Prostate Cancer Screening and Treatment in Men Over 70
National guidelines on prostate cancer screening with the PSA test are set by the US Preventive Services Task Force (USPSTF). This independent panel recommends against screening men older than 70 because prostate cancer tends to be slow-growing and survival benefits from treating PSA-detected prostate cancer in older men are unlikely to outweigh treatment harms.
For a perspective on PSA screening and advanced prostate cancer treatment in older men, we spoke with Dr. Marc B. Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of the Harvard Medical School Guide to Prostate Diseases.
Q&A with Dr. Marc B. Garnick
How often should men over the age of 70 be screened for prostate cancer?
Such testing is performed outside of guidelines and generally follows a discussion with the patient’s physician. It’s not unusual to find advanced metastatic prostate cancer in older men flagged by a PSA test. Some men get a PSA test only after advanced symptoms such as trouble urinating, fatigue, or bone pain. The USPSTF’s PSA guidelines, last published in 2018, are overdue for an update. With increasing life expectancy for men over 70, new guidelines are expected every six years.
What tests follow a positive PSA screening result?
- Prostate needle biopsy
- Digital rectal exam (DRE) to feel for prostate abnormalities
- Magnetic resonance imaging (MRI) of the prostate for precise targeting of biopsy sites
How do we know if the cancer is likely to spread aggressively?
Aggressive tumors have irregular cell shapes that invade adjoining tissues. The Gleason score grades the two most common cancer cell patterns on biopsy, and a simplified Grade Group system ranks tumors from 1 (least dangerous) to 5 (most dangerous). Additional measures include the mitotic rate and genetic tests, such as BRCA1 and BRCA2 mutation testing, which indicate risk for more aggressive disease and have implications for inherited cancer risk in family members.
How do you know if the cancer is metastasizing?
Traditional imaging includes CT scans of the abdomen and pelvis and bone scans for lymph node and bone metastases, but these are increasingly outdated. PSMA scans detect prostate-specific membrane antigen on tumor cells, identifying small metastases. Men with up to three to five metastases are classified as having oligometastatic prostate cancer.
What treatment options are available for metastatic prostate cancer?
- Doublet therapy: leuprolide (Lupron) plus an androgen receptor pathway inhibitor (enzalutamide, darolutamide, apalutamide, or abiraterone)
- Triplet therapy: adding chemotherapy to doublet therapy, or immediate triplet therapy in extensive disease
- Lutetium-177 radioligand therapy for PSMA-positive disease
- Metastasis-directed therapy (MTD) with focused radiation for oligometastatic disease
What happens if a patient is positive on a genetic test for prostate cancer?
Targeted therapies are available: PARP inhibitors (olaparib, rucaparib) for BRCA1/2 mutations and pembrolizumab for microsatellite instability.
How is the outlook for metastatic prostate cancer changing?
Outcomes have improved dramatically. Men often live 10 years or longer with metastatic disease, and recent studies support delivering radiation to the prostate gland itself, which was not previously considered for metastatic cases.
Any final notes?
Men should undergo a cardiac evaluation before starting hormonal therapy because these treatments can exacerbate cardiovascular risk factors.