Management of Older Men With Clinically Localized Prostate Cancer: The Significance of Advanced Age and Comorbidity

Time trends in the use of curative treatment in men 70 years and older with nonmetastatic prostate cancer

BACKGROUND

Undertreatment of otherwise healthy men in their seventies with prostate cancer has been reported previously.

MATERIAL AND METHODS

Using information in a Swedish prostate cancer research database, patterns of management and cancer-specific mortality were compared across age groups in over 70,000 men diagnosed with intermediate- or high-risk nonmetastatic prostate cancer between 2008 and 2020. Crude probabilities of death were estimated non-parametrically. Staging procedures, primary treatment, and cancer death were compared using regression models, adjusting for patient and tumor characteristics.

RESULTS

During the study period, the proportion of men treated with curative intent increased in ages 70-74 (intermediate-risk from 45% to 72% and high-risk from 49% to 84%), 75-79 (intermediate-risk from 11% to 52% and high-risk from 12% to 70%), and 80-84 years (intermediate-risk from < 1% to 14% and high-risk from < 1% to 30%). Older age was associated with lower likelihoods of staging investigations and curative treatment, also after adjustment for tumor characteristics and comorbidity. Men treated with curative intent and those initially managed conservatively had lower crude risks of prostate cancer death than men receiving androgen deprivation treatment (ADT). In adjusted analyses, ADT was associated with higher prostate cancer mortality than curative treatment across ages and risk groups. Among men managed conservatively, prostate cancer mortality was higher in ages 70 and above.

INTERPRETATION

Use of curative treatment increased substantially in older men with prostate cancer between 2008 and 2020. Our findings suggest reduced age-bias and under-treatment, likely reflecting improved individualized decision-making and adherence to guidelines recommending more active management of older men.

Risk Assessment and Considerations for Proper Management of Elderly Men with Advanced Prostate Cancer: A Systematic Review

CONTEXT

Treatment decisions for elderly men with prostate cancer are complicated by the intersection of competing risks of cancer, potential complications of treatment, and individual patients' comorbidities.

OBJECTIVE

To perform a systematic review of data guiding the assessment of elderly prostate cancer patients that addresses the risk from cancer and treatment, and to discuss a patient-centered approach to incorporating these factors into decision making.

EVIDENCE ACQUISITION

Evidence was gathered via a systematic review of the current literature. The search strategy used the terms prostate cancer, elderly, geriatric, >75 yr of age, risk assessment, and treatment in several combinations, and was limited to phase ≥ II clinical trials published between January 2008 and November 2018. Additional supporting literature for the discussion was pulled by hand search.

EVIDENCE SYNTHESIS

The benefits of treatment identified for systemic therapies commonly used to treat men with prostate in general extend to elderly patients. Evidence supports a multifaceted assessment of the risks of cancer and aging, and an understanding of the side effects of treatment to optimally guide therapeutic decision making for elderly patients. There is little evidence defining a geriatric risk stratification system specific to prostate cancer, and recommendations are predominantly based on adapted geriatric oncology approaches and expert consensus.

CONCLUSIONS

The care of elderly men with prostate cancer should incorporate a review of cancer risk, an assessment of aging, and an understanding of the effects of treatment to provide the patient with thorough and personalized guidance for treatment decisions. Future studies of elderly men with prostate cancer can define and validate ideal risk stratification methods as well as management approaches that may be distinct from those for younger populations.

PATIENT SUMMARY

Treatment decisions for elderly men with prostate cancer require consideration of the risk posed by the cancer coupled with an understanding of the patient's general health status.

Co-morbidities in a Retrospective Cohort of Prostate Cancer Patients

Objective

To characterize rates of co-morbidity among prostate cancer patients treated with radical prostatectomy and to examine the association between co-morbidity status and race, clinical factors, and health behaviors for cancer control.

Design/Study Participants

Retrospective cohort study among prostate cancer patients treated with radical prostatectomy.

Setting

Academic medical center located in the southeastern region of the United States.

Main Outcome Measure

Patients with at least one of five co-morbid conditions considered were categorized as having a co-morbidity, and those without any were categorized as not having a co-morbid condition. Co-morbid conditions considered were hypertension, diabetes, heart problems, stroke, and high cholesterol, which had been recorded in the electronic medical record as part of their past medical history.

Results

Fifty-one percent of participants had a co-morbidity, with hypertension being the most common. The average number of co-morbidities among study participants was .87. In a multivariate logistic regression analysis, being diagnosed with prostate cancer within the past four years was associated with an increased likelihood of having a co-morbidity (OR=4.71, 95% CI=2.69, 8.25, P=.0001) compared with diagnosis five or more years ago. Age was also associated with an increased likelihood of having a co-morbidity (OR=1.30, 95% CI=1.005, 1.68, P=.05). In this study cohort, race, stage at diagnosis, and PSA level were not statistically associated with co-morbidity status.

