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Radical Prostatectomy Safe at Least Up to Age 75

Fuerst, Mark L.

doi: 10.1097/01.COT.0000289803.94713.28
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While few men older than 70 are treated with radical prostatectomy, the procedure is a safe option for the treatment of prostate cancer in otherwise healthy men up to at least age 75, according to a new Canadian study.

To determine whether the low use of radical prostatectomy in men ages 70 and older is justified by the rates of complications or mortality, a team led by Shabbir Alibhai, MD, Assistant Professor in the Department of Medicine and Health Policy, Management, and Evaluation at the University of Toronto, evaluated those rates within 30 days following radical prostatectomy in 11,010 men who underwent the surgery in Ontario between 1990 and 1999.

There were three major findings in this retrospective, cohort study, published in the October 19 issue of the Journal of the National Cancer Institute (2005;97:1525–1532), Dr. Alibhai noted in an interview:

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Figure:
Shabbir Alibhai, MD: “We need to think more carefully about who we select for radical prostatectomy, particularly for men above age 70. The perception among patients and urologists is that surgery is not as safe as other treatment options, but if we carefully select older men who are otherwise healthy, the mortality risk is acceptable, and there is not a large increase in risk from comorbidity.”
  • There was a small but statistically significant increase in 30-day mortality with increasing age among men undergoing radical prostatectomy, even after adjusting for comorbidity. The odds roughly doubled in each succeeding decade.
  • Increasing age was statistically significantly associated with increased risks of cardiac, respiratory, and miscellaneous medical complications and decreased risks of miscellaneous surgical complications within 30 days of radical prostatectomy.
  • Increasing comorbidity was associated with increased risks of 30-day mortality and of every category of complications, independent of increasing age.

Overall, 53 men (0.5%) died, and 2,246 (20.4%) experienced one or more complications within 30 days of surgery. In models adjusted for comorbidity and year of surgery, age was associated with an increased risk of 30-day mortality (odds ratio of 2.04 per decade of age). However, the absolute 30-day mortality risk was low (0.66%) even among men age 70 to 79.

“We need to think more carefully about who we select for radical prostatectomy, particularly for men above age 70,” Dr. Alibhai said. “The perception among patients and urologists is that surgery is not as safe as other treatment options, but if we carefully select older men who are otherwise healthy, the mortality risk is acceptable, and there is not a large increase in risk from comorbidity.”

Increasing Comorbidity Is Stronger Predictor than Age of Problems

Increasing comorbidity appears to be a stronger predictor than age of early complications after radical prostatectomy, he said. “We have to pay attention to cardiovascular risk factors, particularly cardiovascular disease or stroke, both of which are associated with changes in both short- and long-term mortality.”

A previous myocardial infarction is one of the cardiovascular factors he is most concerned about, Dr. Alibhai said. “MI patients should see an internist or cardiologist prior to surgery for a preoperative assessment. Patients with no existing coronary artery disease probably are still at low risk and could be accepted for surgery.”

A previous transient ischemic attack or stroke is an indication of significant systemic vascular disease, which increases the risk of complications, Dr. Alibhai added. “These patients need to have a careful preoperative evaluation and should be taking medications to lower their risk of perioperative complications.”

Study Limitations

He admits that the study has some limitations. For example, the number of men over age 75 in the study was small, “so it's harder to extrapolate over age 75,” he said. “We are confident with the data up to age 75.”

Also, the administrative data from the large cancer registry does not have the same clinical richness as would a physician's chart or a clinical record. “Potentially, we are not capturing the severity of comorbid illnesses and interactions between illnesses,” Dr. Alibhai explained. “And we did not look at long-term incontinence and sexual dysfunction, which clearly are at higher risk in older men.

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Figure:
Farhang Rabbani, MD, said that the general guideline at Memorial Sloan-Kettering Cancer Center is that if a patient does not have a 10-year life expectancy, then surgery is not offered for prostate cancer. “We do not think that surgery is a good first choice, because the patient will derive little benefit from an operation compared with radiation therapy, which has a lower incidence of incontinence.”

“For men age 70 to 75, we can confidently say if they are clinically appropriate for surgery in tumor stage and grade with higher-risk disease, careful selection of patients with coexisting medical illnesses can result in a low risk for surgical complications within 30 days.”

Not Sure If Changes Pattern of Practice

Asked for his opinion of the study, Farhang Rabbani, MD, Assistant Attending in the Department of Urology at Memorial Sloan-Kettering Cancer Center, noted that the paper makes no comment on the cancer itself—for example, the Gleason score or severity of disease.

“We can't extrapolate any of that,” he said. “The fact that perioperative mortality is low does not justify surgery. Comorbidity—incontinence and impotence—is more of a consideration in an older age group.”

While it is encouraging that perioperative mortality is low in the over-70 age group if comorbidities are limited, “I'm not sure whether this changes the pattern of practice,” Dr. Rabbani said. “I wouldn't recommend to a patient in that age range to have surgery just because perioperative mortality is low.”

The general guideline at Sloan-Kettering, he said, is that if a patient does not have a 10-year life expectancy, then surgery is not offered for prostate cancer.

“We do not think that surgery is a good first choice, because the patient will derive little benefit from an operation compared with radiation therapy, which has a lower incidence of incontinence,” Dr. Rabbani said. “A case could be made to be more aggressive and offer surgery to a patient who is age 75, has a Gleason score of 7, and higher-volume disease.”

© 2006 Lippincott Williams & Wilkins, Inc.
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