Prostate cancer is the most common cancer in men, and its incidence rises significantly with age. For a man diagnosed in his mid-70s, the decision to pursue treatment is complex. Unlike younger men who often proceed directly to curative treatment, managing prostate cancer in older men requires balancing the disease’s threat against potential treatment side effects. The goal shifts from eradicating the cancer to ensuring the best possible quality of life in the remaining years. This decision involves assessing the patient’s health status and the tumor’s specific characteristics.
Assessing Overall Health and Life Expectancy
The most important factor in determining the best course of action is not chronological age, but biological age and overall health status. Curative treatments are typically recommended only for men with a life expectancy of ten years or longer. This benchmark exists because prostate cancer often grows slowly, and the benefits of aggressive therapy may not be realized until years after the procedure.
Doctors use tools like the Charlson Comorbidity Index to quantify existing health issues, or comorbidities. Conditions such as severe congestive heart failure, COPD, or uncontrolled diabetes significantly reduce life expectancy. A healthy, active 75-year-old man, often referred to as “fit,” may warrant aggressive treatment similar to a younger patient.
Conversely, a frail 75-year-old with multiple health problems is unlikely to tolerate aggressive treatment or recover sufficiently. The side effects of immediate treatment, such as major surgery, would likely cause more harm and diminish quality of life without providing a survival advantage. The distinction between a fit and a frail patient guides whether the focus should be on cure or symptom management.
Determining the Cancer’s Aggressiveness
The tumor’s characteristics are the second major factor guiding the treatment decision. Many prostate cancers are “indolent,” meaning they are slow-growing and unlikely to cause symptoms or spread during the patient’s natural lifespan. Determining the cancer’s potential for harm involves two primary measures: the PSA level and the Gleason Score.
The Prostate-Specific Antigen (PSA) blood test helps in initial risk stratification when combined with other factors. The Gleason Score (or Grade Group) is assigned after a biopsy and describes how abnormal the cancer cells look. A lower Gleason Score, such as 6 (Grade Group 1), indicates a less aggressive, slow-growing cancer.
High-risk prostate cancer is defined by a high PSA level, a high Gleason Score (8 to 10), or locally advanced disease. This means the tumor is highly likely to spread and cause death if left untreated. For an otherwise healthy man, a high-risk tumor typically requires immediate, definitive intervention. Conversely, a low-risk tumor in a man with a limited life expectancy is often monitored rather than actively treated.
Evaluating Active Treatment Options and Quality of Life Trade-offs
If a 75-year-old man is healthy enough and his tumor aggressive enough for curative treatment, options include surgery or radiation therapy. Radical prostatectomy, the surgical removal of the prostate gland, is a major operation with immediate and long-term risks. The most significant trade-offs for an older man are the potential for long-term urinary incontinence and erectile dysfunction.
Following surgery, long-term urinary incontinence (defined as needing multiple pads per day) affects 12 to 16% of patients, with the rate increasing slightly with age. Erectile dysfunction is also common; up to 87% of men report an inability to achieve an erection firm enough for intercourse 24 months after the procedure. These side effects are immediate, though they may improve over time.
Radiation therapy, delivered externally (External Beam Radiation Therapy) or internally (brachytherapy), is less invasive than surgery but still carries quality-of-life consequences. Side effects develop gradually over months or years. While the risk of severe long-term urinary incontinence is lower than with surgery, patients face an increased risk of bowel problems, such as rectal bleeding or urgency, due to the prostate’s proximity to the rectum.
Hormone therapy reduces the body’s testosterone levels. It is often used with radiation or as a palliative measure for advanced disease, as it is not curative on its own but slows cancer growth. However, it can accelerate frailty and lead to side effects like hot flashes, loss of muscle mass, and decreased bone density, which are significant concerns for older men.
Understanding Monitoring Strategies
For older men with low- or intermediate-risk prostate cancer, monitoring is a valid strategy that avoids the morbidity of active treatment. There are two distinct approaches, and the choice depends on the patient’s health and the tumor’s risk level. Both strategies recognize that the patient may die of other causes before the slow-growing cancer becomes life-threatening.
Active Surveillance (AS)
Active Surveillance is the preferred method for relatively healthy 75-year-olds with low-risk cancer. The intent remains curative, meaning treatment will be initiated if the cancer shows signs of progression. This strategy involves frequent, intensive monitoring.
Monitoring includes:
- Regular PSA blood tests.
- Digital rectal exams.
- Repeat biopsies or advanced imaging like MRI, typically every one to three years.
Watchful Waiting (WW)
Watchful Waiting is a less intensive form of monitoring reserved for frail men with significant comorbidities and a limited life expectancy. The intent is palliative, focusing only on treating symptoms like pain or urinary obstruction if they arise, rather than attempting to cure the cancer.
This approach involves fewer tests and no regular biopsies. The goal is preserving quality of life by avoiding treatment side effects while managing cancer-related symptoms.