Survival advantage with surgery for elderly patients with prostate cancer?

JAMA — Survival Associated With Treatment vs Observation of Localized Prostate Cancer in Elderly Men, December 13, 2006, Wong et al. 296 (22): 2683

Conclusions
This study suggests a survival advantage is associated with active
treatment for low- and intermediate-risk prostate cancer in elderly men
aged 65 to 80 years. Because observational data cannot completely adjust
for potential selection bias and confounding, these results must be
validated in randomized controlled trials of alternative management
strategies in elderly men with localized prostate cancer.

An important paper was recently published in JAMA that concluded that men between 65 and 80 may do better with surgery or radiation than with watchful waiting.
The authors did a good job with this observational study. They looked at all men with prostate cancer and compared those who had treatment with radiation or surgery and compared them to men who did not receive therapy for at least 6 months after diagnosis.
They found that there was a 30% lower mortality in the men that had therapy. The authors made an effort to compare the men with regard to other medical conditions and pointed out that without a randomized trial, there may be a selection bias since most urologists counsel men with good 10 year life expectancies to undergo therapy and men with poor life expectancies to have watchful waiting.
This is one study that I can use to help guide patients, but not an absolute decision maker in my opinion.
I reviewed my patients to see how many men I did robotic prostatectomies on. Over my first 200 robotic prostatectomies I operated on 19 men that were 70 or older:
5 were 70
11 were 71-74
1 was 76,78, and 80
I typically counsel them based on their health, the aggressiveness of their cancer and tell these men they will likely be equally cured with surgery or radiation.
12 of the 19 went home in 1 day, 6 in 2 days, and 1 in 3 days. The only medical problem I had was one patient who was re-hospitalized with a pulmonary embolus (blood clot in lung) a few days after going home and did well on blood thinners.
I do feel that these men often have significant BPH symptoms that is greatly helped by surgery. They do seem to have more incontinence in the short run, but they have done well. 9 of the prostates were big (larger than 50 grams), 5 were very big (greater than 75 gms), and 1 was huge (123 grams).
As for continence, 8 of the 15 that I have data on had 1 pad or less incontinence at 1 month, and 8 of 11 had 1 pad or less incontinence at 3 months, and 7 of 7 were in 1 pad or less at 6 months.

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