Background for the proposal of SIOG guidelines for the management of prostate cancer in senior adults
Introduction
Prostate cancer is predominantly a disease of senior adults (i.e., men aged 70 years or older), yet, no specific guidelines exist for this population. Existing guidelines for the management of prostate cancer make little reference to senior adult patients and age-related factors that may affect treatment decisions. Some of them (e.g., National Cancer Centre Network [NCCN] and European Association of Urology [EAU] guidelines) refer to the concept of life expectancy, which depends on many components of a patient's well-being and is often misinterpreted by physicians. This is perhaps owing to the under-representation in clinical trials of senior adult patients with cancer [1], and the subsequent lack of data from which to develop evidence-based recommendations. In this respect, it is pertinent to note that many of the pivotal clinical studies that have formed the basis for current guidelines in prostate cancer were conducted in selected patient populations that, in terms of age and health status, are not representative of the general population with prostate cancer because of various protocol exclusions (i.e., upper age limits, comorbidities, poor performance status, physiological organ impairments and history of other cancer), different access to care and the misconception that senior adult patients are not suitable candidates for more aggressive therapy [2].
The guidelines presented here have been developed through consideration of the published data in senior adult patients with prostate cancer and highlight age-related issues that may affect screening and treatment decision-making. Where possible, recommendations have been made together with suggestions for further research. Aging is a highly heterogeneous process and each patient should be treated as an individual and not solely according to chronological age. The objective of the International Society of Geriatric Oncology (SIOG) prostate cancer guidelines for senior adults is to promote the highest possible standards of care for senior adult men with prostate cancer, and to support treatment decisions that are likely to provide optimal clinical outcomes in these patients.
Section snippets
Epidemiology of prostate cancer
The most recent GLOBOCAN statistics [3] estimated that in 2002, there were 679,023 new cases of prostate cancer worldwide, ranking prostate cancer as the fifth most common cancer in adults and the second most common cancer in men (11.7% of all new cancer cases, excluding skin) after lung cancer. A total of 221,002 men died from prostate cancer in 2002, representing 5.8% of all cancer deaths in men. Prostate cancer is the most prevalent cancer in men, with an estimated (based on 5-year survival)
Comprehensive geriatric assessment
Aging is a highly individual process and as such, a “comprehensive geriatric assessment (CGA)” was developed to assess the various biological and clinical correlates of aging on an individual basis. CGA is a “multidisciplinary evaluation in which the multiple problems of older persons are uncovered, described, and explained if possible, and in which the resources and strengths of the person are catalogued, need for services assessed, and a coordinated care plan developed to focus interventions
Localised prostate cancer
Patients who are considered in this chapter are likely to be treated in the curative setting (i.e., local treatment with or without adjuvant treatment). This group generally includes patients with T1-3N0M0 disease. This section examines the importance of prostate cancer staging with respect to prognostic factors used to evaluate the risk of unfavourable oncological outcome, and to treatment decisions for localised disease. Guidelines used in this review include those of the EAU [63], the
Advanced prostate cancer
This section concerns patients who are unlikely to benefit from curative treatment, i.e., patients with locally advanced disease (T4N0 and T1-4N1) or metastatic disease (M1).
Conclusions
Senior adult patients with prostate cancer should be managed according to their individual health status, which is mainly driven by the severity of associated comorbid conditions and not according to chronological age.
Evidence-based medicine established guidelines must be applied in senior adult patients with prostate cancer in addition to that used for younger patients. Therefore, the standard and universally accepted NCCN and EAU guidelines should be adhered to, but nevertheless, their
Conflict of interest
Dr. Droz has received conference honoraria from Sanofi-Aventis and has acted as consultant for Sanofi-Aventis and Pharmion.
Dr. Fitzpatrick has received conference honoraria from Sanofi-Aventis, GSK, and Pfizer.
Dr. Moul has received consultancies from Ferring, Astra-Zeneca, Sanofi-Aventis. Honoraria from Sanofi-Aventis, Astra-Zeneca, grants from GSK and other funding from Theralogix LLC.
Prof. Van Poppel is member of the advisory board of Astra-Zeneca, Gen Probe, Pfizer, Ferring, Sanofi-Aventis,
Reviewers
Theo M. de Reijke, MD PhD FEBU, Urologist, Academic Medical Center, Urology, Meibergdreef 9, NL-1105 AZ Amsterdam, Netherlands.
Joaquim Bellmunt, MD PhD, Section Chief, Solid Tumor Oncology (GU & GI), Hospital del Mar, Medical Oncology Service, Passeig Marítimo 25-29, E-08003 Barcelona, Spain.
Jean-Pierre Droz obtained his M.D. degree in 1975 at the Paris-VI University School of Medicine, followed by his Ph.D. at the Lyon-I Claude-Bernard University. He was formerly Chairman of the Department of Medicine at the Institut Gustave-Roussy in Villejuif and thereafter, was Chairman of the Department of Medical Oncology and Director of Teaching Program at the Centre Léon-Bérard in Lyon. He is Emeritus Professor of Medical Oncology at the Lyon-RTH Laënnec School of Medicine and Scientific
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Jean-Pierre Droz obtained his M.D. degree in 1975 at the Paris-VI University School of Medicine, followed by his Ph.D. at the Lyon-I Claude-Bernard University. He was formerly Chairman of the Department of Medicine at the Institut Gustave-Roussy in Villejuif and thereafter, was Chairman of the Department of Medical Oncology and Director of Teaching Program at the Centre Léon-Bérard in Lyon. He is Emeritus Professor of Medical Oncology at the Lyon-RTH Laënnec School of Medicine and Scientific Consultant at the Centre Léon-Bérard. His major subjects of clinical research are genitorinary tumours, mainly germ-cell tumours and prostate cancer, geriatric oncology and endocrine tumours medical treatment. He was the chairman of the Genito-Urinary Tumour Group (GETUG) of the French Comprehensive Cancer Center Network (1994–1999). He is past-president of the SIOG (International Society of Geriatric Oncology) and serves as President of the Geriatric Oncology Board of the French National Cancer Institute. He has managed and/or participated to more than 80 clinical trials and has published more than 200 manuscripts in international peer-reviewed journals.