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Prostate surgery risks greater for elderly men

NEW YORK (Reuters Health) - Elderly men who have prostate cancer surgery face heightened risks of complications -- and the majority have the procedure at hospitals with less-than-optimal outcomes, a U.S. study suggests.

Researchers found that of more than 115,000 U.S. men who had their prostates removed to treat cancer, some 2,100 were age 75 or older.

Just over two percent of those elderly men had a surgical complication -- such as an accidental laceration to nerves, blood vessels or structures near the prostate -- compared to about one percent of younger men.

The situation was similar when it came to complications following the surgery, like wound infections and life-threatening breathing trouble. Those affected 17 percent of elderly men, versus 12 percent of younger men.

What's more, the study found, elderly men were more likely to have their surgery at a smaller, non-academic hospital, where rates of prostate surgery complications tend to be higher compared with centers where surgeons perform more of the procedures.

It's not surprising that elderly men would have higher complication risks, according to lead researcher Dr. Quoc-Dien Trinh, a urologist at Henry Ford Hospital in Detroit.

Those findings back up results from earlier studies, he told Reuters Health in an email.

"The novelty of this study is the finding that most elderly men undergo radical prostatectomy (prostate removal) at institutions where less-than-optimal outcomes are recorded," Trinh added.

Overall, 56 percent of elderly men were treated at community hospitals not connected to a medical school. That compared with 44 percent of younger men.

And most elderly men (68.5 percent) had surgery at a small- to mid-size hospital. Among elderly men, those who had surgery at the smallest hospitals also had higher complication rates: 22 percent had a post-surgery complication, for example, versus just over 17 percent at mid-sized centers and 15 percent at large hospitals.

There are many unknowns from the findings, which are published in the British Journal of Urology International.

It's not clear why most elderly men had surgery at smaller, non-academic hospitals. One possibility, Trinh said, is that elderly patients are likely to stay close to home -- which often means a smaller community hospital.

But another possibility, he said, is that surgeons at larger, academic hospitals are "more selective" about whom they'll choose for prostate cancer surgery. They may only rarely operate on men age 75 or older, Trinh said.

That gets to the larger issue of when it is appropriate to treat prostate cancer.

In the U.S., many men now have their cancer diagnosed at an earlier stage through screening with prostate-specific antigen (PSA) blood tests.

The problem is that prostate cancer is often slow-growing and may never progress far enough to threaten a man's life. So finding and treating early tumors can do more harm than good for some men, since treatment carries risks. Common side effects include incontinence and impotence.

Another option for earlier-stage prostate cancer is what doctors call "active surveillance" -- which means monitoring a man's cancer with regular PSAs and other tests to see if the cancer is progressing.

For elderly men, in particular, the risks of surgery are usually thought to outweigh any potential benefit.

In fact, the U.S. Preventive Services Task Force -- an expert panel with federal support -- has long recommended against routinely doing PSA screening in men age 75 and older who have no symptoms of prostate cancer.

For men in that age group, the panel said, there is "moderate certainty" that the harms of PSA screening outweigh any potential benefit. (The USPSTF has also just released draft recommendations advising against routine screening of symptom-free men at any age.)

According to Trinh, it's not possible to tell how many elderly men in this study might have been "overtreated."

The findings are based on hospital discharge records, and the researchers did not have detailed information on the patients' cancer -- including how advanced their tumors were at diagnosis, or whether the cancer was caught through screening or diagnosed after a man developed symptoms.

And there may be instances where an elderly man could benefit from prostate cancer surgery. However, Trinh said, "radical prostatectomy in men aged 75 or older should be an exceptional event."

"Does this mean that they should absolutely avoid surgery? No," Trinh said. "But they should at least seek the care of an expert surgeon/institution, especially when we know that they are at higher risk of complications than their younger counterparts."

In general, Trinh said, surgery should be limited to elderly men who are otherwise in "excellent" health -- and, therefore, could be expected to live long enough to see a survival advantage from prostate cancer treatment.

SOURCE: http://bit.ly/nnpFFW BJU International, online September 6, 2011.

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