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Prostate Cancer Section Heading Section sub Management of Castration Refractory Prostate Cancer in Senior Adults Helen Jane Boyle, MD 1 and Jean-Pierre Droz, MD, PhD 1,2 1. Consultant, Department of Medical Oncology, Centre Léon-Bérard, Lyon, France; 2. Emeritus Professor Medical Oncology, Lyon-Est School of Medicine, Claude-Bernard Lyon 1 University, Lyon, France Abstract Metastatic prostate cancer is frequent in elderly patients. Initial treatment is based on hormone-deprivation treatment. Resistance however occurs and several treatments have been developed and approved for castration-resistant prostate cancer, such as chemotherapy (docetaxel, cabazitaxel), new hormonal treatments (abiraterone, enzalutamide), and bone-targeting agents. These drugs have been studied in large phase III trials, and seem safe and effective even in older men; however, only fit elderly patients were enrolled in the pivotal trials. Keywords Prostate cancer, elderly, chemotherapy, hormone therapy, bone, geriatric evaluation, toxicity Disclosure: Helen Jane Boyle, MD, received research grants from Sanofi, Astellas, and Janssen. Jean-Pierre Droz, MD, PhD, received honorarium from Sanofi. Received: August 6, 2013 Accepted: September 27, 2013 Citation: Oncology & Hematology Review (US), 2013;9(2):97–101 Correspondence: Jean-Pierre Droz, MD, PhD, Centre Léon-Bérard, 28 rue Laënnec 69373, Cedec Lyon 08, France. E: Prostate cancers are a frequently occurring tumor in which incidence increases with age. In 2008, there were around 65,000 new cases in France. Median age at diagnosis is 68 years and 27 % of patients are 75 years of age or more. 1 Most deaths from prostate cancer (70 %) occur in men over 75. Treatment of metastatic prostate cancer is an oncogeriatric problem, 2 and is palliative, at any age. Initial treatment is based on androgen deprivation. The most frequent method is chemical castration with luteinizing- hormone-releasing hormone (LHRH) agonists or, more recently, LHRH antagonists. Surgical castration is still offered to some patients. 3 Most patients respond initially, however, resistance occurs. Median hormone sensitivity is around 18 to 24 months. Until 2010, the only drug that had shown an overall survival (OS) benefit in patients with metastatic castration prostate cancer (mCRPC) was docetaxel. Since then, several new drugs have been developed: new hormone therapies (such as abiraterone acetate and enzalutamide), new chemotherapy agents (cabazitaxel), new bone-targeting agents (denosumab, radium-223), and new immunotherapies. In this article, we will review how to evaluate elderly patients with mCRPC, what data are available on the different treatments, and how we can predict toxicity. Network (NCCN) has determined the impact of geriatric characteristics on decision-making process; the International Society for Geriatric Oncology (SIOG) has published extensive guidelines and a shorter version for clinical use both in the setting of localized and advanced prostate cancer. 4,5 Life expectancy is a major determinant of the potential benefit from therapy yet it varies substantially between individuals within a given age group. It applies to a population and represents a useful tool for public health, but is not valid for a given individual due to the heterogeneity of the patient population. Although it is not possible to calculate the exact chance of living for an individual, variables such as the number and severity of comorbidities and nutritional and functional status can be used to predict life expectancy within an age group. Health status influences patients’ survival and may affect patients’ ability to tolerate treatment-related side effects. A SIOG working group 6 concluded that screening for geriatric problems, with tools such as Instrumental Activities of Daily Living (IADL), ADL, the geriatric depression scale, and Folstein’s mini-mental status, was not sufficient to detect age- related factors that would affect treatment outcomes in senior adults. This screening stage should be followed by a more complete comprehensive geriatric assessment (CGA), which assesses various biologic and clinical correlates of aging on an individual basis and includes diagnostic procedures, specific treatment plans, and geriatric intervention. Geriatric Evaluation and Decision-making The majority of advanced prostate cancer patients are elderly. The trials conducted to determine the effect and toxicity of drugs in the treatment of mCRPC have followed the recommendations generally used for clinical trials: good performance status (PS); no major comorbidities—i.e. everything that is not common in elderly patients. It is therefore warranted to establish recommendations for the management of elderly patients with mCRPC. Few have been published: the National Comprehensive Cancer © TO U CH MEDICAL MED IA 2013 The SIOG Prostate Cancer Working Group reviewed recent literature and opinions on prognostic factors that might affect health status and OS. The most important factors to consider for the evaluation of health status in senior adult patients with prostate cancer are the following: • Comorbidities. The Cumulative Illness Score Rating-Geriatrics (CISR-G) was judged to be the best available tool for assessing the risk for 97