J Korean Med Sci.  2025 Apr;40(15):e57. 10.3346/jkms.2025.40.e57.

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

• Pyun JH
• Ko YH
• Kim SW
• Kang SG
• Son NH

• KMID: 2567202
• DOI: http://doi.org/10.3346/jkms.2025.40.e57

Abstract

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, P < 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 (P < 0.001), 5–6 ng/mL (P < 0.001), 6–7 ng/mL (P < 0.001), 7–8 ng/mL (P < 0.001), 8–9 ng/mL (P = 0.009), and 9–10 ng/mL (P < 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.

Keyword

Prostatic Neoplasms; Aged; Epidemiology; Prostate-Specific Antigen

Figure

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  Fig. 1 Distribution of patients according to age. (A) Histogram for each age (year). (B) Quantile-quantile plot of age.

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  Fig. 2 Distribution of cancer risk according to risk parameters. (A) Risk stratification according to serum PSA. (B) Risk stratification according to cStage. (C) Risk stratification according to GGG. (D) Risk stratification according to overall risk parameters.PSA = prostate-specific antigen, cStage = clinical stage, GGG = Gleason grade group.

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  Fig. 3 Risk stratification according to serum PSA. (A) Low risk (< 10 ng/mL). (B) Intermediate risk (10–20 ng/mL).PSA = prostate-specific antigen.

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  Fig. 4 Risk stratification according to serum PSA below 10 ng/mL.PSA = prostate-specific antigen.

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