29 Jun 2017

Improved prostate cancer management vital for older men

Associate Professor Jeremy Grummet (right) with a patient
by Anne Crawford

Prostate cancer is the most frequent male cancer and the third most common cause of cancer death in Australia.

With an exponentially ageing population and lengthening life expectancy, the burden of this cancer – already a disease of older males – is going to be what Monash University Associate Professor Jeremy Grummet calls “massive”. The number of Australians aged 65 and over is expected to increase from around 2.5 million in 2002 to 6.2 million in 2042; from around 13 per cent of the population to 25 per cent.

It was critical therefore that the issue of how to better manage prostate cancer in older men was properly addressed, said Associate Professor Grummet in a paper he co-authored in ‘European Urology’. Associate Professor Grummet is a urological surgeon at Alfred Health, Adjunct Clinical Associate Professor with the Department of Surgery and Associate of the European Association of Urology (EAU) Guidelines Office.

He was invited to comment on the updated International Society of Geriatric Oncology (SIOG) guidelines for prostate cancer management for older men (aged 70 plus), in the same edition. Previous SIOG guidelines on prostate cancer management for older men have been incorporated into the EAU guidelines, which are well-accepted by in Australia.

“The point of the article was to try to think harder about how we’re going to manage these men, not just to say ‘you’re too old, there’s no point in us testing you, you’re going to die of something else’,” he said. “Some guys in their early seventies may be fighting fit with no other health problems and have hereditary longevity because their parents died in their nineties.”

Conversely, for men in their eighties with a range of other serious medical issues, it was inappropriate to screen for prostate cancer – without symptoms – because the prostate cancer would not cause them any harm.

“The updated guidelines are saying that we should introduce a more structured evaluation for co-morbidities and other medical issues to give us a better idea of a patient’s life expectancy,” he said.

Importantly, they recommended a short test to screen for cognitive function. This could help in managing the patient and, in the case of Alzheimer’s disease, may indicate life expectancy. If a patient’s life was going to be considerably shorter because they had Alzheimer’s, a physician might switch strategies for prostate cancer, deciding not to screen for, or treat it to avoid possible side effects.

“In that case we might say ‘we think you have prostate cancer but we’re not going to treat it because we think we’ll do more harm from the treatment than the prostate cancer will do to you’,” Associate Professor Grummet said.

Prostate surgery can cause erectile dysfunction, which decreases quality of life for the significant proportion of men who were still sexually active at that age, he said. Incontinence could be another undesirable, if less common outcome of surgery, and radiotherapy can have side effects relating to bladder and bowel function.

“So you can imagine with all those potential side effects that you need a really good reason to treat the cancer.”

The authors pointed out that the field of prostate cancer management among older men was still ripe for vigorous clinical research, but in the interim the updated guidelines acted as a very practical clinical tool.

“We need a plan – we really haven’t had one,” said Associate Professor Grummet. “This is a first step towards that,” he said.

Grummet JP, Plass K, N'Dow J. Prostate Cancer Management in an Ageing Population. 
Eur Urol. 2017 Apr 19. pii: S0302-2838(17)30290-7. doi: 10.1016/j.eururo.2017.04.010. [Epub ahead of print]

To find out about the full guidelines

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