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Thread: Have Questions about prostate Biopsies for those over 70 ???

  1. #1
    Newbie New User
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    Have Questions about prostate Biopsies for those over 70 ???

    I am 74 and have had an accelerated psa that went fro.6 to 4.2 in one year. The psa was repeated with the same elevated result

    I will undergo a biopsy in 10 days, and have some questions.

    My urologist told me that it is standard practice that patients over 70 are not having having their prostrates surgically removed if cancer is found, but are being treated with radiation.

    He appears to be a competent urologist who is respected by other medical professionals

    I found this information surprising because f those individuals I know who have had PC have gone the surgery route, but then they were much younger than me.
    Would appreciate any comments about this from those that have had biopsies over the age of 70.

    If no cancer cells are found do you have to receive biopsies periodically ?

    Thanks for your help

  2. #2
    Biopsies are warranted when other tests like PSA, DRE, MRi, or others indicate a suspicion of prostate cancer. I do not know of an upper age limit for prostate biopsies. My doctors will do another if they see unfavorable changes.

    Generally, older people should not be operated on if there is an equally effective treatment that does not involve anesthesia or cutting.

    That is certainly the case with prostate cancer, as radiation has non-recurrence results equal or better than surgery.

    If cancer cells are found and the risk level is low, then you would likely have periodic biopsies to monitor it. If no cancer cells are found, and the other tests remain suspicious, then another biopsy may need to be done, as the needles often miss areas of concern.
    DOB: May 1944
    In Active Surveillance program at Johns Hopkins
    Strict protocol of tests, including PHI, DRE, MRI, and biopsy.
    Six biopsies from 2009 to 2019. Numbers 1, 2, and 5 were negative. Numbers 3,4, and 6 were positive with 5% Gleason(3+3) found. Last one was Precision Point transperineal.
    PSA has varied up and down from 3 to 10 over the years. Is 4.0 as of September 2019.
    Hopefully, I can remain untreated. So far, so good.

  3. #3
    Generally they don’t do surgery unless your life expectancy is 10 years. Heart disease also removes surgery as an option. So if you are in good health, 75 is about the cut off age.

    You need a biopsy.
    YOB 1957

    DX 12/18, GS 8, 4+4 6/12 cores, LL Apex 100%, LM Apex 60%, LL Mid 50%, LMM 40%, LL Base 5%, LM <5%, Right side negative.

    3/6/19. Pathology - Grade Group 4 Intraductal Carcinoma
    T3aNO, 1 mm EPE, GS8, 21 mm uni-focal tumor involved 10% of prostate.

    7 Nodes, SV, SM, PNI, and BNI were negative.

    LVI and Cribriform pattern present.

    Decipher .86 High Risk.

    Post Surgery PSA
    3/25/19 .03. (<1 month)
    4/25/19 <.03. (2 months)
    5/25/19 <.02. (3 months)
    9/10/2019. <.02. (6 months)
    11/27/2019. <.02. T<3. (9 months)

    3 Part Modality Treatment

    2/25/19 Robotic Laparoendoscopic Single Site Surgery outpatient Cleveland Clinic,

    ADT - started 6/19, end date 6/21.

    ART - Completed 9/26/19. (78 Gy, yes, I glow in the dark)

  4. #4
    Radical prostatectomy in patients aged 75 years or older: review of the literature [2019]

    Abstract

    Given the demographic trends toward a considerably longer life expectancy, the percentage of elderly patients with prostate cancer will increase further in the upcoming decades. Therefore, the question arises, should patients ≥75 years old be offered radical prostatectomy and under which circumstances? For treatment decision-making, life expectancy is more important than biological age. As a result, a patient's health and mental status has to be determined and radical treatment should only be offered to those who are fit. As perioperative morbidity and mortality in these patients is increased relative to younger patients, patient selection according to comorbidities is a key issue that needs to be addressed. It is known from the literature that elderly men show notably worse tumor characteristics, leading to worse oncologic outcomes after treatment. Moreover, elderly patients also demonstrate worse postoperative recovery of continence and erectile function. As the absolute rates of both oncological and functional outcomes are still very reasonable in patients ≥75 years, a radical prostatectomy can be offered to highly selected and healthy elderly patients. Nevertheless, patients clearly need to be informed about the worse outcomes and higher perioperative risks compared to younger patients.


