April 18, 2012 -- Warren Buffett's decision to undergo radiation therapy for stage 1 prostate cancer has refocused attention on a debate over screening and treating older men for a disease that most often won't kill them.
Prostate cancer specialists worry that because the high-profile, 81-year-old billionaire has chosen two months of daily radiation treatments, other men automatically will "assume that must be the right treatment and it must be good for me," said Dr. Peter Scardino, chairman of the surgery department at Memorial Sloan-Kettering Cancer Center in New York.
"Generally, in a person over 80 years old, you'd be very hesitant to treat a prostate cancer unless it's clearly life-threatening," Scardino said. "Doctors caution men [that] at that age prostate cancer is very common. Most of the time it's not dangerous to their life or health. It's unusual, in our experience, to treat someone over 80, although I've done it."
Of course, no doctor wants to second-guess Buffett's decision, especially without at least two key pieces of information that he didn't disclose when he announced his diagnosis Tuesday: his PSA score and his Gleason score, both of which help determine whether cancer is low-risk or high-risk, Scardino and other top prostate specialists said.
The PSA test measures levels of prostate specific antigen (PSA), a protein that increases in prostate cancer as well as in benign prostate enlargement.
The Gleason score measures how closely cancer cells resemble normal tissue: The higher the score, the more abnormal the tissue and the more likely it is to spread.
"One would have to know the PSA level and the Gleason grade of the cancer on biopsy to make a proper decision, but the burden would be on the physician to show why immediate treatment is needed for a stage 1 cancer in an 81-year-old man," Scardino said.
Although stage 1 prostate cancer, by definition, hasn't spread beyond the prostate gland, "you could still be stage 1 and have an aggressive tumor," said Dr. Patrick Walsh, a urology professor at Johns Hopkins Medical Institutions in Baltimore who is among the world's top authorities on prostate cancer.
Walsh said one of his own patients, a man whose case had similarities to Buffett's, had his PSA score rise from 2.5 to 8.0 within a year and had a Gleason score of 8 on a scale of 0 to 10, indicating highly abnormal cells.
While readily acknowledging he didn't have important details of Buffett's case, he suggested that "the fact that he is waiting three months to begin radiation suggests to me that he might be going to receive neoadjuvant hormonal therapy and that is consistent with more aggressive disease."
Although recent guidelines and recommendations may create the impression that "if you're old, you don't need to be treated," Walsh said that a University of Rochester study published last year in the journal Cancer found that half the men who die from prostate cancer are diagnosed after age 75, and more than half of metastatic cancer occurs in men over 75.
"The fact is that older men who are diagnosed with prostate cancer oftentimes have more advanced disease than younger men -- the opposite of what we used to believe," he said.
As Baby Boomers age, they're likely to face some of the same decision-making as Buffett, Walsh said.
The number of elderly men is on the rise and they're living longer, according to Social Security Administration figures showing that about 25 percent of healthy men over 75 can be expected to live another 15 years.
Low-Risk Disease Can Be Monitored; High-Risk Disease May Need Treatment
It's hard to apply a one-size-fits-all rule to cancer screening and treatment. Oncologists and surgeons combine results of physical exams, biopsies, PSA and Gleason scores, along with family history of longevity and the patient's own level of concern in helping their patients make decisions about whether to treat prostate cancer or monitor it.
"I believe that active surveillance is an ideal form of treatment for men with low-risk disease who have a lifespan less than 20 years, but there are older men who are healthy who develop aggressive disease for whom treatment may be necessary," Walsh said.
For men with stage 1 disease who expect to live another decade, a choice like Buffett's to undergo radiation therapy is a "perfectly fine," said Dr. Howard Sandler, chairman of radiation oncology at Cedars-Sinai Medical Center in Los Angeles. He said guidelines issued by the National Comprehensive Cancer Network of cancer centers list active surveillance, radiation therapy and radical prostatectomy as viable options for such patients.
"Radiotherapy is more likely to maintain normal urinary function and normal sexual function compared with surgery," Sandler said.
Unlike surgery, which becomes riskier with age, "radiation you can give at any age," Scardino said.
In the last five years, especially, cancer specialists and urologists have tried to convey to the American public that over-testing and over-treating have a cost and that although prostate cancer can be lethal, "it is often not," Scardino said. "That's a message we've all been trying to get out very heavily the last few years, without scaring away people who have dangerous cancers that should be treated."
A National Institutes of Health consensus statement released in December said that optimal treatment for men with early-stage prostate cancer and low Gleason scores is observation "because the majority of these men will never need to be treated," said Dr. Otis Brawley, chief medical officer for the American Cancer Society in Atlanta. "That's the basis for which many of us think that Mr. Buffett likely has a very good prognosis."
However, Brawley said, many cancer patients aren't comfortable with the idea of leaving their disease untreated.
"I've had so many patients who say, 'Goddamn it. I'm an American. I have cancer. I want to be treated," Brawley said.
"Most men will elect to get treatment. Most men under 70 will elect to get radical prostatectomy. And most men over 70 will elect to get radiation therapy. That's well documented in the United States," Brawley said. For men who have thought through their options, "I think that is a very reasonable thing."