| Management of advanced prostate cancer in older patients |
- Metastatic castration-sensitive prostate cancer
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- ADT plus 6 cycles of docetaxel is a recommended first-line treatment in fit men with newly diagnosed hormone-sensitive metastatic prostate cancer. It is only appropriate in the setting of high-volume disease. Use of primary prophylaxis with G-CSF should be considered. (New)
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- ADT plus abiraterone is the other recommended first-line treatment. It is indicated in fit men with newly diagnosed hormone-sensitive metastatic prostate cancer in the setting of high-risk disease. Abiraterone use in the M1 indication should be carefully balanced against potential side effects and costs. (New)
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- In all other cases, ADT alone remains the standard. (Unchanged)
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- Patients treated with ADT should have their bone mineral density evaluated and should receive calcium (if dietary intake is insufficient) and vitamin D supplementation. In those at high risk of low-trauma/fragility fracture, use of denosumab 60 mg subcutaneous injection every 6 months in osteoporosis prevention/treatment-approved doses is recommended. In settings where denosumab is not available, bisphosphonates in osteoporosis prevention/treatment-approved doses should be considered. Fracture risk is best assessed using a validated calculator. (Modified)
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- Prostate radiotherapy should be a standard treatment option for fit men with newly diagnosed disease with a low metastatic burden. (New)
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- Metastatic castration-resistant prostate cancer (mCRPC)
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- In mCRPC, docetaxel 75 mg/m2 every 3 weeks is suitable for fit older patients. For vulnerable older patients, treatment should be guided by the results of a geriatric assessment and intervention, while the biweekly regimen should be considered in those who are unable to receive the 3-weekly regimen. Use of primary prophylaxis with G-CSF should be considered with the 3-weekly regimen. (New)
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- In mCRPC, abiraterone and enzalutamide are suitable first-line options. (Modified)
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- In patients who have received docetaxel, options include cabazitaxel (20 mg/m2), abiraterone, and enzalutamide. (Modified)
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- The optimum sequencing of therapies is subject to research. After failure of a novel endocrine agent, agents with another mechanism of action, including taxanes or radium-223 (although only in cases of bone metastases), should be the preferred option due to cross-resistance between androgen receptor-targeted agents. (New)
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- Careful evaluation of drug-drug interactions and proactive management of adverse events are needed in older patients. It is important to perform an initial cardiac evaluation, to treat pre-existing high blood pressure, to correct hypokalemia, and to monitor CBC, ASAT/ALAT, kalemia, glycaemia, and blood pressure. Prospective evaluation of side effects of new hormone treatment should be studied in routine clinical practice. (New)
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- Patients with bone metastases with no visceral or bulky lymph node metastases receiving first-line treatment, and after failure to docetaxel, are eligible for radium-223. (Modified)
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- Palliative treatments include radiotherapy, radiopharmaceuticals, bone-targeted therapies, palliative surgery, and medical treatments for pain and other symptoms. (Unchanged)
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- Early palliation should be implemented (principally in mCRPC). (Unchanged)
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- Adapted physical activity is advocated at all stages of prostate cancer management; further clinical research in older patients is recommended. (New)
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- The management of the patient and family should include a multidisciplinary approach involving a urologist, medical oncologist, radiation oncologist, geriatrician, primary care physician, nurse, and palliative medicine specialist. (Modified)
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- Developing guidelines applicable in developing countries is a challenge for the future. (New)
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