    ROBOT-ASSISTED RADICAL PROSTATECTOMY IN THE ELDERLY: A PROPENSITY-MATCHED COMPARISON OF ONCOLOGICAL AND FUNCTIONAL OUTCOMES [2019]

    Abstract

    INTRODUCTION AND OBJECTIVES:
    Radical prostatectomy is the recommended definitive surgical treatment for organ-confined prostate cancer in eligible men who meet the criteria for curative radical therapy. One of the main eligibility criteria is that the life expectancy should be at least 10 years. Compared to open surgery, whilst the reduction in the morbidity of surgery through robot-assisted radical prostatectomy (RARP) would intuitively suggest its potential advantage in the elderly, data specifically addressing its outcomes in the elderly are sparse. The aim of this study was to report on the safety (complications) and efficacy (oncological and functional outcomes) of RARP at our institution in those aged over 70.

    METHODS:
    Review of our prospectively collected database (Cancer Information Systems [CAISIS]) identified two hundred and fifteen (215) patients, aged >70, who underwent RARP for localized prostate cancer between July 2003 and August 2017. A propensity score-matched analysis was performed, incorporating multiple covariates (e.g. Charlson Comorbidity Index, ASA, BMI, PSA, D'Amico risk, etc.), to stratify the comparison groups of patients into Age <70 and Age≥71.

    RESULTS:
    Apart from Age (Mean ± SD years: 73.5 ± 2.1 versus 59.5 ± 5.9, p<0.001), the two groups were matched (all p-values >0.05) except for D'Amico grading which was higher in the Age ≥71 group. Median follow-up was 4.9 years. There were no 90-day mortalities in either group. Major [Clavien ≥Grade 3] and minor [Clavien <3] complications (p=0.08 ), Operating time (p=0.79), Estimated Blood Loss (p=0.29), Length of hospital stay (p=0.09) and catheterization duration (p=0.12) were similar. On final pathology, a higher Gleason score (p=0.006) and higher stage (p<0.001) were observed in the Age≥71 group. However, this did not translate adversely into a higher positive surgical margin, positive lymph node, biochemical relapse or cancer-specific mortality (p>0.05), allowing for the current follow-up duration (median 4.9 years). In terms of functional outcomes, there were no differences in post-operative erectile dysfunction (p=0.42). However, pad-free continence was significantly better in the younger cohort (p<0.001).

    CONCLUSIONS:
    RARP should not be denied to those over 70 years solely on the basis of their age. Older men need to be counseled about the likelihood of encountering a higher rate of higher risk features on final pathology and that their pad-free continence may be lower compared to a younger person.


    Recovery of pad-free continence in elderly men does not differ from younger men undergoing robot-assisted radical prostatectomy for aggressive prostate cancer [2019]

    CONCLUSIONS:
    Regardless of age, return to continence in men with aggressive prostate cancer undergoing RARP continues to improve way beyond the first 12 months after surgery. Considering the dire effects of post-operative radiotherapy on continence in this aggressive cancer cohort, advanced age alone should not discourage recommending multimodal therapy involving RARP.

  5. #5
    What the general rule of thumb is that patients under 60 get recommended for surgery, those over 70 for radiation, those in between can go for either.

    Right now, you haven't been diagnosed, so you wouldn't get either.
    Nov 2013 PSA 4.2 Biopsy Jan 2014- 1 core positive, 20% Gleason 6, doctor highly reco'ed robotic RP - 2nd opinion at UPMC April 2014, put on active surveillance. 2nd biopsy Feb 2015, results negative. PSA test Feb 2016, 3.5. 3rd Biopsy Feb 2016. 3 positive cores less than 5%, Gleason 6. Octotype DX done April 2016, GPS Score of 24--rated "Low risk". PSA test 8/2016, 3.2. PSA test 1/2018 2.2 (after 7 months of proscar) PSA test 7/2018 2.3, PSA test 7/2019 2.0


    DOB 1956, in Pittsburgh, USA

  6. #6
    Quote Originally Posted by Southsider View Post
    What the general rule of thumb is that patients under 60 get recommended for surgery, those over 70 for radiation, those in between can go for either.

    Right now, you haven't been diagnosed, so you wouldn't get either.
    Or depending on the G score, another local treatment.
    YOB 1957

    DX 12/18, GS 8, 4+4 6/12 cores, LL Apex 100%, LM Apex 60%, LL Mid 50%, LMM 40%, LL Base 5%, LM <5%, Right side negative.

