A 74 year old male with congestive heart failure and mild dementia was found to have an elevated PSA

on routine screening. On clinical examination prostate is firm and nodular. Biopsy confirms adenocarcinoma with Glasgow score of 4. What will you recommend and why?

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Likely low risk • I will get MRI. • RP should not be done as expected survival is <10 years. • RT+ADT cannot be given due to cardiovascular comorbidity . expected survival < 5 years. Bone scan to see for t stage and mets. comorbidities. • active surveillance : because of age.

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• 48% of the patients had died.PIVOT STUDY • The mean age was 67 and the median PSA was 7. and 7% had Gleason 8-10.8 ng/ml • 50.4% of the patients had clinical stage T1C disease • 70% of the randomized patients had Gleason 6 disease. 18% had a Gleason 7 disease. but only 7% of the patients had died from prostate cancer. .

. as well as those with D’Amico intermediate high risk classification • This death rate from non-prostatic causes is relatively high for 10 years of follow-up in a population of men considered to be radical prostatectomy candidates.• Those with a PSA >10.0 ng/mL had a clear benefit from surgery.

. intermediate-risk disease as a Gleason score of 7 or a Gleason score of ≤6 and a PSA level of >10 and up to 20 ng/mL or clinical stage T2b.(RTOG 9408) • comparing radiation alone to radiation plus 4 months of ADT starting 2 months before radiation • Low-risk disease was defined as a Gleason score of ≤6 a PSA level of ≤10 ng/mL and a clinical stage of T2a or lower. and high-risk disease as a Gleason score of 8 to 10.

• 10-year overall survival rate was 62% for EBRT + ADT as compared to 57% for patients receiving EBRT alone (P = 0.03) • The addition of ADT decreased 10-year prostate cancer-specific mortality from 8% to 4% (P = 0. • There are no trials comparing radiation to observation in patients with low risk prostate cancer . • The risk reduction was primarily attributable to treatment of intermediate-risk patients as no significant reductions in mortality among low-risk patients were noted.001).

All rights reserved. hypercholesterolemia. 2009. or hypertension.017 are significant. Date of download: 10/22/2013 Copyright © 2012 American Medical Association. 2168 with 1 cardiovascular risk factor including diabetes mellitus. P values <. . doi:10. and 256 with known coronary artery disease resulting in congestive heart failure or myocardial infarction.1001/jama.From: Hormonal Therapy Use for Prostate Cancer and Mortality in Men With Coronary Artery Disease–Induced Congestive Heart Failure or Myocardial Infarction JAMA.2009. After applying the Bonferroni correction.1137 Figure Legend: There were 2653 men with no comorbidity.302(8):866-873.

M1 disease • Option will be as ADT naive • Castration : – b/l orchiectomy – LHRH analogues and the antiandrogens (comorbidities as in our patient should be considered) as ADT inc CVS risk. .

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