Memorial Health Care System
Memorial Medical Bldg. East
725 Glenwood Drive, Suite E790
Chattanooga, TN 37404-1163
Prior to the United States Preventative Services Task Force 2008 recommendation against PSA screening in men 75 yrs and older, most men were screened based upon health status and life expectancy. AUA recommends screening for men with an estimated life expectancy of 10 yrs or more. This is based upon studies that suggest it takes 10 yrs to realize a survival benefit from prostate cancer treatment.
Older men are diagnosed with higher grade and higher stage prostate cancer than younger men. Some studies suggest that men older than 75 yrs may obtain a survival benefit from curative treatment of aggressive prostate cancer.
This study analyzes 15 year results from the Scandanavian Prostate Cancer Group trial that randomized 695 men with prostate cancer to a course of watchful waiting or radical prostatectomy. The men were less than 75 years old with a life expectancy that exceeded 10 years. 348 men were observed and 347 were treated surgically.
The study concluded that radical prostatectomy, when compared to watchful waiting, decreased the risk of death from prostate cancer, decreased the risk of death from any cause, decreased the risk of metastases and the use of hormonal therapy. Decreasing the risk of metastases and the use of hormonal therapy is as important as decreasing the risk of death from prostate cancer because of the considerable suffering and morbidity associated with metatstatic disease.
Management recommendations for treating prostate cancer are made with 3 goals in mind:curing the cancer, recovery of urinary control and preservation of erectile function. For surgical management in particular, cancer, urinary and sexual outcomes must be individualized based upon patient age, disease risk, other health issues and level of function before surgery. The satisfied patient is one whose outcomes match their expectations. Establishing realistic expectations is a very difficult challenge. We spend a great deal of time with patients and families before surgery trying to explain and establish realistic expectations. Additionally, all patients are given a 50 page workbook before surgery to assist them with their recovery. It's primary purpose is to establish realistic expectations.
This article from the University of MIchigan analyzes and discusses the difficulties and challenges associated with establishing realistic expectations before surgery. The authors conclude that in spite of preoperative educational programs, many patients still have unrealistic expectations.
They suggest this may be due to a defense mechanism of denial that helps patients cope with their diagnosis and treatment, but also leads them to deny that the information presented to them applies to them specifically.
The authors also point out that the difficulties physician face in predicting urinary and sexual function after surgery are due to differences in baseline function, intraoperative findings and anatomic variations, and postoperative desire and motivation for improved urinary and sexual function. Sexual function is particularly difficult to predict due to the impact of the sexual partners involvement and the emotional and sexual function of the partner.