Conclusion

Better chronic disease management is needed among prostate cancer survivors through more effective survivorship care planning and interventions that promote health behaviors.

Age at diagnosis and prostate cancer treatment and prognosis: a population-based cohort study

Background

Old age at prostate cancer diagnosis has been associated with poor prognosis in several studies. We aimed to investigate the association between age at diagnosis and prognosis, and if it is independent of tumor characteristics, primary treatment, year of diagnosis, mode of detection and comorbidity.

Patients and methods

We conducted a nation-wide cohort study including 121 392 Swedish men aged 55-95 years in Prostate Cancer data Base Sweden 3.0 diagnosed with prostate cancer in 1998-2012 and followed for prostate cancer death through 2014. Data were available on age, stage, grade, prostate-specific antigen (PSA)-level, mode of detection, comorbidity, educational level and primary treatment. We used Cox regression to calculate hazard ratios (HRs) and 95% confidence intervals (CIs).

Results

With increasing age at diagnosis, men had more comorbidity, fewer PSA-detected cancers, more advanced cancers and were less often treated with curative intent. Among men with high-risk or regionally metastatic disease, the proportion of men with unknown M stage was higher among old men versus young men. During a follow-up of 751 000 person-years, 23 649 men died of prostate cancer. In multivariable Cox-regression analyses stratified by treatment, old age at diagnosis was associated with poorer prognosis among men treated with deferred treatment (HRage 85+ versus 60-64: 7.19; 95% CI: 5.61-9.20), androgen deprivation therapy (HRage 85+ versus 60-64: 1.72; 95% CI: 1.61-1.84) or radical prostatectomy (HRage 75+ versus 60-64: 2.20; 95% CI: 1.01-4.77), but not radiotherapy (HRage 75+ versus 60-64: 1.08; 95% CI: 0.76-1.53).

Conclusion

Our findings argue against a strong inherent effect of age on risk of prostate cancer death, but indicate that in current clinical practice, old men with prostate cancer receive insufficient diagnostic workup and subsequent curative treatment.

Racial and Ethnic Differences in Prostate Cancer Survivors' Perceived Engagement in Treatment Decision-Making

OBJECTIVE

We examined prostate cancer patients' perceived engagement in treatment decision-making and associated factors by race/ethnicity in a multiethnic sample.

METHOD

We identified patients through the California Cancer Registry. Patients completed a cross-sectional telephone interview in English, Spanish, Cantonese, or Mandarin. Multivariable logistic regression models, stratified by race/ethnicity, estimated the associations of patient demographic and health status characteristics on (1) doctor asked patient to help decide treatment plan and (2) patient and doctor worked out a treatment plan together.

RESULTS

We included 855 prostate cancer patients: African American (19%), Asian American (15%), Latino (24%), and White (42%). Asian American patients were less likely than White patients to report that their doctors asked them to help decide a treatment plan (OR = 0.31; 95% CI = 0.18-0.53) and that they worked out a treatment plan with their doctors (OR = 0.54; 95% CI = 0.33-0.90). Language of interview was a significant contributing factor in stratified analysis for both outcomes.

CONCLUSION

Asian American prostate cancer patients reported less engagement in treatment decision-making, with Chinese language being a significant contributing factor. Future research should identify patient-centered strategies that effectively engage underserved patients and support healthcare providers in shared decision-making with multiethnic and multilingual patients.

Prostate cancer aggressiveness and age: Impact of p53, BCL-2 and microvessel density

Older men are more likely to have advanced prostate cancer at time of their diagnosis, but whether prostate tumors are inherently (biologically) more aggressive with advancing age is uncertain. To address this gap in knowledge, we analyzed data from veterans (n=971) diagnosed with prostate cancer during 1991–1995. Factors included age, detection of prostate cancer by screening, prostate-specific antigen (PSA) level, anatomic stage, and Gleason score. Information on molecular markers obtained from immunohistochemical staining of prostate tissue, included B cell lymphoma-2 (bcl-2), p53, and microvessel density (MVD), each having a previously documented association with disease progression and increased risk of prostate cancer death. We first examined the bivariate association of demographic, clinical, and molecular factors with age, and found evidence that race, screening status, Gleason score, PSA, bcl-2, p53, and MVD varied across categories of age in this study population. After further characterizing the association between age and Gleason score, we used logistic regression to examine the association between age and molecular markers—accounting for race, screening status, PSA, and Gleason score. Comparing men older than 80 years to those younger than 70 years, adjusted ORs and 95% CIs were 1.89 (0.73 to 4.92), 1.91 (1.05 to 3.46), and 2.00 (1.06 to 3.78), for positive bcl-2, p53, and MVD markers, respectively; no statistically significant associations were found for men 70–79 years old, compared with men younger than 70 years. These novel findings suggest that very elderly men often present with biologically aggressive prostate cancer; the results also have potential implications for therapeutic decision-making.