    3/6/19. Pathology - Grade Group 4 Intraductal Carcinoma
    T3aNO, 1 mm EPE, GS8, 21 mm uni-focal tumor involved 10% of prostate.

    7 Nodes, SV, SM, PNI, and BNI were negative.

    LVI and Cribriform pattern present.

    Decipher .86 High Risk.

    Post Surgery PSA
    3/25/19 .03. (<1 month)
    4/25/19 <.03. (2 months)
    5/25/19 <.02. (3 months)
    9/10/2019. <.02. (6 months)
    11/27/2019. <.02. T<3. (9 months)

    3 Part Modality Treatment

    2/25/19 Robotic Laparoendoscopic Single Site Surgery outpatient Cleveland Clinic,

    ADT - started 6/19, end date 6/21.

    ART - Completed 9/26/19. (78 Gy, yes, I glow in the dark)

  7. #7
    Moderator Top User HighlanderCFH's Avatar
    Join Date
    Nov 2011
    Posts
    7,281
    Welcome to the forum, provlima. Here's hoping you are just passing through and that your biopsy rules out PC.

    If you do get a positive diagnosis, you should consult with a top radiation oncologist AND a uro/surgeon who performs surgery. Learn the in and out of both treatment types.

    You are definitely at an age when most men would opt for radiation. But, for what it's worth, my Dad was diagnosed with PC at the age of 73 and had surgery at Mayo Clinic. He did just fine and the surgery was successful.

    The cure rates between radiation and surgery are virtually the same. So the treatment option -- if you are diagnosed -- would be your choice after consulting with specialists on both sides.

    Please let us know what your biopsy results are when the time arrives.

    Good luck!
    Chuck
    July 2011 local PSA lab reading 6.41 (from 4.1 in 2009). Mayo Clinic PSA 9/ 2011 = 5.7.
    Local uro DRE revealed significant BPH, no lumps.
    PCa Dx Aug. 2011 age of 61.
    Biopsy DXd adenocarcinoma in 3/20 cores (one 5%, two 20%). T2C.
    Gleason 3+3=6. CT abdomen, bone scan negative.
    DaVinci prostatectomy 11/1/11 at Mayo Clinic (Rochester, MN), nerve sparing, age 62.
    Surgeon was Dr. Matthew Tollefson, who I highly recommend.
    Final pathology shows tumor confined to prostate.
    5 lymph nodes, seminal vesicules, extraprostatic soft tissue all negative.
    1.0 x 0.6 x 0.6 cm mass involving right posterior inferior, right posterior apex & left
    mid posterior prostate. Right posterior apex margin involved by tumor over 0.2 cm length,
    doctor says this is insignificant.
    Prostate 98 grams, tumor 2 grams.
    Catheter out in 7 days. No incontinence, minor dripping for a few weeks.
    Eight annual post-op exams 2012 through 2019: PSA <0.1
    Semi-firm erections without "training wheels," usable erections with 100mg Sildenafil.
    NOTE: ED caused by BPH, not the surgery.

  8. #8
    Top User
    Join Date
    Aug 2016
    Posts
    1,939
    Age, as a rule of thumb, in determining healthcare is a useful starting point to discussing the real issues, but it is not alone the final formative source of any choice.

    For example, what is your life expectancy. This is a valid question and the answer guides many health choices. I am fit; have an exceptionally healthy lifestyle; have long lived relatives living well into their 90s; no age related issues such as high blood pressure, obesity, high cholesterol, diabetes, or cardiovascular concerns. I make my healthcare choices on an expectation of living well into my 80s maybe early 90s. Any serious healthcare choice begins with this assessment of yourself and your chronological age becomes a lesser factor in this assessment.

    Two of my brothers have had successful RPs over the age of 70. Both would have had better treatment results if they had acted sooner, not because of their age, but because they failed in early detection and early treatment.

    That said, recovery is slower the older you get for any treatment.

    Take it one step at a time and keep everything on the table as you go. Rules of thumb are useful as far as they go then the facts take over.

    In response to your doctor's comments, there are legitimate reasons to choose surgery or other treatment at your age if you have prostate cancer, and they will become apparent to you as you proceed to educate yourself and investigate your rising PSA. Your age is only one of the factors.

