Dr. Maylath (left) takes time to talk with patient Frederick Gray.

Hank is 82 years old. A retired postman, he settled into a sedentary lifestyle once he stopping walking his postal route. Fifteen years ago he was diagnosed with type 2 diabetes; eight years ago he had his first heart attack. While leafing through the morning paper, he read about a prostate cancer screening being offered by the local hospital.

Question: Should Hank call up and register for the screening?

Born during the Great Depression, Victor is an active 71-year-old. He plays golf twice a week and travels extensively. He was recently honored for his outstanding volunteer service at his grandson’s school. A week after his annual physical, his physician called him in to discuss the results of his PSA blood test. The test indicated the presence of prostate cancer.

Question: Should Victor pursue aggressive treatment of his cancer?

“With prostate cancer in the older man, it’s definitely not a ‘one-size-fits-all’ type of care,” said Dr. Craig Maylath, an assistant professor in the Department of Internal Medicine’s Division of Geriatrics. Because prostate cancer tends to be a more slow growing cancer, Dr. Maylath explained, screening for the disease and treating it might not always be mandated in men over the age of 70. Each patient’s age, individual health history, and personal circumstances all play a part in this very individualized decision. “If you have heart disease and diabetes you are more likely to suffer graver consequences from those diagnoses than from your prostate cancer. Older men more typically die with prostate cancer than from prostate cancer,” he said.

Sometimes physicians and their elderly patients choose not to test for prostate cancer or not to pursue treatment if cancer is diagnosed. “You have to balance the current quality of life and the expected quality of life with the expected benefits of therapy,” Dr. Maylath said. The potential side effects that can accompany treatment factor greatly in this decision.

When a radical prostatectomy is performed to surgically remove the cancerous prostate gland, two of the major risks are incontinence and impotence. “Incontinence can vary from a little dribbling to, in occasional cases, no control at all,” Dr. Maylath said. The risk of impotence is considerable, with Dr. Maylath estimating that at least half of men over the age of 70 will lose the ability to achieve an adequate erection after the surgery.

When radiation therapy is prescribed, patients undergo five to eight weeks of external beam therapy and/or brachytherapy, in which radioactive pellets are inserted into the prostate. “These are legitimate alternatives to surgery,” said Dr. Maylath. “The advantage of these modalities for the older man is that there is no surgery, and there typically is no interruption in his activities.” While radiation typically poses less of a problem with impotence and incontinence, it can cause other side effects, including proctitis, a chronic inflammation that affects normal bowel function.

In some instances patients and their physicians opt not to pursue treatment, but to monitor the prostate cancer, an approach called watchful waiting. “This is usually an older patient who would probably not do well with the side effects of standard intervention,” Dr. Maylath said. Hormone therapy may be used to control the various symptoms of untreated prostate cancer. “While hormone therapy can help improve some of the symptoms, the downside is that men can get hot flashes, painful breast enlargement and loss of libido,” Dr. Maylath noted.

Whether to test for prostate cancer or not is a question that Dr. Maylath gives serious thought. “What are the patient’s long-term health prospects? Do I expect him to live another 15 or 20 years? Then certainly you can think about annual prostate cancer screening,” he said. On the flip side of the coin, Dr. Maylath adds, ”With some men I don’t even bring it up. If there’s a patient in his late 70’s with multiple co-morbidities, I don’t even raise the issue because it can do more harm than good.”

While the PSA (used in conjunction with a digital rectal exam) is the standard test to screen for prostate cancer, there is controversy within the medical field concerning its role in diagnosis. “The PSA is a single crude tool to assess the stage and progress of a man’s cancer,” Dr. Maylath said, explaining that the PSA score does not indicate the aggressiveness of the cancer. Additional diagnostic measures can provide physicians with more information on how quickly or slowly a particular man’s prostate cancer may progress, “yet even with that, there is no set rule,” he said.

In working with men over 70, Dr. Maylath stressed that selecting the course to take with prostate cancer depends on the particular patient. “There are no hard and fast rules when it comes to the diagnosis and treatment of prostate cancer. The patient is best served by having a frank discussion with his primary care doctor. Can the patient expect an improved quality of life if treated or is he best served living with his untreated prostate cancer?”

Reprinted from Connections newsletter, October 2006.

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