSA level over the years, followed by the recent abrupt rise, suggested new-onset prostate cancer. The patient’s daughter shared in the care plan decisions, and specific therapy was indicated to honor the patient’s wishes declared before he had cognitive impairment from dementia.
The following treatment options were available according to the AUA guidelines: active surveillance, watchful waiting, brachytherapy, EBRT, and radical prostatectomy. After thorough discussions with the primary care physician in the nursing facility, the urologist, and the patient’s daughter, the medical team selected brachytherapy as the best option, considering the patient’s life expectancy, quality of life, and previous wishes. This option might not be a suitable choice for patients with an enlarged prostate or complications from treatment for urinary retention and edema of the prostate gland. Our patient did not have any of these contraindications; therefore, it was safe to proceed with brachytherapy. He had adjunctive treatment with ADT 3 months before and after the brachytherapy. The patient tolerated these treatment well, with no adverse effects. He maintained his daily routine and had no change in GU or GI functions following treatment. He has undergone regular examinations with the urologist and radiation oncologist for approximately 3 years. The patient continues to see the urologist every 6 months, who monitors him via PSA testing and a urological examination.
Conclusion
Maintaining a good quality of life and enhancing disease-free survival in the setting of a cancer diagnosis is a challenge at any age and with any form of therapy. Specific treatments for clinically localized prostate cancer are still being studied and may lead to more therapy options targeted to each risk group in the future. In the meantime, many options are available or undergoing clinical trials. The best treatment for clinically localized prostate cancer is one that is individualized based on the patient’s preferences, comorbid conditions, clinical stage, and tolerance to the adverse effects of the selected therapy. Active surveillance is often the chosen option for elders with multiple comorbidities and compromised functional status, especially those with a limited life expectancy.
The authors report no relevant financial relationships.
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