When it comes to prostate cancer in men over 70, national guidelines offer a clear stance. The US Preventive Services Task Force (USPSTF), an independent panel of preventive care experts, advises against routine screening with the PSA test for this age group. The reasoning hinges on the nature of the disease: prostate cancer often progresses slowly. Many older men may live with it rather than die from it. In the view of the USPSTF, the potential survival benefits from treating PSA-detected cancers in older men are unlikely to outweigh the risks and side effects of interventions. However, this doesn’t rule out screening entirely. Men might still undergo testing if symptoms emerge, such as difficulty urinating, persistent fatigue, or bone pain, indicating possible advanced stages.
For a deeper look into how screening and treatment evolve for older men with advanced prostate cancer, we turned to Dr. Marc B. Garnick. He holds the Gorman Brothers Professorship in Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and serves as editor in chief of the Harvard Medical School Guide to Prostate Diseases. Dr. Garnick notes that while PSA testing in men over 70 falls outside official guidelines, it’s not uncommon in clinical practice. Physicians often discuss it with patients on an individual basis. Advanced metastatic prostate cancer can sometimes be identified through a PSA test, even if the disease spreads without obvious symptoms. Some men only seek testing after experiencing signs like urinary issues or bone discomfort.
The current USPSTF guidelines on PSA screening were last updated in 2018. With life expectancy rising for men over 70, there’s anticipation for a revision, as these recommendations are typically reviewed every six years. This update could reflect changing demographics and medical advancements.
If a PSA test suggests something amiss, what comes next? Typically, a prostate needle biopsy is performed. Dr. Garnick also recommends a digital rectal exam (DRE) to check for physical abnormalities in the prostate gland. He cites the example of President Biden, who had urinary symptoms leading to a PSA test and was reported to have a nodule detected during a DRE, though his specific PSA score remains unknown. In recent years, magnetic resonance imaging (MRI) scans of the prostate have gained traction. These provide detailed diagnostic information and can guide biopsies to target suspicious areas more precisely.
Determining whether a cancer might spread aggressively involves several tools. Pathologists examine biopsy samples for cell patterns. A long-standing method, the Gleason score, grades the two most common cancer cell types seen. This system has been refined into a simpler five-tier grading scale, from Grade Group 1 (least dangerous) to Grade Group 5 (most dangerous). These groups align with Gleason scores; for instance, a Gleason score of 3+3=6 corresponds to Grade Group 1 for low-risk cancer, while a score of 4+5=9 matches Grade Group 5 for high-risk disease. Other measures include the mitotic rate, which assesses how quickly cancer cells divide, and genetic tests. Inherited mutations in genes like BRCA1 and BRCA2 can signal a higher risk for aggressive prostate cancer. These genetic findings also have broader implications, as such mutations elevate risks for other cancers like breast and ovarian cancer in family members.
To check if cancer has metastasized, traditional approaches involved computed tomography (CT) scans of the abdomen and pelvis along with bone scans. These look for spread to lymph nodes and bones but are becoming outdated. Today, doctors increasingly use PSMA scans, which detect a protein called prostate-specific membrane antigen (PSMA) that often appears at high levels on tumor cell surfaces. This method is superior for spotting small prostate tumors that other imaging might miss. If metastases are found, doctors classify the disease based on extent. Men with no more than three to five metastases are considered to have oligometastatic prostate cancer.
Treatment for metastatic prostate cancer typically doesn’t start with a single medication. For men with low-volume disease, doublet therapy is common. This combines two drugs that work together to deprive tumors of testosterone, a hormone essential for prostate cancer growth. One drug, leuprolide (Lupron), blocks testosterone production. The others are androgen receptor pathway inhibitors (ARPIs), such as enzalutamide (Xtandi), darolutamide (Nubeqa), apalutamide (Erleada), or abiraterone (Zytiga), which prevent testosterone from binding to cell receptors. If cancer progresses on doublet therapy, chemotherapy may be added, creating triplet therapy (Lupron plus an ARPI plus chemotherapy). In some cases, immediate triplet therapy is recommended based on the spread’s extent.
Additional options exist for specific cases. Men with PSMA-positive disease, where cells express high levels of the protein, might receive Lutetium-177, a radioligand therapy delivered intravenously. It targets PSMA-expressing cells and destroys them with radioactive particles. For those with oligometastatic prostate cancer, metastasis-directed therapy (MTD) is an option, using focused radiation beams to treat metastatic spots from outside the body.
Genetic testing can open doors to targeted therapies. These treatments aim at specific cellular changes driving tumor growth. For instance, men with BRCA1 or BRCA2 mutations might start on doublet therapy plus a PARP inhibitor, such as olaparib (Lynparza) or rucaparib (Rubraca), which are approved for BRCA-positive prostate cancer. Those with a different mutation called microsatellite instability could be eligible for pembrolizumab (Keytruda), another targeted drug.
Dr. Garnick emphasizes that the outlook for metastatic prostate cancer is evolving with these advancements. He also offers a crucial note: before beginning hormonal therapy, men should undergo a cardiac evaluation. Hormonal treatments can worsen cardiovascular risk factors, so addressing these issues before and during therapy is essential for overall health.
