Continued undertreatment of older men with localized prostate cancer

Prognosis after radical prostatectomy in men older than 75 years: long-term results from a single tertiary center

Background

Despite longer lifespans, guidelines for prostate cancer treatment recommend surgery for those with over 10 years of life expectancy, potentially leaving older patients undertreated. This study examines the outcomes of radical prostatectomy (RP) in a large cohort of men older than 75 years.

Materials and methods

We retrospectively analyzed 636 patients from a pool of 4,500 RP cases at a single tertiary institution from 2004 to 2022. Patients younger than 75 years or with incomplete records were excluded. Baseline clinical variables, including PSA and biopsy grade group (GG), as well as postoperative pathology and oncological outcomes, were assessed. Achievement of continence based on no pads and ≤1 pad at last follow-up were evaluated.

Results

Mean age and PSA were 76.4 years and 15.3 ng/ml, respectively. At biopsy, GG1 and 2 were found in 18.1% and 31.5%, respectively, with 28.5% harboring GG4-5 tumors. After RP, 41.5% had GG upgrade compared to biopsy results, with 46.5% with ≥pT3 tumors. In a mean follow-up of 41.5 months, 82.3% were able to attain total continence of 0 pads, and 89.5% used ≤1 pads at the last follow-up. Overall and cancer-specific mortality was observed in 4.3% and 0.9%, respectively, and biochemical recurrence (BCR) occurred in 20.3% after a median of 154 months. At multivariate analysis, age was not a significant factor for BCR, whereas preoperative PSA, biopsy GG, margin positivity, and lymph node invasion were significant.

Conclusion

RP is feasible in men older than 75 years with decent oncological outcome, with absolute age insignificant within this age group. Risk of undertreatment should be acknowledged, and definite treatment must be considered.

Prognostic significance of surgery and radiotherapy in elderly patients with localized prostate cancer: establishing and time-based external validation a nomogram from SEER-based study

OBJECTIVE

Prostate cancer (PC) is a significant disease affecting men's health worldwide. More than 60% of patients over 65 years old and more than 80% are diagnosed with localized PC. The current choice of treatment modalities for localized PC and whether overtreatment is controversial. Therefore, we wanted to construct a nomogram to predict the risk factors associated with cancer-specific survival (CSS) and overall survival (OS) in elderly patients with localized PC while assessing the survival differences in surgery and radiotherapy for elderly patients with localized PC.

METHODS

Data of patients with localized PC over 65 years were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. Univariate and multivariate Cox regression models were used to determine independent risk factors for CSS and OS. Nomograms predicting CSS and OS were built using multivariate Cox regression models. The consistency index (C-index), the area under the subject operating characteristic curve (AUC), and the calibration curve were used to test the accuracy and discrimination of the prediction model. Decision curve analysis (DCA) was used to test the potential clinical value of this model.

RESULTS

A total of 90,434 patients over 65 years and diagnosed with localized PC from 2010 to 2018 were included in the study. All patients were randomly assigned to the training set (n = 63,328) and the validation set (n = 27,106). Univariate and multivariate Cox regression model analysis showed that age, race, marriage, T stage, surgical, radiotherapy, prostate-specific antigen (PSA), and Gleason score (GS) were independent risk factors for predicting CSS in elderly patients with localized PC. Age, race, marriage, surgery, radiotherapy, PSA, and GS were independent risk factors for predicting OS in elderly patients with localized PC. The c-index of the training and validation sets for the predicted CSS is 0.802(95%CI:0.788-0.816) and 0.798(95%CI:0.776-0.820, respectively). The c-index of the training and validation sets for predicting OS is 0.712(95%:0.704-0.720) and 0.724(95%:0.714-0.734). It shows that the nomograms have excellent discriminatory ability. The AUC and the calibration curves also show good accuracy and discriminability.

CONCLUSION

We have developed new nomograms to predict CSS and OS in elderly patients with localized PC. After internal validation and external temporal validation with reasonable accuracy, reliability and potential clinical value, the model can be used for clinically assisted decision-making.

Irradiation of localized prostate cancer in the elderly: A systematic literature review

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Oncological benefit for elderly patients with optimal treatment.

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Elderly patients often received inadequate treatment.

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Elderly comorbidities can influence oncological outcomes and treatment tolerance.

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Optimal curative treatment after oncogeriatric assessment.

Purpose

To analyze the literature that addresses radiation therapy for intermediate and high-risk prostate cancer (PC) in the elderly.

Patients and methods

A PubMed literature search was conducted including articles from 01/01/2000 to 30/06/21, with the following keywords: PC, radiotherapy/brachytherapy and elderly. The analysis mainly focused on the issue of under-treatment in the elderly and the benefit/risk balance of irradiation.

