Elsevier

European Urology

Volume 72, Issue 4, October 2017, Pages 521-531
European Urology

Platinum Priority – Review – Prostate Cancer
Editorial by Jeremy P. Grummet, Karin Plass and James N’Dow on pp. 532–533 of this issue
Management of Prostate Cancer in Elderly Patients: Recommendations of a Task Force of the International Society of Geriatric Oncology

https://doi.org/10.1016/j.eururo.2016.12.025Get rights and content

Abstract

Context

Prostate cancer is the most frequent male cancer. Since the median age of diagnosis is 66 yr, many patients require both geriatric and urologic evaluation if treatment is to be tailored to individual circumstances including comorbidities and frailty.

Objective

To update the 2014 International Society of Geriatric Oncology (SIOG) guidelines on prostate cancer in men aged >70 yr. The update includes new material on health status evaluation and the treatment of localised, advanced, and castrate-resistant disease.

Data acquisition

A multidisciplinary SIOG task force reviewed pertinent articles published during 2013–2016 using search terms relevant to prostate cancer, the elderly, geriatric evaluation, local treatments, and castration-refractory/resistant disease. Each member of the group proposed modifications to the previous guidelines. These were collated and circulated. The final manuscript reflects the expert consensus.

Data synthesis

Elderly patients should be managed according to their individual health status and not according to age. Fit elderly patients should receive the same treatment as younger patients on the basis of international recommendations. At the initial evaluation, screening for cognitive impairment is mandatory to establish patient competence in making decisions. Initial evaluation of health status should use the validated G8 screening tool. Abnormal scores on the G8 should lead to a simplified geriatric assessment that evaluates comorbid conditions (using the Cumulative Illness Score Rating-Geriatrics scale), dependence (Activities of Daily Living) and nutritional status (via estimation of weight loss). When patients are frail or disabled or have severe comorbidities, a comprehensive geriatric assessment is needed. This may suggest additional geriatric interventions.

Conclusions

Advances in geriatric evaluation and treatments for localised and advanced disease are contributing to more appropriate management of elderly patients with prostate cancer. A better understanding of the role of active surveillance for less aggressive disease is also contributing to the individualisation of care.

Patient summary

Many men with prostate cancer are elderly. In the physically fit, treatment should be the same as in younger patients. However, some elderly prostate cancer patients are frail and have other medical problems. Treatment in the individual patient should be based on health status and patient preference.

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

References (57)

  • J.R. Rider et al.

    Long-term outcomes among noncuratively treated men according to prostate cancer risk category in a nationwide, population-based study

    Eur Urol

    (2013)
  • S. Joniau et al.

    Stratification of high-risk prostate cancer into prognostic categories: a European multi-institutional study

    Eur Urol

    (2015)
  • D.P. Dearnaley

    Hypofractionated radiotherapy in prostate cancer

    Lancet Oncol

    (2015)
  • K. Fizazi et al.

    Androgen deprivation therapy plus docetaxel and estramustine versus androgen deprivation therapy alone for high-risk localised prostate cancer (GETUG 12): a phase 3 randomised controlled trial

    Lancet Oncol

    (2015)
  • U.E. Studer et al.

    Using PSA to guide timing of androgen deprivation in patients with T0-4N0-2M0 prostate cancer not suitable for local curative treatment (EORTC 30891)

    Eur Urol

    (2008)
  • A. Widmark et al.

    Endocrine treatment, with or without radiotherapy, in locally advanced prostate cancer (SPCG-7/SFUO-3): an open randomised phase III trial

    Lancet

    (2009)
  • P. Warde et al.

    Combined androgen deprivation therapy and radiation therapy for locally advanced prostate cancer: a randomised, phase 3 trial

    Lancet

    (2011)
  • N. Mottet et al.

    Addition of radiotherapy to long-term androgen deprivation in locally advanced prostate cancer: an open randomised phase 3 trial

    Eur Urol

    (2012)
  • G. Gravis et al.

    Androgen-deprivation therapy alone or with docetaxel in non-castrate metastatic prostate cancer (GETUG-AFU 15): a randomised, open-label, phase 3 trial

    Lancet Oncol

    (2013)
  • N.D. James et al.

    Addition of docetaxel, zoledronic acid, or both to first-line long-term hormone therapy in prostate cancer (STAMPEDE): survival results from an adaptive, multiarm, multistage, platform randomised controlled trial

    Lancet

    (2016)
  • C.L. Vale et al.

    Addition of docetaxel or bisphosphonates to standard of care in men with localised or metastatic, hormone-sensitive prostate cancer: a systematic review and meta-analyses of aggregate data

    Lancet Oncol

    (2016)
  • P.L. Kellokumpu-Lehtinen et al.

    2-Weekly versus 3-weekly docetaxel to treat castration-resistant advanced prostate cancer: a randomised, phase 3 trial

    Lancet Oncol

    (2013)
  • A. Heidenreich et al.

    Safety of cabazitaxel in senior adults with metastatic castration-resistant prostate cancer: results of the European compassionate-use programme

    Eur J Cancer

    (2014)
  • C.J. Ryan et al.

    Abiraterone acetate plus prednisone versus placebo plus prednisone in chemotherapy-naive men with metastatic castration-resistant prostate cancer (COU-AA-302): final overall survival analysis of a randomised, double-blind, placebo-controlled phase 3 study

    Lancet Oncol

    (2015)
  • C.N. Sternberg et al.

    Improved outcomes in elderly patients with metastatic castration-resistant prostate cancer treated with the androgen receptor inhibitor enzalutamide: results from the phase III AFFIRM trial

    Ann Oncol

    (2014)
  • J.N. Graff et al.

    Efficacy and safety of enzalutamide in patients 75 years or older with chemotherapy-naive metastatic castration-resistant prostate cancer: results from PREVAIL

    Ann Oncol

    (2016)
  • F. Maines et al.

    Sequencing new agents after docetaxel in patients with metastatic castration-resistant prostate cancer

    Crit Rev Oncol Hematol

    (2015)
  • International Agency for Research on Cancer. GLOBOCAN 2012. Estimated cancer Incidence: age-specific tables....
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