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

[Therapy of castration-resistant prostate cancer]

Within the last two years the therapy of castration resistant prostate cancer (CRPC) has made major advances. Both the COU-AA-301 phase III trial and the TROPIC trial showed a survival benefit for patients after docetaxel failure treated with abiraterone or cabazitaxel, respectively. With rising interest for chemotherapeutic options and novel drugs, our goal was to review within the context of a multidisciplinary team the available evidence and explore the standards for medical treatment of prostate cancer outside of clinical trials. From this background, we are carefully evaluating the current treatment recommendations, based on the available evidence, and highlight potential future treatment options but also discuss important clinical topics like treatment until progression versus the advantage of chemo holidays and definition of particular patient subgroups. Additionally, we focus on novel molecular entities, which will most likely be available in the near future, such as MDV3100 and Sipuleucel T. The role and importance of palliation with radiotherapy and proactive medical management of pain is also discussed, as well as new options for bone directed therapy. The multitude of treatment options for patients with advanced prostate cancer clearly asks for a close collaboration between urologists, medical oncologists and radiation therapists.

Significance of docetaxel-based chemotherapy as treatment for metastatic castration-resistant prostate cancer in Japanese men over 75 years old

OBJECTIVES

The objective of this study was to evaluate the significance of docetaxel-based chemotherapy in elderly Japanese men with metastatic castration-resistant prostate cancer (CRPC).

MATERIALS AND METHODS

This study included a total of 159 consecutive patients aged≥75 years with mCRPC who were treated with docetaxel-based chemotherapy. The efficacy and tolerability of this therapy were retrospectively analyzed.

RESULTS

In these 159 patients, the median age and prostate-specific antigen (PSA) level before docetaxel-based chemotherapy were 78 years and 44.0 ng/ml, respectively. Of these patients, 42 (26.4%) and 117 (73.6%) received docetaxel as a weekly (30 mg/m2) and 3-weekly (70 mg/m2) regimen, respectively, and estramustine was administered combining with docetaxel in 77 (48.4%). Following docetaxel-based chemotherapy, PSA declined in 118 patients (74.3%), including 87 (54.6%) achieving a PSA decline≥50%, and the median progression-free survival and overall survival (OS) were 2.9 and 23.2 months, respectively. Of several factors examined, univariate analysis identified performance status (PS), significant clinical pain, bone metastasis, schedule of treatment, treatment cycle, and PSA response as significant predictors of OS, of which only PS, treatment cycle, and PSA response appeared to be independently associated with OS on multivariate analysis. The major grade 3-4 toxicities were myelosuppression, including neutropenia, anemia, and thrombocytopenia in 78 (49.1%), 22 (13.8%), and 14 (8.8%), respectively.

CONCLUSIONS

These findings suggest that docetaxel-based chemotherapy is clinically feasible in Japanese men aged≥75 years with mCRPC considering the cancer control as well as safety associated with this therapy.

[Management of advanced prostate cancer in elderly patients]

With the increase of the senior demographic, an increase in cancer including prostate cancer has been seen. The challenge is to offer personalized cancer care because of population specificity. The only way is to share two experiences: the oncologist's experience who knows prostate cancer, prognosis and adverses effects of treatments and geriatrician's experience who consider old patients in their entirety thanks to comprehensive geriatric assessment (CGA). This article provides data about treatments of prostate cancer and geriatric evaluation to demonstrate the importance to work together for a "tailored" care.

Recommendations from the Spanish Oncology Genitourinary Group for the treatment of patients with metastatic castration-resistant prostate cancer

Prostate cancer is the most prevalent urogenital malignancy. However, despite initial disease control using androgen deprivation, most of patients eventually develop progressive disease that is resistant to further hormone manipulation. For these patients with castration-resistant prostate cancer (CRPC), and particularly patients with metastatic disease, options have been limited, and prognosis is grim. However, as newer regimens and agents become available, higher rates of objective and biochemical response are being achieved, providing renewed hope for the management of these patients. With the aim of facilitating the treatment of these patients, the Spanish Oncology Genitourinary Group (SOGUG) has issued a series of the recommendations which have been collected in this review. Each recommendation is accompanied by the appropriate level of evidence and grade of recommendation on the basis of the characteristics of the data available.

[Role of chemotherapy in castration-resistant prostate cancer: are there new approaches?]

Chemotherapy options for the treatment of metastatic castration-resistant prostate cancer (CRPC) have been very limited for many decades. Until 2004, only mitoxantrone was approved, providing palliation, but no survival benefit. With the introduction of docetaxel, the landscape of chemotherapy for CRPC changed substantially. Prednisone and three-weekly docetaxel showed an overall survival (OS) benefit compared to mitoxantrone plus prednisone, in addition to a significant improvement of quality of life and pain reduction. Further strategies to treat CRPC with chemotherapy include reinduction with docetaxel in responding patients and the use of cabazitaxel, a novel semi-synthetic microtubule inhibitor, in the docetaxel-refractory population. This review article is meant to guide physicians through the optimal use of chemotherapy in CRPC patients in daily clinical practice.