Results

Of the 176 references analyzed, 24 matched the selection criteria. The definition of “elderly patient” varied from 70 to 80 years. The analysis was impacted by the inhomogeneous primary end points used in each cohort. Age was often an obstacle to radical treatment, with a subsequent risk of under-treatment, particularly in patients with a poorer prognosis. However, comparable elderly oncological outcomes were compared to younger patients, both with external beam radiotherapy alone or combined with brachytherapy boost. Late toxicity rates are low and most often comparable to younger populations. However, a urinary over- toxicity was observed in the super-elderly (>80 years) after brachytherapy boost. The use of ADT should be considered in light of comorbidities, and may even be deleterious in some patients.

Conclusion

Due to the increase in life expectancy, the management of PC in the elderly is a challenge for patients, clinicians and health insurance payers. Except for unfit men, elderly patients remain candidates for optimal curative treatment (i.e. regardless of age) after oncogeriatric assessment. More solid data from prospective trials conducted specially in this population will provide better guidance in our daily clinical practice.

High-Dose-Rate brachytherapy boost for elderly patients with intermediate to high-risk prostate cancer: 5-year clinical outcome of the PROSTAGE cohort

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Intermediate/high risk elderly prostate cancer benefits less from received standards of care.

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Age is an independent factor for disease control and tolerance.

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Brachytherapy boost remains efficient and feasible in the elderly.

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Careful discussion for super elderly patients (>80 y) is warranted.

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Oncogeriatric assessment is necessary to identify best candidates.

Purpose

To analyze the oncological outcome in elderly (>70 years) prostate cancer after high-dose rate brachytherapy (HDB) boost.

Materials/methods

In this retrospective study, patients with intermediate (IR) and high-risk (HR) prostate cancer underwent external beam radiation therapy (EBRT) followed by HDB boost with/without androgen deprivation therapy (ADT). The impact of age (≤70y vs. > 70y) was investigated. Oncological outcome focused on biochemical relapse-free survival (bRFS), cause-specific (CSS) and overall survival (OS). Late genito-urinary (GU) and gastro-intestinal (GI) toxicities were investigated.

Results

From 07/08 to 01/22, 518 pts received a HDB boost, and 380 were analyzed (≤70y:177pts [46.6%] vs. > 70y:203pts [53.4%]). Regarding NCCN classification, 98 pts (≤70y: 53pts; >70y: 45pts; p = 0.107) and 282 pts (≤70y: 124pts; >70y: 158pts; p = NS) were IR and HR pts respectively. Median EBRT dose was 46 Gy [37.5–46] in 23 fractions [14–25]. HDB boost delivered a single fraction of 14/15 Gy (79%). ADT was used in 302 pts (≤70y: 130pts; >70y: 172pts; p = 0.01). With MFU of 72.6 months [67–83] for the whole cohort, 5-y bRFS, 5-y CSS and 5-y OS were 88% [85–92], 99% [97–100] and 94% [92–97] respectively; there was no statistical difference between the two age groups except for 5-y CSS (p = 0.05). Late GU and GI toxicity rates were 32.4% (G ≥ 3 7.3%) and 10.1% (no G3) respectively.

Conclusions

For IR and HR prostate cancers, HDB boost leads to high rates of disease control with few late G ≥ 3 GU/GI toxicities. For elderly pts, HDB boost remains warranted mainly in HR pts, while competing comorbidity factors influence OS.

Robot-assisted radical prostatectomy in indian men of age 75 years and above: a propensity score-matched analysis

Older men undergoing robot-assisted radical prostatectomy (RARP) have been thought to have worse perioperative, functional and oncological outcomes than younger men. However, there is a dearth of matched studies on this subject in the currently available literature. Our study is a matched pair analysis of perioperative, oncological and functional outcomes of RARP in men < 75 years of age versus ≥ 75 years (62 in each group). There was no statistically significant difference in complications, length of stay, pathological stage, positive surgical margins (PSM) and nodal involvement. Older men were less likely to undergo nerve sparing in our study (8.0 vs 75.8% p = 0.01). Potency rates were too low to be compared. The 1-year continence rates, time to continence and the proportion of men with biochemical recurrence (BCR) were similar between the groups. Men ≥ 75 years developed BCR much earlier than < 75 years (30 versus 78 months p = 0.07). However, this was not statistically significant. Age ≥ 75 years was associated with a statistically insignificant 53.5% rise in the risk of BCR. It was also not associated with any increased risk of postoperative complications or PSM. RARP is a safe procedure in senior adults. The oncological and functional outcomes of RARP in senior adults are similar to younger men.

Targeted Mass Spectrometry of a Clinically Relevant PSA Variant from Post-DRE Urines for Quantitation and Genotype Determination

PURPOSE

The rs17632542 single nucleotide polymorphism (SNP) results in lower serum prostate specific antigen (PSA) levels which may further mitigate against its clinical utility as a prostate cancer biomarker. Post-digital rectal exam (post-DRE) urine is a minimally invasive fluid that is currently utilized in prostate cancer diagnosis. To detect and quantitate the variant protein in urine.

