Guidelines

The Iowa Prostate Cancer Consensus (Abstract)

Practice Patterns in Screening and Management of Prostate Cancer in Elderly Men (Abstract)

• Advise patients with risk factors (e.g., positive family history, African-Americans) regarding potential treatment options and relative benefits
• If patient is unlikely to pursue further therapy or deemed unlikely to benefit from treatment of known prostate cancer, obtaining diagnostic PSA should only be done after careful deliberation
• Reassess with patient the benefits of initiating prostate cancer screening in men >75 years
• If screening is pursued, utilize age-based PSA values to determine normal levels (see Management)

Previously Screened Patients

Discontinue PSA screening if:

• many co-morbidities exist
• patient is not likely to pursue therapy
• patient does not have functional life expectancy of >5-10 years

Resume PSA testing if symptoms appear such as:

• hematuria
• irritative or obstructive voiding symptoms
• bone pain
• back pain
• involuntary weight loss

After Initiation/Resumption of Screening

If initial PSA >4.0 ng/ml, with normal DRE, repeat PSA at 4-6 weeks

Pursue further evaluation if:

• Repeat PSA is >6.5ng/ml

OR

• PSA is increasing >0.75ng/ml year in comparison with at least 2 prior PSA values drawn at least 6 months apart

AND adedquate levels as determined by:

• ECOG Performance Status (0-2)
• Karnofsky Performance Scale (>70)
• Activities of Daily Living (ADL)*
• Instrumental Activities of Daily Living (IADL)*

*Any impairment in a basic or instrumental activity of daily living should prompt further investigation before deciding on definitive therapy, since there may be important coexisting medical, cognitive, or psychiatric illness.

THE IOWA PROSTATE CANCER CONSENSUS:
SCREENING AND MANAGEMENT IN MEN >75 YEARS OF AGE

Prostate cancer is the most common non-skin malignancy diagnosed in American men. Current recommendations and guidelines emphasize a starting age for prostate cancer screening but the age at which to discontinue screening has not been stated clearly. Indiscriminate and haphazard use of screening practices in the elderly can result in significant cost and potential morbidity from interventions performed to evaluate abnormal screening tests or unnecessary treatment of diagnosed prostate cancer. The rapidly rising elderly population makes it highly imperative to have a standardized approach to screening and management of prostate cancer in this population.

The multidisciplinary Iowa Prostate Cancer Consensus Recommendations Committee has put forth a set of recommendations based on a risk-stratified approach to management of prostate cancer with consideration of functional status and life expectancy.

Initiation of prostate cancer screening in elderly men should be undertaken only after careful consideration. In men >75 years with risk factors (e.g. positive family history), screening should be initiated only after detailed discussion with the patient regarding potential treatment options and relative benefits. Men with life expectancy less than 10 years and with low grade/stage cancer (stage T1, Gleason score <6) are unlikely to obtain significant survival benefit from the treatment of prostate cancer. Screening should be done very selectively if it is likely that the patient will not pursue treatment should prostate cancer be diagnosed. If screening is pursued, age-based PSA values should be utilized to determine normal levels.

In patients >75 years who have previously been screened, a discussion explaining the risks and benefits of screening should be conducted prior to continuation of screening. It is essential to make the patient aware of the current lack of concrete evidence that prostate cancer screening prolongs survival, particularly in older men. It is prudent to discontinue screening in men with life expectancy <10 years, comorbidities or a low likelihood of pursuing therapy. Diagnostic PSA testing can be restarted in patients with symptoms suggestive of prostate cancer such as hematuria, bone pain, back pain, unexplained weight loss or obstructive voiding symptoms.

Evaluation for prostate cancer is recommended in certain situations. In men who have never previously had a serum PSA or if the most recent PSA was more than 5 years prior, and the current PSA is abnormal (>4.0 ng/ml) with a normal DRE, we recommend that the PSA be repeated at an interval of 4-6 weeks. If repeat value is >6.5 ng/ml, further evaluation of prostate cancer should be conducted, especially in symptomatic men. Further evaluation should also be conducted in men with a rapidly rising PSA, i.e, PSA increasing at a velocity of >0.75 ng/ml per year based on comparison with at least 2 prior PSA values drawn at least 6 months apart.¹

It is encouraged that referral be undertaken following an assessment of functional status and patient comorbidities. ECOG performance status (0-2 recommended), Karnofsky performance scale (>70 recommended) and Activities of Daily Living or Instrumental Activities of Daily Living scales are recommended tools for functional assessment. A clinical plan of action following PSA testing should be documented in the patient chart.

Management of prostate cancer is based on risk stratification to predict likelihood of disease recurrence and disease-specific survival. One of the commonly applied disease stratification schemes is as follows²:

• Low risk: PSA <10ng/ml, Gleason score <6, clinical stage <T2a
• Moderate risk: PSA 10-20ng/ml, Gleason score 7, clinical stage T2b
• High risk: PSA >20ng/ml, Gleason score 8-10, clinical stage >T2c

Patients with low or moderate risk are best managed by expectant observation (watchful waiting/active surveillance) with intent to treat once symptoms develop. Functional and cognitive assessment should be conducted to assist in therapeutic decision making. Therapy would consist of radiation with or without concomitant androgen ablation.

These recommendations have been drafted to serve as a guide for physicians in their care of elderly men.

References

1. Carter HB, Pearson JD, Metter EJ, et al. Longitudinal evaluation of prostate-specific antigen levels in men with and without prostate disease. JAMA 1992;267:2215-2220.
2. D'Amico AV, Whittington R, Malkowicz SB, et al. Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer. JAMA 1998;280:969-974.

This publication was supported by Cooperative Agreement U55/CCU721906-04 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention.