Dear Sumner:
Mr. Y., an 86 year old man, came to my office last week complaining of progressive slowing of his urinary stream along with rather severe lower back pains. The back pains lessened with the use of Tylenol, local heat and bed rest. He is a bit “fragile,” having had a heart attack about 3 years previously and is generally quite weak. He is currently on prophylactic low dose aspirin. On rectal examination I found his prostate to be hard and bumpy. I obtained a PSA level, which the lab reported as 32 (normal level for that lab is <4). style=""> Where should we go from here? Do we need a tissue diagnosis prior to starting hormonal therapy?
Dear Bob:
I certainly agree with you about the high probability of your patient having prostate cancer. The question arises as to the best way of handling the current situation. I had a long discussion with both Mr. Y and his family about the “statistics” of prostatic cancer with increasing age: i.e. after the age of 70, there is approximately a 70% chance of there being a focus of cancer in the prostate, over the age of 80, an 80% incidence, and after 90, almost all men will have a focus of cancer in the prostate. The message is: if you live long enough, you will die with, but not from, prostate cancer. (Of course, in this case, he could, indeed, die from metastatic disease.).
Re the question you brought up about the necessity of obtaining a tissue diagnosis prior to initiating treatment, under the best of circumstances, prostatic biopsies run the risk, albeit very low, of possible complications such as bleeding or infection, not to mention the discomfort. And taking into account your patient’s age, his past medical history, the fact that he is on prophylactic aspirin, and the clinical picture of probable prostatic cancer (PSA of 32 with an underlying firm and irregular prostate), I would opt for starting him on anti-androgen therapy without having a tissue diagnosis.
