Don’t overlook the elderly for prostate cancer treatment

Prostate cancer is a common malignancy in men with a predilection for the elderly. Despite this, many prostate cancer medical trials under-represent the geriatric population and there is a risk of under treatment within this age group. The associated article ‘Radiotherapy in elderly patients with prostate cancer’ attempts to guide clinicians through the management of the geriatric prostate cancer patient with specific focus on the role of radical radiotherapy.

Key to the treatment of the geriatric prostate cancer patient is a comprehensive medical review that can give the clinician confidence that the patient has the medical robustness to tolerate the therapy being offered. The comprehensive geriatric assessment tool (CGA) is widely used and reported on but it can be cumbersome in a busy clinical setting. The International Society of Geriatric Oncology (SIOG) favoured G8 assessment is quicker to use and guides the clinician as to when further specialist geriatric assessment should be sought to optimise individual patients.

While the role of adjuvant androgen deprivation therapy in the elderly prostate cancer patient maybe more controversial, there is an increasing body of evidence that appropriately assessed geriatric patients not only tolerate radical radiotherapy well but gain a survival advantage compared to their peers treated with palliative intent alone.  It is important that clinicians do not decide therapy based on patient chronological age alone and I would point anyone who is interested in further reading to the recommendations of a task force of the SIOG on the management of prostate cancer (click here). Wherever possible, clinical trials should be designed to include geriatric patients to develop the evidence base.

What are your thoughts an experiences on this topic? Please feel free to leave comment below.  

Comments (4) Add yours ↓
  1. Christopher Woodhouse Retired Urologist

    As soon as you refer to patients as ‘geriatric’ a negative attitude of mind is created. All men with a limited life expectancy and carcinoma of the prostate are in a race between the cancer and whatever the co-morbidities may be. Both need detailed assessment before deciding on management. Active surveillance is not ‘palliation’ but an active plan to introduce treatment if and when needed.

    July 26, 2018 Reply
  2. Antoine Kass-Iliyya ST5 Urology

    15 year prostate cancer specific mortality in the elderly >75 increses from 10% to 33% when comparing low risk to high risk disease patients. (Swedish national prostate cancer registery, Rider et al). This suggests that radical treatment in the elderly with high risk disease should be of benefit.

    I think the main challange is perhaps changing the mind-set of Urologists in the UK towards treating an elderly patient with prostate cancer both at diagnosis and treatment levels.

    for some reason 80 seems to be the key age in the UK.

    In most hospitals I worked with, Elderly patients (>80) with raised PSAs 20 or >50.

    Many elderly patients >80 with proven prostate cancer on biopsies (if they made it to biopsy) (including high risk disease) are not necessarily offered radiotherapy (even in cases of fit 80 year olds or frail with reversibe causes). The majority are offered watchful waiting or hormones.

    I think the reluctance to give radiotherpay stems from a lack of conviction among urologists that a significant years of life is gained by offering radical treatment as opposed to watchful waiting in this high risk group of elderly patients. (To be fair, I am not sure myself how many years is actually gained as the literature is scarce)

    It makes sense to adopt a screening approach with G8 and mini-COG for all geriatric prostate cancer patients and have this information readily available at the MDT to be able to make an informed and fair decision regarding the management of this age group and ultimately, elderly patients who are fit with high risk localised disease should be offered radiotherapy as the literature suggests that it reduces mortality. (SPCG-7 Trial (RT and hormones halves the 10 year prostate cancer specific mortality compared to hormones alone, in locally advanced or high risk prostate cancer in 67-75 year olds))

    Oncologists are usually more amenable to offering radiotherapy to the latter group of patients, and perhaps, as urologist, we should be referring more patients to our oncology colleagues who, I am sure, will be welcoming the referral.

    August 11, 2018 Reply
  3. Antoine Kass-Iliyya ST5 Urology

    Correction:
    In most hospitals I worked with, Elderly patients (>80) with raised PSAs 20 or >50.

    August 11, 2018 Reply
  4. Antoine Kass-Iliyya ST5 Urology

    In most hospitals I worked with, Elderly patients (>80) with raised PSAs of less than 20 do not get biopsies. (as expected, lot of them have T2 feeling prostates), they might get a bone scan if PSA >20 or >50.

    August 11, 2018 Reply

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