EXPERIMENTAL DESIGN

Fifty-three post-DRE urines from rs17632542 genotyped individuals processed and analyzed by liquid chromatography/mass spectrometry (LC-MS) in a double-blinded randomized study. The ability to distinguish between homozygous wild-type, heterozygous, or homozygous variant is examined before unblinding.

RESULTS

Stable-isotope labeled peptides are used in the detection and quantitation of three peptides of interest in each sample using parallel reaction monitoring (PRM). Using these data, groupings are predicted using hierarchical clustering in R. Accuracy of the predictions show 100% concordance across the 53 samples, including individuals homozygous and heterozygous for the SNP.

CONCLUSIONS AND CLINICAL RELEVANCE

The study demonstrates that MS based peptide variant quantitation in urine could be useful in determining patient genotype expression. This assay provides a tool to evaluate the utility of PSA variant (rs17632542) in parallel with current and forthcoming urine biomarker panels.

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.

Impact of age at diagnosis on overall and disease-free survival in men with prostate cancer following conformal 3D radiation therapy

Aims and background

The impact of age on prostate cancer outcome has been controversial. The aim of the study was to evaluate the role of age on overall survival and disease-free survival in patients affected by prostate cancer when treated with 3D conformal radiation therapy.

Methods and study design

From 1999 to 2005, 1002 patients with T1–T3 prostate cancer were treated with 3D conformal radiation therapy, delivering a median dose of 75.6, 66.6 and 45 Gy to the prostate, seminal vesicles and pelvic nodes (if necessary), respectively. Patients were divided into four groups (<65, 65–70, 70–75, >75 years) according to age at diagnosis. The relationship between age and both overall survival and disease-free survival was calculated with Kaplan-Meier analysis and the comparison between curves was performed by the logrank test. ROC analysis allowed assessment of the best age cutoff.

Results

Mean age was 71 ± 6 years (median, 72). Median and mean follow-up was 71.4 and 69 months, respectively. In multivariate analysis, there was no significant difference in the distribution of disease risk between age groups. Analysis demonstrated that older age is a strong positive predictor of survival (odds ratio for stratified patients older than 70 years was <1). In fact, at the 90 month follow-up, overall survival and disease-free survival varied with age, increasing from 85% to 95% and from 78% to 94%, respectively. ROC curve analysis yielded a cutoff age value discriminating overall survival and disease-free survival of 72 years.

Conclusions

Age is a strong positive predictor of overall survival and disease-free survival, playing a protective role for stratified patients up to 72 years of age.

Comorbidity assessment in localized prostate cancer: a systematic review protocol

The objective of this study is to review and summarize the methods and tools used to measure comorbidity in localized prostate cancer (PCa) and in particular to assess whether these tools are adequately validated and reliable for determining the impact of comorbidity on survival and treatment decisions for this disease.Specifically, the review questions are.

The prognostic value of stromal FK506-binding protein 1 and androgen receptor in prostate cancer outcome

BACKGROUND

Improving our ability to predict cancer progression and response to conservative or radical intent therapy is critical if we are to prevent under or over treatment of individual patients. Whereas the majority of solid tumors now have a range of molecular and/or immunological markers to help define prognosis and treatment options, prostate cancer still relies mainly on histological grading and clinical parameters. We have recently reported that androgen receptor (AR) expression in stroma inversely associates with prostate cancer-specific survival, and that stromal AR reduces metastasis. For this paper, we tested the hypothesis that the AR-regulated gene FKBP51 could be used as a marker of AR activity to better predict outcome.

METHODS

Using immunohistochemistry on a cohort of 64 patient-matched benign and malignant prostate tissues, we assessed patient outcome by FKBP51 and AR levels. Immunoblot and RT-qPCR were used to demonstrate androgen regulation of FKBP51 in primary and primary human prostatic fibroblasts and fibroblast cell-lines.

RESULTS

As predicted by FKBP51 level, high AR activity in cancer stroma was associated with longer median survival (1,306 days) compared with high AR alone (699 days), whereas those with low AR and/or low FKBP51 did poorly (384 and 338 days, respectively). Survival could not be predicted on the basis cancer epithelial AR levels or activity, and was not associated with immunoreactivity in patient matched benign tissues.

CONCLUSION

FKBP51 improves the ability of stromal AR to predict prostate cancer-specific mortality. By adding additional immunological assessment, similar to what is already in place in a number of other cancers, we could better serve patients with prostate cancer in prognosis and informed treatment choices. Prostate 77:185-195, 2017. © 2016 Wiley Periodicals, Inc.

Comorbidity as a predictor of overall survival in prostate cancer patients treated with external beam radiotherapy combined with HDR brachytherapy boosts

BACKGROUND

The risk stratification currently applied prior to curative treatment for localized prostate cancer (PC) does not take into account comorbidity or age. Therefore, we investigated the impact of comorbidity on overall survival (OS) in PC patients treated with external beam radiotherapy (EBRT) and high-dose rate (HDR) brachytherapy boost.

MATERIAL AND METHODS

At a single center, 611 consecutive patients diagnosed with localized PC from 1998 to 2004 underwent definitive EBRT (50 Gy) and HDR brachytherapy boosts (2 × 10 Gy) combined with neoadjuvant total androgen blockade. Comorbidity was assessed with the Charlson comorbidity score. The impact of risk factors on OS and disease-free survival (DFS) was calculated using Cox proportional hazard ratios. Risk groups were defined as follows: low-risk PC: PSA <10, WHO grade 1 and T stage 1; high-risk PC: PSA >20 and/or WHO grade 3 and/or T stage 3a; intermediate-risk PC representing patients who did not fit either the low- or high-risk PC group.

RESULTS

Mean age in the study cohort was 66.4 years, and 51% of the patients reported some degree of comorbidity. Divided into risk groups 8.2% were categorized as low-risk, 64% as intermediate-risk and 27.8% as high-risk PC. Overall 10-year survival was 72.2%, and 89% of the patients were relapse-free. In the univariate and multivariate analyses using Cox proportional hazard ratios, age, comorbidity and T stage were statistically significant predictors of OS: hazard ratios 1.56, 1.44 and 1.2 (p-values .002, .04 and .05), respectively. WHO grade, PSA at diagnosis, T stage and comorbidity were also significant predictors of DFS (p-values .0001, .0001, .009 and .003, respectively).

CONCLUSION

Comorbidity assessed with the Charlson score predicts OS in patients with localized PC treated with curative intent using combined EBRT and HDR brachytherapy boost, and should be considered when making decisions before radical treatment.

Radical Prostatectomy in Korean Men Aged 75-Years or Older: Safety and Efficacy in Comparison with Patients Aged 65-69 Years

Prostate cancer is the most common type of male cancer worldwide. Although radical prostatectomy (RP) is advised for prostate cancer in patients with a life expectancy of more than 10 years by various guidelines, most elderly men still do not undergo the procedure regardless of increasing life expectancy. This study aimed to determine whether RP is suitable for patients with prostate cancer aged 75 years or older. A retrospective study of patients who underwent RP at 6 institutions between 2005 and 2012 was conducted. Patients were divided into 2 groups at the time of surgery: 65-69 years (younger group) and 75 years or older (older group). We compared clinical characteristics, pathological results, complication rates, and recurrence-free survival between the two groups. Compared with the younger group, the older group had significantly higher preoperative serum prostate-specific antigen level, pre- and postoperative Eastern Cooperative Oncology Group (ECOG) performance status grade, hypertension prevalence, and Gleason score at biopsy and RP. However, except urinary incontinence, there were no statistically significant differences in the peri- and post-operative complications. After median follow-up periods of 36 months (younger group) and 40 months (older group), the biochemical recurrence-free survival rates were not significantly different (P = 0.581). Although the urinary incontinence rate was higher in the older group, RP was a suitable option for selected Korean men aged 75 years or older with limited complication rates and excellent outcomes similar to those for patients aged 65-69 years.

Evaluation and Management of the Geriatric Urologic Oncology Patient

The geriatric population presents a unique set of challenges in urologic oncology. In addition to the known natural history of disease, providers must also consider patient factors such as functional and nutritional status, comorbidities and social support when determining the treatment plan. The development of frailty measures and biomarkers to estimate surgical risk shows promise, with several assessment tools predictive of surgical complications. Decreased dependence on chronologic age is important when assessing surgical fitness, as age cutoffs prevent appropriate treatment of many elderly patients who would benefit from surgery. Within bladder, kidney and prostate cancers, continued refinement of surgical techniques offers a broader array of options for the geriatric patient than previously available.

Designing therapeutic clinical trials for older and frail adults with cancer: U13 conference recommendations

A majority of cancer diagnoses and deaths occur in patients age ≥ 65 years. With the aging of the US population, the number of older adults with cancer will grow. Although the coming wave of older patients with cancer was anticipated in the early 1980s, when the need for more research on the cancer-aging interface was recognized, many knowledge gaps remain when it comes to treating older and/or frailer patients with cancer. Relatively little is known about the best way to balance the risks and benefits of existing cancer therapies in older patients; however, these patients continue to be underrepresented in clinical trials. Furthermore, the available clinical trials often do not include end points pertinent to the older adult population, such as preservation of function, cognition, and independence. As part of its ongoing effort to advance research in the field of geriatric oncology, the Cancer and Aging Research Group held a conference in November 2012 in collaboration with the National Cancer Institute, the National Institute on Aging, and the Alliance for Clinical Trials in Oncology. The goal was to develop recommendations and establish research guidelines for the design and implementation of therapeutic clinical trials for older and/or frail adults. The conference sought to identify knowledge gaps in cancer clinical trials for older adults and propose clinical trial designs to fill these gaps. The ultimate goal of this conference series is to develop research that will lead to evidence-based care for older and/or frail adults with cancer.

