Elsevier

The Lancet Oncology

Volume 15, Issue 9, August 2014, Pages e404-e414
The Lancet Oncology

Review
Management of prostate cancer in older patients: updated recommendations of a working group of the International Society of Geriatric Oncology

https://doi.org/10.1016/S1470-2045(14)70018-XGet rights and content

Summary

In 2010, the International Society of Geriatric Oncology (SIOG) developed treatment guidelines for men with prostate cancer who are older than 70 years old. In 2013, a new multidisciplinary SIOG working group was formed to update these recommendations. The consensus of the task force is that older men with prostate cancer should be managed according to their individual health status, not according to age. On the basis of a validated rapid health status screening instrument and simple assessment, the task force recommends that patients are classed into three groups for treatment: healthy or fit patients who should have the same treatment options as younger patients; vulnerable patients with reversible impairment who should receive standard treatment after medical intervention; and frail patients with non-reversible impairment who should receive adapted treatment.

Introduction

Prostate cancer is the most frequently diagnosed male cancer in both the USA1 and Europe,2 and one of the three most common causes of cancer-related death.1 It is predominantly a disease of older men, with a median age at diagnosis of 66 years; 70% of deaths due to prostate cancer occur in men aged 75 years or older. The burden of the disease is expected to increase with the ageing of the population.

Available treatment guidelines make few specific recommendations for older men with prostate cancer.3, 4, 5, 6 In 2010, the International Society of Geriatric Oncology (SIOG) undertook a systematic bibliographical search of procedures and treatment options for localised and advanced prostate cancer to develop recommendations for the management of older men with prostate cancer.7, 8 Recommendations from the 2013 European Association of Urology (EAU) guidelines,6 which include chapters on the treatment of prostate cancer in older men and on issues related to quality of life, accord with the 2010 SIOG guidelines.7, 8 Both highlight the under-treatment of older men, and the importance of assessing health status and comorbidities in management decisions. The recent EAU recommendations on early detection of prostate cancer specify that screening for prostate-specific antigen (PSA) should be offered to any man with a life expectancy of at least 10 years.9

The previously published SIOG guidelines7, 8 stated that age alone should not the provision of preclude effective treatment for prostate cancer. The aim of this report is to provide physicians with an updated comprehensive summary of evidence-based recommendations, including specific decision-making algorithms, for the management of localised and advanced prostate cancer in men older than 70 years. These care decisions should be made while taking into account patient preference.

Section snippets

Assessment of life expectancy, comorbidities, and health status

Although life expectancy is a major determinant of the potential benefit from therapy, it varies substantially between individuals of the same age. For example, the median life expectancy for a 75-year-old man is 8 years, but the individual's life expectancy will depend on other factors, such as comorbidities. Men in the highest quartile (likely to be healthy individuals) will live at least 14 years, whereas those in the lowest quartile (frail individuals with substantial comorbidities) will

Comorbidities

Comorbidities, as measured by the Charlson index,17 are major predictors of survival, after the exclusion of death from prostate cancer.11 The Cumulative Illness Score Rating-Geriatrics (CISR-G) is the best available method to assess the risk of non-prostate-cancer death;17 it rates non-lethal conditions according to their severity and potential degree of control by treatment (where grade 0 equates to no condition whereas grade 4 equates to an extremely severe condition requiring immediate

Treatment of prostate cancer Background

The SIOG Prostate Cancer Working Group examined the standard approaches for the management and treatment of localised and advanced prostate cancer, and applied, when possible, evidence-based considerations specific to a senior adult population. Retrospective studies of treatment for localised prostate cancer have focused mainly on patients in good health or fitness. In trials with chemotherapeutic agents and new hormone-targeted treatments that have shown the same benefit in elderly patients as

Treatment decisions

The aim of treatment for localised prostate cancer (T1–3, N0, M0 disease) is generally curative. Treatment decisions in older men with localised prostate cancer should take into account the risk of dying from the cancer (which depends on its grade and stage), the risk of dying from another cause (which depends more on the severity of comorbidities than on age), potential treatment risks, and the patient's preferences.

Treatment decisions should also take into account the risk of developing

Androgen deprivation therapy

This approach is the mainstay of treatment for patients with metastatic prostate cancer. Castration by surgery, or through use of agonists or antagonists of luteinising-hormone releasing hormone (LHRH), is the standard first-line treatment. No difference in efficacy between these treatments has been established. The standard procedure for second-line hormonal treatment is cessation of antiandrogen therapy (if given as first-line treatment in association with an LHRH agonist). No established

Early diagnosis of prostate cancer

The screening policy in older men with prostate cancer is controversial. Individual early diagnosis decisions should be based on the patient's health status, not on age. Two other important factors to be taken into account when screening are the increasing incidence of aggressive prostate cancer with increased age, and a patient's wish to be screened. Most guidelines do not recommend routine PSA screening in men aged 70 years or older or in any man with a life expectancy of less than 10 years.5

Conclusion

On the basis of the recommendations of the SIOG Prostate Cancer Working Group, and other international bodies, older patients with prostate cancer should be managed according to their individual health status, which is driven mainly by the severity of associated comorbid conditions, and not by patient's age. Screening for health status should include a validated screening instrument (G8), and the assessment of comorbid disorders (CISR-G scale), dependence status (IADL and ADL scales), and

Search strategy and selection criteria

Members of the International Society of Geriatric Oncology (SIOG) task force searched Medline and PubMed in English for “prostate cancer”, “neoplasms”, “elderly”, and “age limit >70 years”, focusing preferentially on 2009–13. American Urological Association (AUA), European Association of Urology (EAU), European Society for Medical Oncology (ESMO), and National Comprehensive Cancer Network (NCCN) guidelines were consulted from the respective bodies' websites. EAU, AUA, American Society of

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