EURURO Vol. 72 No. 4

Introduction

Prostate cancer is the most frequent male cancer in

developed countries

[1]

and is also common in less

developed countries. The median age at diagnosis is

66 yr, and 69% of deaths occur in men aged 75 yr. Since

incidence and mortality rise steeply with age, the prostate

cancer burden will increase with exponential ageing of the

population.

The current paper, which focuses on men aged

70 yr,

updates existing International Society of Geriatric Oncology

(SIOG) guidelines for the management of elderly prostate

cancer patients

[2–4]

. Issues considered include the risks of

both overtreatment and undertreatment and the impor-

tance of assessing overall health status, comorbidities, and

cognitive function in personalising management. Previous-

ly published SIOG guidelines on prostate cancer

[3,4]

argued

that age alone should not preclude effective treatment.

Since 2014, the SIOG recommendations have been fully

endorsed by the European Association of Urology (EAU) and

are now referred to as the EAU/ESTRO/SIOG guidelines

[5,6]

The most important new features of these updated

guidelines are: (1) the introduction of initial screening for

cognitive function; (2) the rewording of health status

classification to align with terms currently used in the

geriatric literature; (3) consideration of the most important

advances in the treatment of advanced prostate cancer and

their implications for elderly patients; and (4) a recommen-

dation for the early introduction of palliative management.

Choice of therapy should not be based on chronological

aging, which proceeds at the same pace for all, but on

biological aging and health status, which differ greatly from

one person to another. In the USA, a 70-yr-old man in the

healthiest 25% of his peers can expect to live 18 yr, while for

the frailest 25% life expectancy is only 7 yr

[7]

. Evaluation of

health status is therefore vital to appropriate management.

Assessment of social situation is also important and can

usefully include whether or not a family care-giver is

present, financial resources, and access to services. A further

factor, of course, is patient preference, both in relation to the

goals of therapy and the means of attaining them.

The gold standard for evaluating health status is the

Comprehensive Geriatric Assessment (CGA)

[8] .

This

includes data on demographic, social, functional, nutrition-

al, cognitive, and mental health status; and the presence of

comorbidities and geriatric syndromes. It predicts survival

and chemotherapy toxicity, identifies reversible conditions,

and reflects patients’ capacity to make decisions as well as

their values and treatment goals

[9] .

Although relatively

simple, the Activities of Daily Living (ADL) measure of

dependency has been used to determine the need for social

and healthcare interventions and has prognostic value.

Aside from prostate cancer itself, comorbidity is the

strongest predictor of death among men with localised

disease

[10]

. The Cumulative Illness Score Rating-Geriatrics

(CISR-G)

[11]

is used to assess comorbidity. In this context,

it is helpful to ascertain the stage and potential reversibility

of the condition, its history, and the risk of acute organ

failure.

However, a CGA is time-consuming and requires

specialist staff. Moreover, it is probably needed in only a

minority of patients. A rational approach is to screen all

patients to identify those who need further assessment. This

further assessment can take the form of a simplified

geriatric evaluation or a full CGA.

Evaluation of health status

Evaluation of health status involves a stepwise process

starting with screening using the G8 and mini-COG

[4_TD$DIFF]

[12]

. This is followed, where indicated, by a simplified

geriatric assessment and then, again when indicated, by full

geriatric assessment, particularly when complex geriatric

interventions are needed.

2.1.

G8 screening

In a comprehensive review of tools to establish the need for

CGA, the G8

( Table 1

) was the most robust

[8,13]

. Thus, a

rational approach is to screen with the G8 scale, which was

developed specifically for older cancer patients and can be

completed in less than 5 min

[13] .

Its eight components

cover food intake, weight loss, body mass index, mobility,

neuropsychological problems, polypharmacy, self-per-

ceived health status and age.

In a prospective noninterventional study of almost a

thousand men aged 70 yr, an abnormal score on the G8

( 14 on a scale from 0 to 17) strongly predicted mortality

over 3 yr and hence a need for full assessment

[13]

. Follow-

ing studies showing that the G8 is a good way of identifying

patients requiring a CGA, the European Organisation for

Research and Treatment of Cancer (EORTC) made G8

screening compulsory for all patients aged 70 yr included

in the organisation’s trials. It is also recommended in EAU

guidelines.

Conclusions:

Advances in geriatric evaluation and treatments for localised and advanced

disease are contributing to more appropriate management of elderly patients with prostate

cancer. A better understanding of the role of active surveillance for less aggressive disease is

also contributing to the individualisation of care.

Patient summary:

Many men with prostate cancer are elderly. In the physically fit,

treatment should be the same as in younger patients. However, some elderly prostate

cancer patients are frail and have other medical problems. Treatment in the individual

patient should be based on health status and patient preference.

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