    That said, if you expressed concern as a bias against surgery many doctors will follow your lead and offer supportive comments to keep you engaged, i.e. we don't do surgery at your age. Any treatment is better than no treatment if treatment is called for.

    Your doctor may already be aware of some specific issues related to you making you a poor candidate for surgery leading to his remark. If this is the case, he should have outlined those in the moment in context with his comment. If he didn't, make a mental note your doctor may not be as forth coming, direct, and informative as you may like if facing a serious disease such a prostate cancer.

    There are protocols and rules of thumb. They are distinct. You want to know the protocols and abide them as you go down this path. They are time tested. We have a long working health history with prostate cancer. It is detectable, highly treatable for long term cures, and manageable for long term quality of life. Rules of thumb in this journey are useful only as far as they go.

    Then there is the 80 rule. Eighty percent of all men will have prostate cancer by the time they are 80. The average male life expectancy in this country is 76.1 and falling. So unless you expect to live beyond 76 you have nothing to worry about.

    Finally, if you may live another 20 years and are diagnosed with an aggressive form of prostate cancer and detect it early enough for a possible cure, and this cancer comes in many forms, you may want to consider a more aggressive form of treatment. Surgery gives you a pathology report of the type, location, and volume of cancer not fully available from a biopsy. This is useful for follow up radiation. You may also switch your care to a cancer center of excellence in this scenario. I guarantee you will not hear a comment such as your doctor's there. They will consider the facts first. Don't put the cart before the horse.

    Your PSA is not unusually high for your age, but the rapid change is notable. Are you taking testosterone supplements? This is becoming more common, especially in younger men, and it is a wild card with prostate cancer. It is not a recommended use to counter the effects of aging.

    Hang out here. You will not find a better more supportive and informative forum on the internet.
    Last edited by Another; 11-18-2019 at 10:35 AM.

  9. #9
    Top User garyi's Avatar
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    I tolerated surgery above 70 very well, no ill effects. I think what your urologist is telling you is nonsense. The potential side effects from radiation, when combined with ADT, are daunting. There are no free lunches when it comes to prostate cancer.

    I hope someone else will read and evaluate your biopsy, and I would arrange now to get have your slides sent to Johns Hopkins for a second opinion. With a bit of luck, you may not require any treatment.

    Good luck!

  10. #10
    How to choose proper local treatment in men aged ≥75 years with cT2 localized prostate cancer? [2019, Full Text]

    Abstract

    Background
    For localized prostate cancer (PCa), radical prostatectomy (RP) and radiotherapy (RT) are two standard interventions to decrease PCa mortality. Contemporary studies contained the elderly people; analyses focusing on patients over 75 years of age were still lacking.

    Method
    In the Surveillance Epidemiology and End Results (SEER) database (2004‐2015), people over 75 years of age with cT2 stage were selected in our research. Multivariable Cox proportional hazard models were used to analyze cancer‐specific mortality (CSM) and overall mortality (OM) after adjustment. The propensity score matching was performed to assume the randomization. An instrument variate (IVA) was used to calculate the unmeasured confounders.

    Results
    Radical prostatectomy is superior to RT in OM and CSM after adjustment for covariates (HR = 0.54, 95% CI = 0.47‐0.62, P < 0.001 and HR = 0.30, 95% CI = 0.20‐0.45, P < 0.001, respectively). The cox model after matching indicated similar consequence (OM: HR = 0.53, 95% CI = 0.46‐0.62, P < 0.001; CSM: HR = 0.27, 95% CI = 0.17‐0.43, P < 0.001). In the IVA‐adjusted model, the effect of treatment changed slightly (OM: HR = 0.65, 95% CI = 0.54‐0.78, P < 0.001; CSM: HR = 0.21, 95% CI = 0.12‐0.37, P < 0.001). Subgroup analyses showed that for patients with GS = 7, those received RP obtained the highest risk decline for overall death (HR = 0.41, 95% CI = 0.32‐0.52); and for patients with younger age, those received RP obtained the highest risk decline for CSM (HR = 0.11, 95% CI = 0.01‐0.52).

    Conclusion
    Patients over 75 years of age with cT2 stage will obtain more benefit from RP compared with RT, especially for patients with GS = 7 and younger age.

 

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