Optimal management of colorectal liver metastases in older patients: a decision analysis

BACKGROUND

Comparative trials evaluating management strategies for colorectal cancer liver metastases (CLM) are lacking, especially for older patients. This study developed a decision-analytic model to quantify outcomes associated with treatment strategies for CLM in older patients.

METHODS

A Markov-decision model was built to examine the effect on life expectancy (LE) and quality-adjusted life expectancy (QALE) for best supportive care (BSC), systemic chemotherapy (SC), radiofrequency ablation (RFA) and hepatic resection (HR). The baseline patient cohort assumptions included healthy 70-year-old CLM patients after a primary cancer resection. Event and transition probabilities and utilities were derived from a literature review. Deterministic and probabilistic sensitivity analyses were performed on all study parameters.

RESULTS

In base case analysis, BSC, SC, RFA and HR yielded LEs of 11.9, 23.1, 34.8 and 37.0 months, and QALEs of 7.8, 13.2, 22.0 and 25.0 months, respectively. Model results were sensitive to age, comorbidity, length of model simulation and utility after HR. Probabilistic sensitivity analysis showed increasing preference for RFA over HR with increasing patient age.

CONCLUSIONS

HR may be optimal for healthy 70-year-old patients with CLM. In older patients with comorbidities, RFA may provide better LE and QALE. Treatment decisions in older cancer patients should account for patient age, comorbidities, local expertise and individual values.

Resource utilization and use of life-extending therapies and corticosteroids in prostate cancer patients with corticosteroid-sensitive comorbidities

OBJECTIVES

Corticosteroids (CSs) are used concomitantly with life-extending therapies (LETs) in patients with castration-resistant prostate cancer (CRPC). This study examined time to LETs, LETs and concomitant CS adherence, and monthly all-cause healthcare utilization and costs in patients with CPRC with and without CS-sensitive comorbidities in the Veterans Health Administration population.

METHODS

Patients had CRPC if records showed prostate cancer diagnosis, medical/surgical castration and ≥2 prostate-specific antigen increases through 1 June 2007-31 May 2012. CS-sensitive comorbidities were assessed 6 months prior to the index date. Adherence, defined as medication possession ratio (MPR) ≥0.8, among patients initiating LETs (cabazitaxel, docetaxel, or abiraterone acetate) before 30 November 2011, resource utilization and costs among patients with concomitant CS were assessed. Statistical analysis included descriptive, Cox proportional hazards, and logistic regression models.

RESULTS

Common CS-sensitive conditions among 12,128 patients with CRPC included hypertension (75.74%) and hyperlipidemia (54.69%). Those with glaucoma (hazard ratio [HR] = 0.67), ischemic heart disease (HR = 0.78), and peripheral vascular disease (PVD) (HR = 0.78) were less likely to be prescribed LETs (all p < 0.01). Duration of LET was shorter among patients with CS-sensitive comorbidities (125.02 vs 133.08 days; p = 0.04) in the 6 month follow-up period. Among LET-treated patients with and without CS-sensitive comorbidities, less than half had MPR ≥ 0.8 (LET: 48.72% vs 54.05%; concomitant CS: 42.19% vs 40.54%, respectively). Cerebrovascular disease (odds ratio = 0.107; 95% confidence interval = 0.012 to 0.966) and PVD (odds ratio = 0.523; 95% confidence interval = 0.276 to 0.991) were associated with reduced CS adherence. Among patients with concomitant CS, those with CS-sensitive comorbidities had more inpatient stays than those without (20.45% vs 12.88%; p = 0.033), incurring higher monthly inpatient costs ($1157 vs $342; p < 0.0001) and total costs ($5725 vs $4772; p = 0.036).

CONCLUSION

CS-sensitive conditions influence initiation and duration of LETs, concomitant CS adherence, inpatient stays, and total costs. Future efforts should focus on specific strategies for treating prostate cancer patients with CS-sensitive comorbidities to ensure that they have appropriate access to LETs and to reduce costs and inpatient stays. Study limitations include the use of retrospective claims data and the relatively restricted subpopulation of older North American males.

Prognostic significance of YWHAZ expression in localized prostate cancer

BACKGROUND

Prostate cancer (PCa) patients are often over-treated because of the lack of biomarkers needed to distinguish the lethal from the indolent form of PCa. YWHAZ was recently identified as a potential therapeutic target in castration-resistant PCa (CRPC). Therefore, this study focused on determining the prognostic significance of YWHAZ in localized PCa.

