The Older the Patients, the More Aggressive the Prostate Cancer Detected Even Among Those With a Prostate-Specific Antigen Level Below the Low-Risk Threshold: Analysis Using Nationwide Korean Data.

Background: To investigate the clinicopathologic pattern of prostate cancer (PCa) in elderly patients compared with their younger counterparts with a prostate-specific antigen (PSA) level below the low-risk threshold (< 10 ng/mL), which is often a deciding factor for biopsy.

Methods: A nationwide database of PCa at the time of biopsy from 2010 to 2020 was constructed from 39 hospitals. Patients were categorized into age groups of < 64 years, 65-69 years, 70-74 years, and ≥ 75 years considering guidelines that recommend PSA testing only for those aged 55-69 years during the study period, the average age of Korean PCa registrants of 70.3 years (2010-2020), and the average life expectancy of Korean males of 80.3 years (2020).

Results: The mean ± standard deviation age was 70.3 ± 8.2 years, which was normally distributed (kurtosis = 0.095). Among 14,548 subjects, 54.1%, 39.5%, and 6.4% of them had high-risk disease, intermediate-risk disease, and low-risk disease, respectively. Based on three risk parameters, a marked increase in high-risk cancer was observed in the oldest age group (linear combination, < 0.001). The same pattern was observed among patients with low-risk disease (PSA < 10 ng/mL), who were divided into PSA tiers as follows: 4-5 ng/mL ( < 0.001), 5-6 ng/mL ( < 0.001), 6-7 ng/mL ( < 0.001), 7-8 ng/mL ( < 0.001), 8-9 ng/mL ( = 0.009), and 9-10 ng/mL ( < 0.001). In all PSA tiers between 4 and 10 ng/mL, multivariate analysis demonstrated a significantly higher prevalence of high-risk cancer in the oldest age group than in the youngest age group. In the lowest tier (4-5 ng/mL), 35.2% of those aged over 75 years had high-risk PCa.

Conclusion: The older the patient, the more aggressive the PCa. Moreover, there was an increase in high-risk PCa in older males compared with younger males even with a PSA level below the low-risk threshold of 10 ng/mL, suggesting the need to strengthen cancer screening policies in the older population.