Factors associated with current and severe physical side-effects after prostate cancer treatment: What men report

We identified patient and disease characteristics associated with (1) "current" physical side-effects of any severity; and (2) "severe" physical side-effects "ever" experienced by 3,348 (54%) prostate cancer (PCa) survivors in Ireland diagnosed 2-18 years previously. Postal questionnaires collected symptoms at diagnosis, post-biopsy complications, comorbidities, primary treatments and physical side-effects post-treatment (urinary incontinence, erectile dysfunction, libido loss, bowel problems, breast changes, hot flushes, and fatigue, "ever" and "current" at time of questionnaire completion). Men were grouped by "early" (localised) and "late" (locally advanced/advanced) disease at diagnosis. Multivariable logistic regression analysis identified patient and disease-related factors associated with post-treatment side-effects. Complications post-biopsy were associated with higher risk of "current" libido loss and impotence. Radical prostatectomy was associated with higher risk of "current" and "severe" incontinence, libido loss and impotence in both early and late disease. In early disease, brachytherapy was associated with lower risk of "current" fatigue and "severe" impotence. Comorbidities were associated with higher risk of "current" experience of four side-effects (incontinence, libido loss, bowel problems, fatigue). Men on active surveillance/watchful-waiting reported lower risk of sexual dysfunction. These findings could inform development of tailored information on side-effects, which, in turn, could inform treatment decision-making and post-treatment monitoring.

Undiagnosed prostatic malignancy at the time of radical cystoprostatectomy after prior prostatic radiation therapy

Purpose:

We determined the prevalence of prostatic malignancy in patients undergoing radical cystoprostatectomy (RC) for urothelial carcinoma (UC) with a history of radiation therapy (XRT) treatment for prostatic adenocarcinoma (PCa).

Materials and Methods:

Fifty-three men who underwent a RC for UC that were previously treated for PCa with XRT were retrospectively identified. Pathology reports were reviewed to assess for residual PCa or prostatic UC at the time of surgery.

Results:

Thirteen (25%) patients had residual PCa, 16 (30%) had prostatic UC, and 8 (15%) had both. Sixteen (30%) patients had no evidence of prostatic disease. Patients with PCa had median tumor volume of 2.2 cc (interquartile range: 1.2–2.5 cc) and one-third had high-risk features (Gleason score >8 or pT3-T4 disease). Sixteen of 24 patients (67%) with prostatic UC had a stromal invasion, 5 (21%) had a ductal invasion, and 3 (13%) had carcinoma in situ. Tumors at bladder neck or trigone during transurethral resection were predictive of prostatic UC (odds ratio: 4.32, 95% confidence interval: 1.2–15.5, P = 0.025).

Conclusions:

Despite prior XRT for PCa, less than one-third of patients had no prostatic disease at the time of RC. Routine prostatic sampling should be considered in these patients especially if considering the orthotopic diversion.

Quality of Life and Sexual Health in the Aging of PCa Survivors

Prostate cancer (PCa) is the most common malignancy in elderly men. The progressive ageing of the world male population will further increase the need for tailored assessment and treatment of PCa patients. The determinant role of androgens and sexual hormones for PCa growth and progression has been established. However, several trials on androgens and PCa are recently focused on urinary continence, quality of life, and sexual function, suggesting a new point of view on the whole endocrinological aspect of PCa. During aging, metabolic syndrome, including diabetes, hypertension, dyslipidemia, and central obesity, can be associated with a chronic, low-grade inflammation of the prostate and with changes in the sex steroid pathways. These factors may affect both the carcinogenesis processes and treatment outcomes of PCa. Any treatment for PCa can have a long-lasting negative impact on quality of life and sexual health, which should be assessed by validated self-reported questionnaires. In particular, sexual health, urinary continence, and bowel function can be worsened after prostatectomy, radiotherapy, or hormone treatment, mostly in the elderly population. In the present review we summarized the current knowledge on the role of hormones, metabolic features, and primary treatments for PCa on the quality of life and sexual health of elderly Pca survivors.

[Management of prostate cancer in the elderly]

The management of prostate cancer in elderly patients is a topic of controversial discussion. The current guidelines recommend diagnosis and treatment of prostate cancer only in patients with a life expectancy of more than 10 years. Especially in elderly patients pre-existing comorbidities play a crucial role in life expectancy. In clinical practice mostly patient age alone is considered for the treatment decision; however, a guideline-based therapy of prostate cancer should also be offered to elderly patients. The treatment decision should be based on patient general health status and the oncological risk. The patient individual health status can be determined on the basis of comorbidities present and patient nutritional and performance status. For an optimal therapy regime the oncological risk has to be considered in treatment decisions. The aim of this article is to give an overview of risk stratification and treatment options for localized and metastatic prostate cancer in elderly patients.