Aspectos Preocupantes

Francisco Madeira Pina*, Nuno Lunet†, Manuel Macedo Dias‡

*Serviço de Urologia, Hospital de São João, Porto; † Serviço de Higiene e Epidemiologia, Faculdade de Medicina da Universidade do Porto; ‡Serviço de Anatomia Patológica, Hospital de São João, Porto

Resumo

O envelhecimento cursa com adaptações de hormonas, citocinas, e factores de crescimento progressivas, umas com função provavelmente protectora, outras ligadas ao aumento de risco de morte por causas cardiovasculares e neoplásicas. Relativamente às terapêuticas androgénicas de substituição no idoso, em utilização crescente e prolongada, mantem se a dúvida sobre o impacto no risco de desenvolvimento do cancro da próstata. A nossa experiência em casos incidentes de cancro da próstata demonstra que, à medida que a idade avança, sobe também a proporção de doentes com cancros da próstata com piores factores de prognóstico de recidiva/progressão (PSA basal mais elevado, risco de metastização óssea, tumores com pior diferenciação histológica). Enquanto que a prevenção primária quimio-endócrina aguarda resultados de vários estudos em curso (nomeadamente com inibidores da 5 α-reductase, selénio e vitamina E) para se afirmar, a prevenção secundária, baseada em resultados parciais de grandes estudos internacionais e na expansão das medidas básicas do diagnóstico precoce (exame digital rectal e PSA), avança com a generalização das terapêuticas radicais. A nossa experiência de 15 anos de prostatectomia radical revela que os indivíduos idosos (> 65 anos) representam metade dos candidatos, nos quais se observa uma maior proporção de indivíduos com tumores com Gleason ≥ 7, e maior proporção de indivíduos classificados em grupos de maior risco de recidiva/progressão. As diferentes formas de hormonoterapia, integradas na prevenção terciária, como adjuvante de terapêuticas radicais, como paleação de doentes em recidiva bioquímica, ou no contexto de tratamento primário paliativo, apresentam vantagens e desvantagens que devem ser individualmente ponderadas.

Palavras-chave: cancro da próstata; epidemiologia; envelhecimento; prevenção; terapêutica androgénica de substituição; hormonoterapia.

Prostate Cancer and Aging

Abstract

Aging is accompanied by progressive changes in hormones, cytokines and growth factors, some of them probably beneficial and others being associated with a higher risk of death by cardiovascular and oncological causes. Androgen replacement therapy in the elderly is becoming more frequent and is being used for longer periods, but the doubt remains regarding its impact in the risk of prostate cancer. Our experience from incident cases of prostate cancer shows that the proportion of patients presenting worse prognostic factors for relapse or progression (higher basal PSA, risk of bone metastasis, tumours with worse histological differentiation grade) increases with age. While chemo-endocrine primary prevention waits for the results from ongoing studies (e.g. 5α-reductase inhibitors, selenium, vitamin E), secondary prevention, based on the partial results from large international studies and the expansion of measures for early diagnosis (digital rectal examination and PSA), takes the lead with the generalization of radical therapies. According to our 15-year experience of radical prostatectomy, the group of elderly patients (>65 years) represents half the subjects eligible for this treatment, has a higher proportion of subjects with a Gleason score ≥ 7 or classified in the groups of higher risk of recurrence or progression. The risks and benefits to be expected from the different forms of hormonotherapy, integrated in tertiary prevention, as adjuvant of radical therapies, as palliative in patients in biochemical relapse, or in the context of palliative primary treatment, need to be evaluated at an individual level.

Key-words: prostate cancer; epidemiology; aging; prevention; androgen replacement therapy; hormonotherapy.

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Correspondência:

Dr. Francisco Madeira Pina

Serviço de Urologia

Alameda Prof. Hernâni Monteiro

4200 - 319 Porto

e-mail: madeirapina@gmail.com