EURURO Vol. 72 No. 4

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The task force also had a number of specific recommen-
dations. First, prospective studies should be initiated to
validate screening tools in elderly prostate cancer patients.
The G8 in particular should be validated in this specific
population. Second, prospective studies to validate this
pragmatic classification should follow establishment of
consensus among oncogeriatric specialists. Third, nomo-
grams should be developed to predict outcome in older
prostate cancer patients in different settings when using
tools that assess health status (comorbidities through CISR-
G, dependence, and malnutrition).
4. Treatment of elderly prostate cancer patients
We examined standard management of localised and
advanced disease and applied when possible considerations
specific to elderly men.
4.1. Localised disease
Treatment is based on risk In a large study ,
mortality at 15 yr was independent of age at diagnosis but
directly linked to risk group, ranging from 10% (low risk) to
20% (intermediate risk) and 35–40% (high risk). Non–
prostate cancer mortality was mainly linked to comorbid-
ities, but the aggressiveness of the disease outweighed
comorbidity in intermediate- and high-risk groups. The aim
in T1–3N0M0 disease is generally curative. Decisions in the
elderly should take into account the risk of dying from
prostate cancer (ie, tumour grade and stage), the risk of
dying from another cause (ie, comorbidities), the risks of
treatment, and patient preferences.
Healthy elderly patients with high-risk prostate cancer
are often undertreated. However, there is also concern
about the overtreatment of many low-risk patients with
comorbidities and limited life expectancy It is impor-
tant to assess both oncologic outcomes (extracapsular
disease, metastases, lymph node invasion, and cancer-
specific death) and functional outcomes (eg, erectile
dysfunction and incontinence).
4.1.1. Radical prostatectomy (RP)
Older men are more likely to have larger and higher-grade
tumours , and thus might benefit more from a local
treatment including RP. For high-risk lesions, cancer-
specific survival is up to 91% after surgery combined with
adjuvant and/or salvage modalities. Survival can be up to
95% with one risk factor (ie, Gleason >7, stage >T2, or
prostate-specific antigen [PSA] >20 ng/ml), and 79% with
three risk factors .
We do not know whether surgery should be open or
minimally invasive. A recent review suggested that in older
patients, a minimally invasive approach led to higher rates
of transfusion, postoperative genitourinary complications,
incontinence, and stricture when compared to the same
procedure in younger men .
Although 30-d mortality after RP increases with age, it is
only 0.66% in men aged 70–79 yr . Death and
complications following RP depend more on comorbidities.
Conversely, incontinence and erectile dysfunction are
predominantly influenced by age . Even so, continence
rates are still good in older men, with 86% aged 70 yr
regaining continence . Recent data on robotic prosta-
tectomies do not reveal any difference in complications and
continence between patients aged <70 and 70 yr. Only
potency recovery was better among younger patients. An
Australian cohort compared continence after robotic RP in
men <70 and 70 yr and found no difference
4.1.2. Radiation therapy
Image-guided intensity-modulated radiotherapy (RT)is
now standard for external-beam RT. Evidence is accumu-
lating regarding brachytherapy (low and high dose rates) as
a ‘‘boost’’ or as monotherapy.
Combined RT and androgen deprivation therapy (ADT) is
standard for locally advanced or intermediate- to high-risk
T1/T2 disease. The optimum duration of ADT with higher-
dose RT is yet to be determined. Adding ADT to RT confers
no benefit to patients with localised high-risk prostate
cancer and competing moderate to severe comorbidities, as
the latter have a greater impact on survival than the cancer
.
Age does not increase acute or late urinary or bowel
toxicity, but does predict reduced sexual function. However,
90% of patients surveyed about their treatment would make
the same decision if asked again .
In the CHHIP study, standard RT fractionation (37 frac-
tions over 7.5 wk) was compared to a hypofractionated
regimen (20 fractions over 4 wk). Most patients had
intermediate-risk disease. Acute bowel toxicity was greater
with hypofractionation, but other acute and late toxicities
were comparable. At 5 yr the biochemical control rate was
not inferior to standard fractionation and actually favoured
patients aged >69 yr .
4.1.3. Neoadjuvant/adjuvant treatment
The GETUG 12 trial reported on ADT plus docetaxel and
estramustine versus ADT alone in patients (median age 62–
64 yr) with treatment-naive prostate cancer and at least one
risk factor. However no data were presented that relate
specifically to elderly patients.
4.1.4. Minimally invasive therapies
Hemi-gland ablation or ablation of the index lesion(s) may
provide well-tolerated control in the elderly at low to
intermediate risk, but at present remains experimental.
Options include high-intensity focused ultrasound, cryo-
therapy, brachytherapy, photodynamic and laser therapy,
and irreversible electroporation.
4.1.5. Androgen deprivation therapy
In patients with high-risk nonmetastatic prostate cancer
who are too frail to receive curative treatment, immediate
ADT has a very modest role . It improves overall survival
(OS; hazard ratio [HR] 1.21, 95% confidence interval [CI]
1.05–1.39), but not cancer-specific survival. If not initially
treated with ADT, the median time to start ADT on the basis
of symptoms was 7 yr, and 44% of patients in the deferred
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