METHODS

YWHAZ expression was assessed by immunohistochemistry on formalin-fixed paraffin-embedded tissue from 213 men who underwent radical prostatectomy. Kaplan-Meier analysis and Cox proportional-hazards models were used to assess the prognostic value of YWHAZ intensity.

RESULTS

High YWHAZ expression was strongly associated with high Gleason score at the time of diagnosis (P < 0.001) and PSA relapse (P = 0.001). Importantly, patients with high expression of YWHAZ had a higher risk of CRPC development (P = 0.002) and reduced survival time (P = 0.002).

CONCLUSIONS

Our findings indicate that YWHAZ could serve as a promising prognostic biomarker in localized PCa to predict poor prognosis and to identify a subgroup of tumors, which might benefit from earlier adjuvant or YWHAZ-targeted therapy.

Challenges of managing elderly men with prostate cancer

The incidence of prostate cancer increases with age. Current evidence suggests that prostate cancer is under treated in patients aged ≥70 years, despite evidence of efficacy and acceptable toxicity. Radical cystectomy and definitive radiotherapy are often denied owing to fears of post-operative complications and radiotherapy-associated gastrointestinal and genitourinary toxicity. However, modern radical prostatectomy techniques provide excellent clinical outcomes with low perioperative morbidity. Moreover, volume-restricted intensity-modulated radiation therapy is a significant improvement over previous 2D conformal radiotherapy with similar efficacy and lower toxicity. Androgen-deprivation therapy is also under-prescribed among the elderly, owing to concerns of increases in cardiac deaths and osteoporosis acceleration. However, prospective trials have not identified any increase in cardiovascular mortality among elderly men receiving androgen-deprivation therapy compared to age-matched controls. Most patients on androgen deprivation eventually progress to a castration-resistant state. At this stage, the disease still responds to newer agents that target the androgen pathway and to chemotherapy. Among the elderly, chemotherapy is under-prescribed even though it has been demonstrated to be palliative and improve survival. We describe the trends in prostate cancer management in the elderly and the importance of assessing comorbidity status, tumour characteristics, and health status, including a complete geriatric evaluation, before making treatment recommendations.

Management of prostate cancer in elderly men

Elderly men comprise a large percentage of men diagnosed with prostate cancer (PrCa). Although localized PrCa is often indolent, older men tend to be diagnosed with higher-stage disease and are more likely to die from PrCa than younger men. Multiple factors other than age play an important role in determining who will benefit from active treatment, such as comorbid conditions, life expectancy, and tumor characteristics. Careful consideration of such factors can help prevent the overtreatment of elderly men with low-risk disease and undertreatment of elderly men with high-risk disease. Management decisions should be individualized by weighing the benefits of treatment against potential risks and side effects pertinent to the elderly population, whether evaluating for surgery, radiation, or androgen deprivation.

Risk-based prostate cancer screening: who and how?

The purpose of this review is to identify clinical risk factors for prostate cancer and to assess the utility and limitations of our current tools for prostate cancer screening. Prostate-specific antigen is the single most important factor for identifying men at increased risk of prostate cancer but is best assessed in the context of other clinical factors; increasing age, race, and family history are well-established risk factors for the diagnosis of prostate cancer. In addition to clinical risk calculators, novel tools such as multiparametric imaging, serum or urinary biomarkers, and genetic profiling show promise in improving prostate cancer diagnosis and characterization. Optimal use of existing and future tools will help alleviate the problems of overdiagnosis and overtreatment of low-risk prostate cancer without reversing the substantial mortality declines that have been achieved in the screening era.

[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.

The relation between age and androgen deprivation therapy use among men in the Medicare population receiving radiation therapy for prostate cancer

OBJECTIVES

Neoadjuvant and concurrent androgen deprivation therapy (ncADT) is recommended for men with high-risk prostate cancer, but not low-risk cancer or short life expectancy. It is unclear whether the use of ncADT among older men in the community setting is aligned with the potential for clinical benefit.

MATERIALS AND METHODS

We used the Surveillance, Epidemiology, and End Results–Medicare database to assess patterns of ncADT use among men diagnosed with prostate cancer during 2004–2007 who received radiation therapy. Men were stratified according to tumor risk groups and life expectancy. We used logistic regression to identify factors associated with ncADT use within each risk group.

RESULTS

There were 10,686 men in the sample (mean age 74.2 years; 83.4% white). The use of ncADT was 80.7%, 54.1%, and 27.8% in the high-, intermediate-, and low-risk groups, respectively. Men with a life expectancy<5 years had higher rates of ncADT use than men with a life expectancy≥10 years in all risk groups. Within each risk group, advancing age was associated with higher likelihood of receiving ncADT (odds ratio for men aged 80–84 compared to 67–69=1.93 (95% CI 1.37–2.70); 1.51 (95% CI 1.22–1.87); and 1.71 (95% CI 1.14–2.57) for high-, intermediate-, and low-risk groups, respectively).

