What is the recommended monitoring and treatment plan for a 72-year-old male with stage one prostate cancer, and why is immediate prostate removal not typically considered?

Management of Stage One Prostate Cancer in a 72-Year-Old Male

For a 72-year-old male with stage one prostate cancer, active surveillance is the preferred management approach rather than immediate surgical removal, as it avoids unnecessary treatment side effects while maintaining excellent cancer-specific survival rates.

Risk Stratification and Initial Assessment

Stage one prostate cancer typically falls into the low-risk category, defined as:

• Clinical stage T1-T2a
• Gleason score ≤6
• PSA <10 ng/mL

Why Not Immediate Prostate Removal?

Several key reasons support active surveillance over immediate radical prostatectomy for this patient:

1. Age and Life Expectancy Considerations:

   • At 72 years old, the patient's life expectancy is likely <10 years
   • NCCN Guidelines specifically recommend observation for men with low-risk prostate cancer with life expectancy <10 years 1
   • Prostate cancer is typically slow-growing, with cancer-specific mortality rate of only 3% at 10-15 years for low-risk disease 2, 3

2. Treatment Side Effects vs. Benefit:

   • Radical prostatectomy causes significant side effects:
     • Erectile dysfunction (80% vs. 45% with observation)
     • Urinary incontinence (49% vs. 21% with observation) 1
   • The PIVOT trial showed no significant survival benefit for surgery vs. observation in low-risk patients 1

3. Indolent Nature of Low-Risk Disease:

   • Long-term studies show metastatic progression rate <1% at 15 years for very low-risk patients on active surveillance 2
   • Many low-grade prostate cancers are not destined to progress to clinically significant tumors 4

Recommended Management Plan

Active Surveillance Protocol

1. Regular Monitoring:

   • PSA testing every 6 months (unless clinically indicated) 1
   • Digital rectal examination every 12 months (unless clinically indicated) 1
   • Repeat prostate biopsy within 6 months if initial biopsy was <10 cores 1
   • Consider annual repeat biopsies to assess for disease progression 1, 2
   • Consider multiparametric MRI if PSA increases and systematic biopsy is negative 1, 2

2. Indications for Intervention:

   • Gleason grade 4 or 5 cancer found on repeat biopsy
   • Cancer found in greater number of prostate biopsies
   • Significant PSA velocity changes (>0.75 ng/mL per year) 5
   • Patient preference or anxiety 2

Advantages of Active Surveillance

• Avoidance of treatment side effects that may be unnecessary
• Preservation of quality of life and normal activities
• Reduction in risk of unnecessary treatment of indolent cancers 1

When to Consider Definitive Treatment

If disease progression occurs, treatment options include:

• Radical prostatectomy
• External beam radiation therapy
• Brachytherapy 1

Potential Pitfalls to Avoid

1. Inadequate Monitoring: Ensure adherence to the surveillance protocol
2. Overreaction to PSA Fluctuations: PSA may fluctuate without indicating cancer progression
3. Neglecting Patient Preferences: Some patients may prefer definitive treatment despite recommendations
4. Missing High-Risk Features: Ensure thorough initial risk stratification

Conclusion

For a 72-year-old man with stage one prostate cancer, active surveillance represents the most appropriate management strategy according to current guidelines. This approach balances the low risk of disease progression against the significant potential side effects of immediate treatment, while maintaining the option for intervention if the cancer shows signs of progression.