Management of prostate cancer in older men – an overview

This study evaluated recommendations for the management of prostate cancer in older men. Authors concluded that older men should be managed according to their individual health status and cancer risk classification, rather than by age.

The ageing of the population is expected to increase the number of older men living with prostate cancer. However, there are few available guidelines that make specific recommendations for older men with prostate cancer. The International Society of Geriatric Oncology formed a panel of experts to review evidence and provide recommendations for the management of prostate cancer in older men. 

Older men with prostate cancer can be classed as either fit, vulnerable, or frail. This can depend on number of factors, such as other diseases, lifestyle, weight, and age (if older than 85 years). Men classed as fit are expected to tolerate any form of standard cancer treatment. Vulnerable and frail patients can try to improve their health status before treatment or receive adapted treatment.

The aggressiveness of the cancer or the risk of cancer recurrence should also be taken into account for the choice of treatment. One large study involving 117,328 men showed that mortality risk at 15 years was linked to risk of cancer recurrence, not age. Mortality risk was 10% for those at low risk of recurrence, 20% for those at intermediate risk, and 35 to 40% for those at high risk.

Localized prostate cancer

Prostate surgery is suitable for patients with tumors confined to the prostate and a life expectancy of 10 years or more. Patients should have few other conditions and low-grade disease (less aggressive cancer cells).

Radiation therapy can be recommended for men with low-risk prostate cancer and a life expectancy of more than 20 years. Brachytherapy (radiation source is placed inside the prostate) can be recommended for patients with smaller prostates and few symptoms. Men with intermediate-risk disease may undergo radiation therapy whatever the predicted life expectancy.

Hormone therapy is generally not recommended for older men with localized prostate cancer, unless used with breaks between treatments. It is associated with an increased risk of fractures, diabetes, and heart and blood vessel disease. However, men with intermediate-risk disease may benefit from short-term hormone therapy.

Men with low-risk disease and/or those with short expected survival may benefit from watchful waiting (waiting for symptoms to worsen) or active surveillance (active monitoring of the tumor with no actual treatment given) rather than treatment.

Advanced prostate cancer

Androgen deprivation therapy (ADT) is recommended as first-line treatment for advanced prostate cancer. ADT involves either the surgical removal of the testicles or drug therapy. Calcium and vitamin D or bone-targeted drugs (such as bisphosphonates and denosumab) should also be given to decrease the risk of brittle bones and fractures.

Chemotherapies, such as docetaxel (Taxotere) or cabazitaxel (Jevtana), have been found to be suitable for older men no longer responding to ADT. However, older men with other conditions and more aggressive disease have an increased risk of severe side effects.

In men no longer responding to ADT, secondary hormone therapies, such as abiraterone acetate (Zytiga) and enzalutamide (Xtandi), have been found to enhance survival. Enzalutamide was associated with a 4.5-month survival advantage in men older than 65.

The immunotherapy (a therapy that stimulates the immune system to fight cancer cells the way it would a virus) sipuleucel-T (Provenge) was associated with improved overall survival in both younger and older patients. 

Authors concluded that older men with prostate cancer should be managed according to their individual health status and cancer risk classification, and not by age.