CONCLUSION

ncADT use is not consistent with guideline recommendations and is more frequent among men who are older, have shorter life expectancy, and are less likely to benefit from therapy.

Barriers to accessing radiation therapy in Canada: a systematic review

INTRODUCTION

Radiation therapy (RT) is effective treatment for curing and palliating cancer, yet concern exists that not all Canadians for whom RT is indicated receive it. Many factors may contribute to suboptimal use of RT. A review of recent Canadian literature was undertaken to identify such barriers.

METHODS

MEDLINE, CINAHL, and EMBase databases were used to search keywords relating to barriers to accessing or utilizing RT in Canada. Collected abstracts were reviewed independently. Barriers identified in relevant articles were categorized as relating to the health systems, patient socio-demographic, patient factors, or provider factors contexts and thematic analysis performed for each context.

RESULTS

535 unique abstracts were collected. 75 met inclusion criteria. 46 (61.3%) addressed multiple themes. The most cited barriers to accessing RT when indicated were patient age (n = 26, 34.7%), distance to treatment centre (n = 23, 30.7%), wait times (n = 22, 29.3%), and lack of physician understanding about the use of RT (n = 16, 21.6%).

CONCLUSIONS

Barriers to RT are reported in many areas. The role of provider factors and the lack of attention to patient fears and mistrust as potential barriers were unexpected findings demanding further attention. Solutions should be sought to overcome identified barriers facilitating more effective cancer care for Canadians.

Individualized decision-making for older men with prostate cancer: balancing cancer control with treatment consequences across the clinical spectrum

Prostate cancer (PCa) is the most prevalent non-skin cancer among men and is the second leading cause of cancer death in men. PCa has an increased incidence and prevalence in older men. Age-associated incidence is on the rise due to increased screening in the older population. This has led to a sharp rise in the detection of early stage PCa. Given the indolent nature of many prostatic malignancies, a large proportion of older men with PCa will ultimately die from other causes. As a result, physicians and patients are faced with the challenge of identifying optimal treatment strategies for localized PCa, biochemically recurrent PCa and later-stage PCa. Age-related changes can impact tolerance of hormonal therapy and chemotherapy in men with metastatic disease and shift the risk-benefit ratio of these treatments. Tools such as the Comprehensive Geriatric Assessment (CGA) can help estimate remaining life expectancy and can help predict treatment-related morbidity and mortality in older men. Application of CGA in older men with PCa is important to help individualize and optimize treatment strategies. Research that integrates multidisciplinary and multidimensional assessment of PCa and the patient's overall health status is needed.

Comorbidity, treatment and mortality: a population based cohort study of prostate cancer in PCBaSe Sweden

PURPOSE

We examined associations among comorbidity, treatment decisions and mortality in patients with prostate cancer.

MATERIALS AND METHODS

A total of 77,536 men diagnosed with prostate cancer between 1997 and 2006 were identified in PCBaSe Sweden from the National Prostate Cancer Register of Sweden. Logistic, Cox and competing risk regression were used to assess associations among Charlson comorbidity index, treatment and mortality. The Charlson comorbidity index was categorized into no (0), mild (1) and severe comorbidity (2+).

RESULTS

In men with low risk prostate cancer 5,975 of the 13,245 (45.1%) patients without comorbidity underwent radical prostatectomy compared to 256 of the 1,399 (18.9%) men with severe comorbidity. Following adjustment for age and period of diagnosis, radical prostatectomy was less likely to be offered to men with severe comorbidity (OR 0.48, 95% CI 0.41-0.55). In men with high risk prostate cancer, radiotherapy was more common (range 7.7% to 21.3%) than radical prostatectomy (range 3.0% to 11.2%) regardless of comorbidity burden. All cause and competing cause but not prostate cancer specific mortality were increased in men with severe comorbidity (all cause HR 1.99, 95% CI 1.93-2.05; competing cause sHR 2.66, 95% CI 2.56-2.78; prostate cancer specific sHR 0.98, 95% CI 0.93-1.03). The cumulative probability of prostate cancer death given no death from competing causes was significantly higher in men with severe comorbidity in all risk groups (p<0.01).

CONCLUSIONS

Comorbidity affects treatment choices, and is associated with all cause, competing cause and conditional prostate cancer specific mortality. An increased conditional prostate cancer specific mortality in men with severe comorbidity may reflect less aggressive treatment, impaired tumor defense, lifestyle factors and poor general health behavior.

Impact of age at diagnosis on prostate cancer treatment and survival

PURPOSE

Older men are more likely to be diagnosed with high-risk prostate cancer and to have lower overall survival. As a result, age often plays a role in treatment choice. However, the relationships among age, disease risk, and prostate cancer-specific survival have not been well established.

