Prostate cancer is the most common malignant tumor in older men. Most cases (70%) occur in people over 65 years of age and their incidence increases in proportion to age.
Therefore, it is difficult to carry out an optimal therapeutic approach in the elderly population. The choice of treatment will depend more on the concomitant diseases than on the patient’s own age. Thus, elderly patients with good functional status and without associated pathologies receive treatment similar to that of younger patients.
Symptoms of prostate cancer
The manifestations of prostate cancer are more evident as the cancer progresses and in its initial stages it is completely asymptomatic, for which its early detection is prudent. Usually, the more advanced the cancer is, the greater the number of symptoms it produces and the greater their intensity. The most frequent symptoms are those derived from the enlargement of the prostate , with obstruction of the flow of urine or those caused by the spread of the disease to other organs.
Visit the urologist from the age of 45
A routine annual urological evaluation is currently recommended for all patients over 45 years of age , including digital rectal examination and determination of prostate specific antigen (PSA), increasing this frequency to a six-monthly visit for those with a family history of prostate cancer even when they appear in the maternal branch. This methodology allows the early diagnosis of a large part of incipient prostate cancers confined to the gland.
Over 70 years
There is an important controversy regarding the performance of routine prostate examinations in patients older than 70 years , since it is assumed that in this group of patients there is a high frequency of prostate cancer whose course may not be relevant for their life. The prolongation of life and the improvement in its quality in this age group, however, has led to a constant increase in the age up to which the aforementioned examination is suggested and it is possible that this practice will continue in the future. future if it is considered that at present it is very likely that a 70-year-old man has a life expectancy close to 85 years.
The diagnosis of prostate cancer , when suspected, is carried out through the following actions:
- Rectal examination: it allows to suspect prostate cancer when it has grown enough to deform the prostate, or when it is located near the rectum. Since digital rectal examination does not allow evaluation of the anterior part of the prostate, other more reliable diagnostic means are required.
- PSA (prostate specific antigen): used to assess the response to treatment but not to diagnose prostate cancer, since PSA is also increased by many diseases such as benign prostatic hypertrophy, prostatitis, cystitis, seminal vesiculitis, digital rectal examination, breast cancer, sexual activity, stress, etc. However, it does help to assess the need for further testing if it is elevated.
- Conventional prosthetic ultrasound: It allows to have an approximate idea of the size and internal texture of the prostate; Helps guide the prostate biopsy to suspicious areas.
- Prostate biopsy: It can determine the presence of cancer with great certainty when suspicious areas are identified by ultrasound; on the other hand, its effectiveness decreases when they do not appear and it is carried out by sampling in the different areas of the prostate (when the disease is searched for when the PSA is repeatedly elevated).
In general terms, the treatment of choice for prostate cancers confined to the gland in patients younger than 70 years is considered to be radical prostatectomy via the suprapubic or laparoscopic route . This surgery consists of the complete removal of the gland along with the primary draining lymph nodes. This operation, which is currently performed routinely and with low morbidity and mortality, has a very high possibility of cure depending on the clinical status and histological type of the tumor, but is estimated to be higher than 90% in cases confined to the prostate. The main complications of radical prostate surgeryThey include erectile impotence, which occurs in approximately 50% of cases depending on the age of the patient, the previous state of potency, and the extent of the resected tumor. Urinary incontinence, which occurs in approximately 5% of patients, should also be considered.
Hormone therapy and radiation therapy
Apart from surgery, the treatment is complemented with hormonal therapy and sometimes radiation therapy . In most centers, radiation therapy is preferred as the primary treatment for patients with medical conditions that make major surgery impractical. Hormonal treatment is available in patients with more advanced disease. This treatment is extremely effective in reducing the size of the gland and the discomfort secondary to metastatic extensions, but in general it is unable to achieve complete healings. Despite this, very significant referrals are the rule rather than the exception. Hormonal treatment is currently carried out through androgen deprivation, which can be achieved through surgical castration (orchiectomy) , in disuse, or through medications. Orchiectomy is equally effective and may be less costly than drug management, however it has a greater psychological impact, so it is hardly performed.