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Definitive vs Conservative Treatments for Older Men With Prostate Cancer

February 24, 2021


Sagar Patel, MD, Winship Cancer Institute of Emory University, Atlanta, Georgia, discusses results from an analysis investigating utilization trends and survival outcomes associated with guideline-supported treatment options in older men with high-risk prostate cancer in the United States.

These results were presented at the virtual 2021 ASCO Genitourinary Cancers Symposium.


I'm Dr. Sagar Patel. I'm a radiation oncologist at the Winship Cancer Institute of Emory University based out of Atlanta, Georgia.

Our research group presented recent data that we acquired from the National Cancer Database, looking at utilization and survival outcomes between definitive and conservative treatment measures in elderly men with high‑risk prostate cancer. We presented this data at the ASCO Genitourinary Symposium just in February of 2021.

What led our group to really look at this question was just pragmatically what we face in clinic frequently. We often see men over the age of 75, in particularly over 80, who have clinically aggressive prostate cancer but are not offered definitive therapy. They often see us at a tertiary medical center for second opinions. We face this not too uncommonly, especially with the widespread use of PSA screening.

These men typically aren't routinely recommended to undergo PSA screening just based on their age. A lot of healthy men continue PSA screening by their local primary care doctors and do get diagnosed with prostate cancer.

To give a little bit of context on how the epidemiology and how prevalent this is. Obviously, prostate cancer is extremely widespread in the United States. It encompasses over 20% of our cancer incidences in men in the United States.

Among men over 80 in particular, cancer actually remains the second leading cause of mortality. Within that cohort, prostate cancer is the second leading cause of cancer death. It is a real problem in the United States.

We know from multiple prior studies that older men are less likely to undergo curative treatment. That's likely based due to competing risk of comorbidities and other caused mortalities. Also, on the provider side, it's just difficult to measure life expectancy for these men.

We wanted to look at updated utilization and survival outcomes in the United States at a contemporary cohort. We decided to look into the National Cancer Database, which is a pretty rich resource that encompasses about 70% of incident cancer diagnoses in the Unites States. We thought this was a representative population to look at.

We confined the analysis just to men with high‑risk prostate cancer. We thought that these are the men that represent the most clinically relevant cancer, if you will, to where the decision base between treatment vs observation or palliative decisions is much more difficult.

We looked at men just 80 years and older with high‑risk prostate cancer. Of course, that's based on the National Comprehensive Cancer Network guidelines, so men with clinical T stage 3 or 4, PSA over 20, or Gleason score 8 to 10.

What we found was that the vast majority of men, over 50%, do not undergo curative treatment in the United States. That's been from 2004 to 2016. That has not changed. Less than half of men get offered definitive treatment.

However, the trend has been favorable. In particular, when we mean definitive treatment, we mean radiation therapy or surgery. The use of radiation therapy actually has been increasing in the United States from 2004 to 2016.

The use of surgery however, has been flat and stagnant. Less than 2% of men do get surgery year after year in the United States. That's been unchanged over the past decade.

When we refer to palliative treatment, we're talking about androgen deprivation therapy alone or observation in men. These are non‑curative treatment options. Those have been pretty stagnant. That encompasses about half the men over this decade receiving palliative treatments.

The most important point of this study that we found was that we compared overall survival between men with definitive or curative treatment vs palliative treatment. We found that there is about a 50% increase in mortality in men who did not get definitive treatment.

Men who received androgen deprivation therapy alone or observation, they had a 50% higher chance of dying in their lifespan compared to men who did receive radiation or surgery.

That was compelling. This is clinically relevant, because a lot of times, we see these men in clinic. We feel that their prostate cancer won't pose any life threat due to competing risk of cardiac disease, diabetes, or other comorbidities.

In this population‑based registry, we found that actually, men who do not undergo curative treatment have a substantially higher risk of dying overall. That's not just prostate cancer death. That's death overall.

This is an important point to take home. That men who are older, who do have higher risk disease, and who do have a good performance status, we should be thinking more thoroughly on their life expectancy, trying to do more thorough life expectancy calculations, using things like the Social Security actuary tables and looking at their comorbidities.

For men who are fairly healthy, who do have an expected lifespan of 5 years or more, they should be offered definitive therapy.

As a secondary study we did within this analysis, we also looked at socio‑demographic influences that may play into whether an elderly man in the United States gets definitive treatment or palliative treatment.

What we found was that race was significantly associated with receiving definitive treatment. In particular, black men were significantly less likely to receive definitive treatment over white men.

We know from multiple studies that black Americans are much more likely to die with prostate cancer than white men. That's due to multiple reasons. More recently, we've been looking at socioeconomic construct associated with the race as a driving feature.

That's something similar that we found in our analysis. On multiply statistical analysis we did, we found that the socioeconomic factors associated with race may be driving that disparity or the undertreatment of this population.

Overall, in this analysis, which again, we presented at ASCO GU in 2021, what we found was that in men 80 years or older in the United States with high‑risk prostate cancer, majority of men do not receive definitive therapy. Again, that means surgery or radiation therapy.

Over 50% of men typically receive palliative or conservative treatments. That's hormone therapy alone or observation. Interestingly, we found that definitive treatment was associated with a 50% reduction in overall mortality compared to conservative treatments.

Treating these men weren't a discussion. There weren't actually critical thinking in the clinic to really determine whether a man has a decent performance status in a relatively long life expectancy, meaning over 5 years, to where treatment should be considered.

In a note, another compelling point is that race is significantly associated with a likelihood of undertreatment. Particularly, black Americans are at risk of undertreatment compared to white Americans.

Patel SA, Gay HA, Michalski JM. Utilization and survival outcomes between definitive versus conservative treatments among elderly men with high-risk prostate cancer. Presented at: the virtual 2021 ASCO Genitourinary Cancers Symposium; February 11-13, 2021. Abstract 204.

Dr Patel reports no relevant financial relationships.

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