PATIENTS AND METHODS

We studied men in the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) database with complete risk, treatment, and follow-up information. High-risk patients were identified by using the validated Cancer of the Prostate Risk Assessment (CAPRA) score. Competing risks regression was used to identify the independent impact of age on cancer-specific survival. We also analyzed the effect of local treatment on survival among older men with high-risk disease.

RESULTS

In all, 26% of men age ≥ 75 years presented with high-risk disease (CAPRA score 6 to 10). Treatment varied markedly with age across risk strata; older men were more likely to receive androgen deprivation monotherapy. Controlling for treatment modality alone, or for treatment and risk, age did not independently predict cancer-specific survival. Furthermore, controlling for age, comorbidity, and risk, older men with high-risk tumors receiving local therapy had a 46% reduction in mortality compared with those treated conservatively.

CONCLUSION

Older patients are more likely to have high-risk prostate cancer at diagnosis and less likely to receive local therapy. Indeed, underuse of potentially curative local therapy among older men with high-risk disease may in part explain observed differences in cancer-specific survival across age strata. These findings support making decisions regarding treatment on the basis of disease risk and life expectancy rather than on chronologic age.

Prostate cancer in the elderly

Prostate cancer is the most frequent malignancy in men and predominantly in elderly men. The issue of prostate cancer is likely to assume greater importance with progressive aging of the population. With frequent use of PSA testing most patients were diagnosed with localized cancer even in senior adults. Cancer-specific mortality is low in elderly men with prostate cancer and is dependent on the aggressiveness of the tumor. Currently, no established guidelines for the management of prostate cancer in the elderly exist, and treatment of senior adults with localized cancer is not optimal. While elderly men with indolent disease will not benefit from curative treatment, some patients with aggressive cancers will progress if not adequately treated. Comorbidity is the main predictor of life expectancy in the elderly. In everyday clinical practice, treatment decisions are much more influenced by age than by comorbidity. Curative treatment is an effective treatment option for selected elderly with localized prostate cancer. Conversely, most elderly men with prostate cancer received hormonal therapy, although the benefit of hormonal therapy in localized cancer is not clear and is associated with severe toxicities in some patients. In conclusion, there is a need for more risk stratified approaches for the management of prostate cancer in the elderly to avoid unnecessary intervention in men who unlikely benefit from such intervention, and allow treatment in those who might benefit from it.

[Prostate cancer: what role for curative radiotherapy in elderly?]

PURPOSE

Discuss the place of radiotherapy given in a curative intent in elderly patients with localised prostate cancer according to complications, local control, survival observed in a specific and a review of the literature.

PATIENTS AND METHODS

The cohort consisted of 65 males aged 80 or more with localised prostate cancer who choose radiotherapy as a curative modality. Twelve radiotherapy centres affiliated to the Rare Cancer Network participated to the study. The retrospective analysis was carried out on immediate and late side-effects, biological free of relapse survival and global survival. Multivariate analysis took into account the comorbidities, the initial prostatic specific antigen (PSA) value, the Gleason score and the therapeutic modalities.

RESULTS

From January 1990 to December 2000, 65 patients were included into the cohort. Mean age was 81 years. The specific series consisted of 10 T1, 40 T2 and 15 T3 N0M0. Median follow up was 65 months. Immediate and late complications were comparable to those described in younger patients who received a similar irradiation. There were no negative impact of the treatment on disease free survival and global survival. Recent literature did suggest analogous results.

CONCLUSIONS

Radiation therapy with a curative intent should not be systematically withheld in elderly patients with localised prostate cancer.

Curative external beam radiotherapy in patients over 80 years of age with localized prostate cancer: a retrospective rare cancer network study

PURPOSE

To analyse tolerance and outcome of patients over 80 years of age who choose external beam radiation therapy to the prostate as a curative treatment.

METHODS AND MATERIAL

We evaluated acute and late side effects, biological DFS (bDFS) and actuarial survival as well as causes of death in relation to the clinical status including co-morbidity, PSA value, Gleason score and modalities of external radiotherapy in patients with localised prostate cancer >80 years of age.

RESULTS

From January 1990 to December 2000, 65 eligible cases (median age: 81) were treated by 12 different participating institutions in the Rare Cancer Network. Tumour stage was T1N0M0, T2N0M0 and T3N0M0 for 10, 40, and 15 patients, respectively. Median follow-up was 65 months (range 22-177). Five-year overall survival rate was 77% with a 5-year bDFS rate of 73%. The incidence of grade 3 early toxicity was 12% and 9% for urinary and digestive tract, respectively.

CONCLUSIONS

Radiation therapy given with curative intent is well tolerated in this selected group of patients aged over 80 years with localised prostate cancer. Results in terms of survival do not suggest a deleterious impact of this treatment. Therefore the authors recommend that radiation therapy with curative intent should not be withheld in selected elderly patients with localised prostate cancer.