Annals of Long Term Care

Prostate cancer is a common disease and is the second leading cause of cancer-related death in men. However, many older men with prostate cancer will die from comorbid illness rather than cancer. Survival from prostate cancer with available treatment options, including surgery, radiation, androgen suppression, and watchful waiting, is mediated by age, tumor grade, and comorbid illness. Due to the long natural history of prostate cancer and the presence of competing comorbidities, the majority of elderly men with newly diagnosed prostate cancer will not benefit from curative therapy. Even more relevant to the long-term care population is the further lack of benefit from diagnosing early-stage prostate cancer in men with advanced age, multiple comorbidities, and a high prevalence of dementia. Thus, in the long-term care population, a rational approach to the detection of prostate cancer is to evaluate suspected symptomatic or metastatic disease exclusively. (Annals of Long-Term Care: Clinical Care and Aging 2009;17[11]:22-28)

Introduction

Although prostate cancer is a common cause of cancer-related mortality in men, the majority of men with prostate cancer will not die from the disease. Most patients present with localized disease, and men who are diagnosed with low-grade prostate cancer are more likely to die from comorbidities rather than from the cancer.^1,2

With increasing age and increasing number and severity of comorbid illnesses, the impact of the stage of prostate cancer at diagnosis on survival diminishes. Thus, the benefit of diagnosing earlier stage disease through regular screening is not achieved, while the risk of physical and emotional discomfort that may result from screening persists.

The purpose of this review is to discuss recommendations for the evaluation of prostate cancer in men residing in long-term care (LTC). As such patients have multiple comorbidities and a limited life expectancy, a discussion of the detection and subsequent treatment of prostate cancer in this vulnerable population is warranted. Due to the indolent nature of the disease, the high incidence in elderly men, and the risk-benefit ratio for treating prostate cancer in men with a life expectancy of 10 years or less, screening for prostate cancer in LTC settings should not be routine. Symptoms of prostate cancer should be evaluated and treated, but a diagnosis of prostate cancer should be pursued only when symptomatic disease is suspected.

Background

Prostate cancer is the most common cancer in men. In the United States in 2007, over 200,000 new cases of prostate cancer were diagnosed, and 27,000 deaths were attributed to prostate cancer. Despite the fact that prostate cancer is the second leading cause of cancer death in men, it causes only about 3% of all deaths in men.³

The incidence of prostate cancer in the United States rose significantly between 1987 and 1992. This increase is attributable to the widespread screening for prostate cancer using the prostate-specific antigen (PSA) test. Figure 1 shows the trend of increasing incidence of prostate cancer in the Surveillance, Epidemiology, and End Results Program.