Management of localized prostate cancer in men over 65 years

With the pervasive use of prostate-specific antigen-based screening, many men in the US are now diagnosed with prostate cancer in their 50s or earlier. However, the majority of tumors are still detected among men over 65-years-old. The appropriate management of localized disease among these older men is controversial.

The US Preventive Services Task Force recently strengthened its recommendation against screening men over 75 years old. To date, however, screening among older patients remains common, and does not adequately reflect patient life expectancy. Older men are more likely to be diagnosed with higher-risk tumors, but are less likely to receive curative local therapy, and are more likely to be managed with primary androgen deprivation therapy. Careful active surveillance is an increasingly viable option for selected older men with low-risk tumors; focal therapy and low-intensity medical therapy may be emerging alternatives in the near future.

Decisions regarding both screening and treatment should consider patient comorbidity, life expectancy, and treatment preferences rather than chronologic age. Treatment also must be tailored to the level of tumor risk. Increased use of active surveillance, together with diet and lifestyle intervention, is appropriate for many older men with lower-risk tumors. Conversely, those with high-risk disease should not be denied the opportunity for curative local therapy on the basis of age alone.