Platinum Priority – Review – Prostate CancerEditorial by Jeremy P. Grummet, Karin Plass and James N’Dow on pp. 532–533 of this issueManagement of Prostate Cancer in Elderly Patients: Recommendations of a Task Force of the International Society of Geriatric Oncology
Introduction
Prostate cancer is the most frequent male cancer in developed countries [1] and is also common in less developed countries. The median age at diagnosis is 66 yr, and 69% of deaths occur in men aged ≥75 yr. Since incidence and mortality rise steeply with age, the prostate cancer burden will increase with exponential ageing of the population.
The current paper, which focuses on men aged >70 yr, updates existing International Society of Geriatric Oncology (SIOG) guidelines for the management of elderly prostate cancer patients [2], [3], [4]. Issues considered include the risks of both overtreatment and undertreatment and the importance of assessing overall health status, comorbidities, and cognitive function in personalising management. Previously published SIOG guidelines on prostate cancer [3], [4] argued that age alone should not preclude effective treatment. Since 2014, the SIOG recommendations have been fully endorsed by the European Association of Urology (EAU) and are now referred to as the EAU/ESTRO/SIOG guidelines [5], [6].
The most important new features of these updated guidelines are: (1) the introduction of initial screening for cognitive function; (2) the rewording of health status classification to align with terms currently used in the geriatric literature; (3) consideration of the most important advances in the treatment of advanced prostate cancer and their implications for elderly patients; and (4) a recommendation for the early introduction of palliative management.
Choice of therapy should not be based on chronological aging, which proceeds at the same pace for all, but on biological aging and health status, which differ greatly from one person to another. In the USA, a 70-yr-old man in the healthiest 25% of his peers can expect to live 18 yr, while for the frailest 25% life expectancy is only 7 yr [7]. Evaluation of health status is therefore vital to appropriate management. Assessment of social situation is also important and can usefully include whether or not a family care-giver is present, financial resources, and access to services. A further factor, of course, is patient preference, both in relation to the goals of therapy and the means of attaining them.
The gold standard for evaluating health status is the Comprehensive Geriatric Assessment (CGA) [8]. This includes data on demographic, social, functional, nutritional, cognitive, and mental health status; and the presence of comorbidities and geriatric syndromes. It predicts survival and chemotherapy toxicity, identifies reversible conditions, and reflects patients’ capacity to make decisions as well as their values and treatment goals [9]. Although relatively simple, the Activities of Daily Living (ADL) measure of dependency has been used to determine the need for social and healthcare interventions and has prognostic value. Aside from prostate cancer itself, comorbidity is the strongest predictor of death among men with localised disease [10]. The Cumulative Illness Score Rating-Geriatrics (CISR-G) [11] is used to assess comorbidity. In this context, it is helpful to ascertain the stage and potential reversibility of the condition, its history, and the risk of acute organ failure.
However, a CGA is time-consuming and requires specialist staff. Moreover, it is probably needed in only a minority of patients. A rational approach is to screen all patients to identify those who need further assessment. This further assessment can take the form of a simplified geriatric evaluation or a full CGA.
Section snippets
Evaluation of health status
Evaluation of health status involves a stepwise process starting with screening using the G8 and mini-COG™ [12]. This is followed, where indicated, by a simplified geriatric assessment and then, again when indicated, by full geriatric assessment, particularly when complex geriatric interventions are needed.
Categorisation of patients and implications for treatment
It is generally argued that candidates for definitive therapy for localised prostate cancer should have a life expectancy of ≥10 yr. In metastatic castration-resistant prostate cancer (mCRPC) it is important to assess 2-yr and 5-yr survival. Available tools can predict 1-yr or 5-yr survival for patients living at home or in hospital or nursing home settings [21], but no classification or prognostic model based on health status has been validated in urologic oncology. Recent recommendations are
Treatment of elderly prostate cancer patients
We examined standard management of localised and advanced disease and applied when possible considerations specific to elderly men.
Conclusions
A SIOG prostate cancer task force has updated recommendations for the management of elderly men with prostate cancer. Overall, the urologic approach in the fit elderly should be the same as in younger patients and based on existing international recommendations. Individual elderly patients should be managed according to their health status and not according to age.
Evaluation of health status should include a validated screening tool (the G8) and the assessment of comorbid conditions (CISR-G
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