How we treat early systemic prostate cancer in older men

TOward a comPrehensive supportive Care intervention for Older men with metastatic Prostate cancer (TOPCOP3): A pilot randomized controlled trial and process evaluation

INTRODUCTION

Current management of metastatic prostate cancer (mPC) includes androgen receptor axis-targeted therapy (ARATs), which is associated with substantial toxicity in older adults. Geriatric assessment and management and remote symptom monitoring have been shown to reduce toxicity and improve quality of life in patients undergoing chemotherapy, but their efficacy in patients being treated with ARATs has not been explored. The purpose of this study is to examine whether these interventions, alone or in combination, can improve treatment tolerability and quality of life (QOL) for older adults with metastatic prostate cancer on ARATs.

MATERIALS AND METHODS

TOPCOP3 is a multi-centre, factorial pilot clinical trial coupled with an embedded process evaluation. The study includes four treatment arms: geriatric assessment and management (GA + M); remote symptom monitoring (RSM); geriatric assessment and management plus remote symptom monitoring; and usual care and will be followed for six months. The aim is to recruit 168 patients between two cancer centres in Toronto, Canada. Eligible participants will be randomized equally via REDCap. Participants in all arms will complete a comprehensive baseline assessment upon enrollment following the Geriatric Core dataset, as well as follow-up assessments at 1.5, 3, 4.5, and 6 months. The co-primary outcomes will be grade 3-5 toxicity and QOL. Toxicities will be graded using the National Cancer Institute Common Terminology Criteria for Adverse Events version 5.0. QOL will be measured by patient self-reporting using the EuroQol 5 dimensions of health questionnaire. Secondary outcomes include fatigue, insomnia, and depression. Finally, four process evaluation outcomes will also be observed, namely feasibility, fidelity, and acceptability, along with implementation barriers and facilitators.

DISCUSSION

Data will be collected to observe the effects of GA + M and RSM on QOL and toxicities experienced by older adults receiving ARATs for metastatic prostate cancer. Data will also be collected to help the design and conduct of a definitive multicentre phase III randomized controlled trial. This study will extend supportive care interventions for older adults with cancer into new areas and inform the design of larger trials.

TRIAL REGISTRATION

The trial is registered at clinicaltrials.gov (registration number: NCT05582772).

Impact of age at diagnosis of de novo metastatic prostate cancer on survival

BACKGROUND

An older age at the diagnosis of prostate cancer has been linked to worse prostate cancer-specific survival (PCSS). However, these studies were conducted before the approval of many life-prolonging drugs. This study was aimed at describing outcomes in a contemporary cohort of men diagnosed with de novo metastatic prostate cancer (mPCa) and assessing associations with the age at diagnosis while controlling for known prognostic factors.

METHODS

The Surveillance, Epidemiology, and End Results registry was used to identify men diagnosed with mPCa from 2004 to 2014. Men were classified by 4 age groups: ≤54, 55 to 64, 65 to 74, and ≥75 years. The median overall survival, PCSS, and restricted mean survival times for any-cause mortality and prostate cancer-specific mortality (PCSM) were calculated. Multivariable and subdistribution hazard ratios for PCSM according to age group and with controlling for race, marital status, and income were estimated.

RESULTS

Compared with men aged ≤54 years, men aged ≥75 years experienced a mean PCSS at 5 years that was 6.7 months shorter (95% confidence interval [CI], 5.5-7.8 months). In multivariable analyses, men aged ≥75 years had a 49% increase in the rate of PCSM in comparison with those aged ≤54 years (95% CI, 1.39-1.60). The subdistribution hazard ratio for PCSM between these groups was 1.41 (95% CI, 1.32-1.50).

CONCLUSIONS

Age was found to be an independent predictor of shorter PCSS in men diagnosed with de novo mPCa even in an era with more effective therapies. Further work is needed to determine the reason for poor outcomes in older men with mPCa.

Treatment outcomes in older patients with advanced gastrointestinal stromal tumor (GIST)

BACKGROUND

The aim of the study was to analyze the treatment results of advanced GIST in the largest, homogenous series of older patients.

METHODS

Between 2001 and 2016, 686 patients with metastatic/unresectable GIST were treated initially with imatinib and 656 were included in the analysis. Subsequently 232 patients were treated with sunitinib after imatinib failure. We have analyzed the outcomes of patients who have been treated with the tyrosine kinase inhibitor at the age ≥ 70 years and compared to control group of patients younger than 70 years old.

RESULTS

In the group of patients treated with imatinib, 139 (21%) started therapy at the age of at least 70 years (median age of the entire cohort: 60). Median progression-free survival (PFS) on 1st line imatinib did not differ between patients ≥70 yo (years old) and < 70yo (38.5 vs 44.9 months), but median overall survival (OS) was significantly better for younger patients (81 months vs. 50; p = 0.0001; although disease-specific survival - DSS was similar). Distribution of primary tumor mutational status was generally similar in older and younger patients. Permanent dose reduction (300-100 mg/day) was required for 23 patients (16.9%) in the older group and was significantly more frequent as compared to younger patients (5%). Drug-related adverse events were mainly of grades 1/2, but grade 3/4 toxicity occurred more frequently in older (14.7%) than in younger patients (3.8%). Similarly in group of patients treated with second-line sunitinib median PFS and DSS were comparable in groups of patients ≥70 yo (n = 55) and < 70yo (9.7 months vs 10.3 months; p = 0.7, and 21.5 vs 22.9 months). >40% of patients in both groups required dose adjustments to 37.5-25 mg daily.

