March 2, 2007

Radical Prostatectomy For Octogenarians: How Old Is Too Old? There is no defined recommendation for when to stop prostate cancer (CaP) screening, except when the life expectancy decreases to less than 10 years. In the United States, it is relatively uncommon for a man to undergo radical prostatectomy (RP) as definitive therapy beyond the age of 75 years. Yet life expectancy for a man in his upper 70s is about 10 years. Some men older than age 80 are fit and demand definitive therapy in the form of RP. Dr. Thompson and colleagues at the Mayo Clinic, Rochester MN identified a group of 19 men over age 80 who underwent RP and report on their outcomes in the November issue of Urology.

From 1986 to 2003, 13,154 men were treated with RP at the Mayo Clinic. Of these, 19 (0.4%) were 80 years or older at surgery. Overall, their database revealed that 876 men were diagnosed with localized CaP during this time period. The clinical, pathological, oncologic and functional outcomes were retrospectively assessed.

Mean patient age was 81 years, median pre-operative PSA was 10.2ng/ml, all men had clinical T1-2 disease and no patient had known metastasis. The mean American Society of Anesthesiologists score was 2.4. Records indicated that 5 patients specifically demanded RP and were opposed to age discrimination and in addition, 5 patients were physicians. On pathology, 13 (68%) had organ-confined disease, 2 had pT3a, 4 had pT3b, and 3 had a positive surgical margin. Gleason score was 7 or greater in 11 men (58%) and all had a negative pelvic lymphadenectomy.

While no peri-operative complications occurred and 3 received a blood transfusion, but these men all had surgery prior to 1992. Median follow-up was 10.5 years and no patient died within the first year after RP. Three men died less than 10 years after RP and no patient died from CaP. Ten patients survived more than 10 years, with 7 alive at a mean follow-up of 12.8 years. No overall survival difference was found comparing the survival of these patients (79%) with patients 60-69 years old (84%) and 70-79 years olds (75%) from the Mayo database during the same time period. Four men experienced a biochemical recurrence of PSA level 0.4ng/ml or greater. One patient with a positive surgical margin received adjuvant radiotherapy.

Regarding functional outcomes, one year after RP, 14 patients (74%) were using less than 1 pad/day for incontinence, 2 used 1 pad/day, 2 needed 2 pads/day or more and 1 required an artificial urinary sphincter. Nerve sparing was not performed in these men.

To the authors' knowledge, this is the first report of RP in octogenarians. While their data supports that RP can be performed safely in these men with good outcomes, it does not answer the question whether it is necessary. Other non-definitive modalities such as active surveillance and delayed androgen deprivation might give comparable results but were not compared in this study.

ThompsonВ RH, SlezakВ JM, WebsterВ WS, LieberВ MM
Urology 2006; 685(5):1042-45

Reviewed by Contributing Editor Christopher P. Evans, MD

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