PARIS – Health status should be evaluated when determining how best to treat an older man with prostate cancer, attendees at an international congress on anticancer treatment were told.
According to recently updated guidelines issued by the International Society of Geriatric Oncology (SIOG), patient preferences should also be a priority when deciding upon prostate cancer treatment, but not their chronological age.
Dr. Jean-Pierre Droz
“In the first SIOG guidelines [Crit. Rev. Oncol. Hematol. 2010;731:68-91], we introduced an approach for assessing health status that was somewhat difficult to use by urologists or medical oncologists who had no training in geriatric oncology,” Dr. John-Pierre Droz, professor emeritus of medical oncology at Université Claude Bernard in Lyon, France, said in an interview.
In the updated guidelines (Lancet Oncol. 2014;15:e404-14), however, the use of the G-8 simplified health assessment tool is recommended that takes just 4 minutes to compete and can be used to determine if further health status assessments are necessary.
“This assessment can be performed by a trained nurse,” Dr. Droz said, making the assessment much easier to integrate into clinician’s daily practice.
The G-8 screening tool (Ann. Oncol. 2012;23:2166-72) consists of eight items that take into account patients’ food intake and weight loss in the past 3 months, their body mass index, mobility, prescription drug use, and neuropsychological status. Their age and assessment of their perceived health status in comparison to people of the same age are also included.
A score above 14 is favorable on the G-8 and patients can be categorized as being “fit” and no further geriatric assessment is suggested. But the guidelines recommend a more comprehensive geriatric assessment if a score below this threshold is obtained, which includes comorbidities measured via the Cumulative Illness Rating Scale-Geriatric, evaluation of nutritional status, and patients’ cognitive and physical functions. The latter includes using the familiar concepts of activities of daily living and independent activities of daily living.
Based on these further assessments elderly patients can be categorized as vulnerable, where the health status parameters are potentially improved with appropriate measures; or frail,when changes to health status are deemed permanent or irreversible.
In general, elderly men with prostate cancer who fall into the “fit” health assessment category should have the same treatment options as younger patients. Patients who fall into the “vulnerable” category should be able to receive standard treatment after measures are taken to address any reversible impairments such as malnutrition. Adapted treatment might be more appropriate in senior men who fall into the “frail” category, and palliative care is recommended for those identified with terminal illness.
The potential for side effects to occur and patients’ willingness to accept these is vital to consider when selecting treatments, perhaps more so in elderly individuals who may be more prone to experience adverse events, particularly if they have comorbid disease. Age marginally influences genitourinary and gastrointestinal toxicity seen with external beam radiation therapy, for example, but increases the risk for erectile dysfunction in older men.
Considering first-line treatment for metastatic castrate-resistant prostate cancer disease, “This is exactly the same as in younger patients,” Dr. Droz said. So, docetaxel at the usual dose of 75 mg/m2 given three times a week should be suitable for the treatment of both fit and vulnerable patients. A reduced frequency docetaxel regimen, such as weekly or twice weekly, may be more suitable in a frail patient.
Abiraterone acetate is also suitable in the first-line setting in asymptomatic or mildly symptomatic patients who do not have liver metastases. Bone-targeted drugs can also be used to prevent bone loss and for the treatment of bone metastases.
As for second-line treatment, cabazitaxel, abiraterone, and enzalutamide are available, but careful monitoring is needed in older patients, advised Dr. Droz. As in younger men, the optimal sequence of these therapies needs further research.
Dr. Droz commented that the efficacy of treatments for both localized and advanced prostate cancer in older men is similar to that in younger men. However, “the critical issue in the decision-making process is the competition between the risk of death due to prostate cancer and the risk of death due to health status,” he observed.
Dr. Droz has received honoraria from Sanofi.