Treating prostate cancer in elderly men: how does aging affect the outcome?

OPINION STATEMENT

Prostate Cancer (PCa) is the second most common cancer in United States and remains the second leading cause of death in the Western world. Because the median age of diagnosis for men with prostate cancer is greater than 75 years, PCa can be considered a disease of the elderly. Several disease-specific factors (e.g., stage, tumor grade, prostate-specific antigen (PSA) level) and patient-specific factors (e.g., age, co-morbidity, and functional status) need to be considered in the decision-making process. In an attempt to incorporate these important factors to select optimal treatment for older individuals, several decision models have been published, yet their utility in clinical practice remains poorly understood. Current guidelines for the management of patients with PCa do not make specific recommendations for the elderly. Clearly there is a need to improve our understanding of the complex interrelationships between old age, co-morbidities, and their impact on expected outcomes.

Cardiovascular comorbidity and treatment regret in men with recurrent prostate cancer

Study Type - Therapy (case series). Level of Evidence 4. What's known on the subject? and What does the study add? Treatment regret can have an adverse impact on a patient's overall outlook and has been associated with a poorer global quality of life. Understanding predictors of regret can help clinicians better counsel patients about their treatments so that later regret can be avoided. In previous studies, regret has been associated with lesser educational attainment, non-White race, greater post-treatment declines in sexual function and systemic symptoms. The present study found that, among men with recurrent prostate cancer, those with cardiovascular comorbidity were >50% more likely to regret their treatment choice than men without cardiovascular comorbidity. This study highlights the growing importance of considering comorbidity when counselling patients about prostate cancer treatment options, and provides a rationale for men with cardiovascular comorbidity to give additional consideration to active surveillance for their newly diagnosed prostate cancer.

OBJECTIVE

• To determine whether cardiovascular comorbidity is associated with increased treatment regret among men with recurrent prostate cancer.

METHODS

• The study cohort comprised 795 men in the Comprehensive, Observational, Multicenter, Prostate Adenocarcinoma (COMPARE) registry who experienced biochemical recurrence at a median (interquartile range) of 5.5 (2.8-9.1) years after prostatectomy (n= 410), external beam radiation therapy (n= 237), brachytherapy (n= 124) or primary androgen deprivation therapy (n= 24). • Multivariable logistic regression analysis was used to determine whether cardiovascular comorbidity was associated with treatment regret. • Cardiovascular comorbidity, which included myocardial infarction, congestive heart failure, angina, diabetes, stroke or circulation problems, was defined using a validated two-question screening process after adjusting for sociodemographic and treatment factors and post-treatment bladder and bowel toxicity.

RESULTS

• Of 795 men, 14.8% reported regret. • Men with cardiovascular comorbidity were more likely to experience post-therapy bowel toxicity (P= 0.022). • In the adjusted multivariable model, the factors associated with increased treatment regret were: cardiovascular comorbidity (adjusted odds ratio [AOR]= 1.52 [95% CI:1.00-2.31], P= 0.048); younger age (AOR: 0.97 [95% CI 0.94-0.99] per year increase in age, P= 0.019); and bowel toxicity after treatment (AOR 1.58 [95% CI 1.03-2.43], P= 0.038).

CONCLUSIONS

• Among men with recurrent prostate cancer, those with cardiovascular comorbidity were >50% more likely to experience treatment regret than men without cardiovascular comorbidity. • These data provide a rationale for men with cardiovascular comorbidity to give additional consideration to active surveillance for their newly diagnosed prostate cancer.

[Prostate cancer. Current and practice-relevant news from urology in 2011]

The effect of 5α reductase inhibitors in prostate cancer has been extensively investigated. The studies determined that finasteride and also dutasteride reduced the risk of prostate cancer; however, particularly high-grade cancer was not reduced and may possibly even have been increased. This is appropriately reflected in the S3 guideline on prostate cancer. New data on early recognition show that after longer term observation prostate cancer-specific mortality can be more effectively reduced by screening than was initially shown by the original data from the ERSPC study. Active surveillance is becoming more important for the therapy of early prostate cancer. Other new publications have shown good results for patients who underwent surgery for high risk prostate cancer. For metastasized prostate cancer new immunotherapeutic, chemotherapeutic and hormonal options are now available or will soon be approved.

Care of the elderly patient with prostate cancer: what's new and what's the same

As the number of men in the United States 65 years of age or older increases--from 12% in 2000 to 20% in 2030--the burden of prostate cancer also is increasing. Standard therapy is appropriate for healthy men with a life expectancy of more than 10 years; however, clinicians may fear either overtreating frail patients or undertreating patients who are physically fit. Evidence suggests the best approach is to conduct a comprehensive geriatric assessment using available measures and published guidelines to individualize treatment plans. Recent Food and Drug Administration approval of cabazitaxel, sipuleucel-T, and denosumab has expanded available treatment options. Managing symptoms related to disease complications and side effects of treatment is increasingly more complicated with the addition of these new regimens and extended life expectancy. Pharmacists' participation in patient assessment and supportive care are necessary components of comprehensive care for cancer patients.