Tumour characteristics, oncological and functional outcomes in patients aged ≥ 70 years undergoing radical prostatectomy

Abstract

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? The marked increase in life expectancy in recent years calls for reconsideration of the decision-making process for the treatment of prostate cancer, a condition particularly affecting the elderly. To date the general approach in elderly patients has tended to be more conservative, not least as it is generally thought that prostate cancer in these patients is less biologically aggressive. The present data showed that patients aged ≥70 years had biologically more aggressive tumours significantly more often than those aged <70 years. Nevertheless, advanced age itself was not an independent predictor of survival after retropubic radical prostatectomy, whereas adverse prostate cancer features and severe comorbidities were.

Objective: To investigate the effect of advanced age (≥70 years) on prostate cancer characteristics, oncological and functional outcomes in patients undergoing retropubic radical prostatectomy (RP).

Patients and methods: Between June 1997 and September 2009, 1636 patients underwent RP at one institution. Of these patients, 1225 were aged < 70 years and 411 ≥70 years. Both groups were compared for prostate cancer characteristics, oncological and functional outcomes. Multivariate analyses were used to estimate the effect of advanced age on overall survival (OS), cancer-specific survival (CSS), biochemical recurrence-free survival (BFS) and postoperative continence.

Results: The median (range) age of the patients aged ≥ 70 years was 72 (70-85) years and for those aged < 70 years was 64 (40-69) years (P < 0.001), respectively. The patients aged ≥ 70 years were assigned higher American Society of Anesthesiologists (ASA) classes (P < 0.001) reflecting a higher rate of severe comorbidities in this group. In the patients aged ≥ 70 years there were significantly more clinically palpable and pathologically non-organ-confined tumours (P= 0.030 and P= 0.026, respectively), and higher biopsy and RP Gleason scores (P= 0.002 and P= 0.004, respectively). Accordingly, patients aged ≥ 70 years presented with a higher proportion of high-risk prostate cancer, although the difference was not significant (P= 0.060). There were no differences between the groups for preoperative prostate-specific antigen level (P= 0.898), rate of pelvic lymph node dissection (P= 0.231), pN+ (P= 0.526) and R+ status (P= 0.590). Kaplan-Meier curves showed a significantly lower 10-year OS (67 vs 82%; P= 0.017) and a trend towards a lower 10-year CSS (70 vs 83%; P= 0.057) in patients aged ≥ 70 years. However, on multivariate analysis advanced age was not an independent predictor of OS (P= 0.102) or CSS (P= 0.195), whereas pN+ status (both P < 0.001), RP Gleason scores 8-10 (both P < 0.001) and ASA classes 3-4 (P= 0.037 and P= 0.028, respectively) were. The 2-year postoperative continence rates was comparable between the groups (International Continence Society [ICS] male incontinence symptom score 2.10 vs 2.01; P= 0.984). In multivariate analysis it depended only on the preoperative ICSmale incontinence symptom score (P < 0.001) but not on advanced age (P= 0.341).

Conclusions: Patients aged ≥ 70 years had biologically more aggressive and locally advanced tumours significantly more often than those aged < 70 years. However, advanced age itself was not an independent predictor of survival after RP. Rather, survival was associated with adverse prostate cancer features and severe comorbidities. Consequently, it seems unjustifiable to generally exclude elderly patients from RP, not least because surgery achieved excellent postoperative continence in this age group, too.