CONCLUSIONS

Our study confirms that current therapy of advanced GIST with tyrosine kinase inhibitors (both in 1st and 2nd line) in older patients enable to achieve the similar disease control rate and final outcomes as in younger patients, but it demands close cooperation of experienced oncologist with patients for dose modifications and side effects management. Limitation of our study is that the patients did not undergo a comprehensive geriatric assessment, what might be helpful for personalized management of patients. Nevertheless, we confirm that older patients with GIST should not receive less treatment irrespective of comorbidities.

Are prostate biopsies necessary for all patients 75years and older?

PURPOSE

To develop nomograms predicting prostate cancer (PCa) and high-grade PCa (HGPCa) in the elderly population.

METHODS

We reviewed the data of patients aged 75years and older who underwent first-time prostate biopsy and multiparametric magnetic resonance imaging (mpMRI). The nomograms were developed based on multivariate analysis and evaluated. We performed the external validation and calibration of the risk calculators from the European Randomized Study of Screening for Prostate Cancer (ERSPC) and the Prostate Cancer Prevention Trial (PCPT).

RESULTS

The present study included 302 subjects with a median age of 78years (range: 75-91years). Overall, 225 and 129 subjects were diagnosed with PCa and HGPCa (Gleason score≥4+3), respectively. The ratio of free-to-total PSA, prostate-specific antigen density (PSAD), transrectal ultrasound (TRUS), and Prostate Imaging Reporting and Data System (PI-RADS) were used to develop the PCa-predicting nomogram, and PSAD, TRUS, and PI-RADS were used to develop the HGPCa-predicting nomogram. The area under the curve (AUC) values of PCa-predicting and HGPCa-predicting nomograms were 0.90 and 0.87. The ERSPC calculator had acceptable external calibration and validation outcomes. We recommended a cut-off probability of 42% for PCa-predicting nomogram when used in healthy older men to achieve a sensitivity of 95.6%, and a cut-off probability of 73% for HGPCa-predicting nomogram when used in vulnerable older men to achieve a specificity of 98.3%.

CONCLUSIONS

The present nomograms could help discriminate patients with PCa from healthy elder adults for standard treatment, and discriminate patients with HGPCa from vulnerable elder adults for modified treatment. External validation is expected.

Screening and Treating Prostate Cancer in the Older Patient: Decision Making Across the Clinical Spectrum

Treatment of the growing geriatric patient population is increasingly being recognized as a necessary priority of the oncology community. As the most common cancer among men in developed countries, prostate cancer afflicts a sizable portion of elderly men. Caring for this population requires knowledge of aspects of disease presentation, screening strategies, treatment approaches, and survivorship care considerations unique to the geriatric population. In this article, we review characteristics of prostate cancer screening and treatment decision making for localized disease in elderly men, including a discussion of the biology of disease in the elderly population. We also review best practices for providing treatment for localized and recurrent disease in an elderly population, including engaging in a basic geriatric assessment to determine fitness for treatment, eliciting information about patient preferences and support systems, and balancing treatment decisions in the context of these factors using the resources of a multidisciplinary care team. We then consider complications of prostate cancer survivorship related to systemic treatment in the elderly population of men with this disease. Finally, we emphasize the importance of engaging patients in treatment decision making across the spectrum of disease to personalize treatment plans and provide optimal care.

Metastatic castration-resistant prostate cancer in very elderly patients: challenges and solutions

The treatment of elderly patients with cancer is usually viewed by clinicians as a challenge, because of the age-related decline in normal organ function and the frequent concomitant administration of multiple drugs for comorbid conditions. Clinicians therefore tend not to prescribe antineoplastic agents (mainly in the case of chemotherapy) to elderly patients, with the fear of excess toxicity leading to an unfavorable cost:benefit ratio. The cutoff age defining a cancer patient as elderly is usually 70 years, but over the last 10 years clinicians have paid more attention to functional status, as evaluated by means of a comprehensive geriatric assessment and comorbidity burden, rather than chronological age. In the case of metastatic castration-resistant prostate cancer (mCRPC), depending on their age at the time of diagnosis of PC, many (if not most) of the patients are more than 70 years old, and a fair number are very elderly patients aged ≥80 years. The availability of various agents capable of significantly prolonging survival has dramatically changed the therapeutic landscape of mCRPC patients, but very elderly patients are usually underrepresented in pivotal trials. This narrative review considers the available data concerning elderly and very elderly mCRPC patients enrolled in pivotal trials and the information provided by reports of everyday clinical practice, in order to explore the challenges related to the clinical management of this special population.

The implications of ageing and life expectancy in prostate cancer treatment

In patients diagnosed with prostate cancer, the selection of treatment, including the type of therapy and its aggressiveness, is often based on a patient's age and life expectancy. Life expectancy estimates are too often calculated solely on the patient's chronological age, overlooking comorbid conditions and their severity, which can greatly affect life expectancy. If, in addition to chronological age, comorbid conditions are used to assess a patient's life expectancy, the most appropriate treatment options are more likely to be selected. Older, healthy patients might be able to tolerate more aggressive treatment than would be administered on the basis of their age alone, and younger patients with numerous comorbid conditions could avoid harsh therapy that might not be appropriate given their current state of health. The key idea to consider in treatment selection is what a patient's quality of life would be like with or without a particular treatment option. In an era of precision medicine, decisions regarding the provision of health care should be made rationally and on the basis of objective estimates of the threat of disease and the benefits and costs of intervention and within the context of the patient's characteristics and desires.