Editors’ pick

Irradiation of localised prostate cancer in the elderly: A systematic review - PDF Version

Delphine Marotte, Marie-Eve Chand-Fouche, Rabia Boulahssass, Jean-Michel Hannoun-Levi

Clin Transl Radiat Oncol. 2022 Apr 20;35:1-8. doi: 10.1016/j.ctro.2022.04.006

What was your motivation for initiating this study?

During our weekly urologic medical staff meeting, physicians are more and more confronted with difficult clinical situations involving elderly patients with high-risk prostate cancer. International guidelines propose recommendations helping physicians and patients in the decision-making process to choose the optimal treatment. The aggressiveness of prostate cancer, competing comorbidity factors and the benefit/risk balance of irradiation have to be discussed (1-4).

We performed a PubMed literature search including articles published during the last 10 years to answer the two following questions (5):

• Are elderly patients undertreated?
• What is the benefit/risk balance of radiation therapy in the elderly in regard to oncological outcomes (external radiotherapy, brachytherapy and androgen deprivation therapy), tolerance (toxicity and QoL), and influence of comorbidities?

What were the main challenges during the work?

The three main challenges were:

• The lack of homogeneity between the different articles regarding the definition of ‘elderly patient’ with a cut-off that ranged between 70 and 80 years.
• The lack of homogeneity of primary endpoints used for analysis (disease-free survival, cause-specific survival, overall survival), making the comparisons between elderly and younger patients difficult to perform.
• The lack of robust data on elderly high-risk prostate cancer management due to a lack of representativeness or specific analysis (in subgroups) in prospective or randomised clinical trials, leading to insufficient proof level.

What are the most important findings of your study?

• Age was often an obstacle to radical treatment, with a subsequent risk of under-treatment, particularly in patients with a poorer prognosis.
• Comparable oncological outcomes were noticed between elderly and younger patients after external beam radiotherapy alone or combined with brachytherapy boost.
• Late toxicity rates were low and most often comparable to younger populations. However, a urinary over-toxicity was observed in the super-elderly (> 80 years) after brachytherapy boost.
• The use of ADT should be considered in light of comorbidities, and may even be deleterious in some patients.
• Elderly comorbidities can influence oncological outcomes (overall and cause-specific survival) and treatment tolerance (EBRT and/or ADT), with a decrease in specific mortality and an increase in overall mortality

The PRSOTAGE cohort analysis, which compared elderly (> 70 years) and younger patients with high-risk prostate cancer treated with a combination of external beam radiation therapy, brachytherapy boost and androgen deprivation therapy, confirmed these findings (6).

What are the implications of this research?

• Except for unfit patients, elderly men remain candidates for optimal curative treatment (i.e. regardless of age) after onco-geriatric assessment.
• Onco-geriatric assessment remains crucial to build the treatment process precisely. A strong collaboration between the onco-geriatric team and prostate cancer care providers is warranted in order to propose shared decision-making with the patient and their family/relatives.
• More solid data from prospective trials conducted, especially in this population, are needed to provide better guidance in our daily clinical practice.

 

Jean-Michel Hannoun-Levi
Department of Radiation Oncology
Antoine Lacassagne Cancer Center
University of Côte d'Azur
Nice, France

References:

1. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Prostate Cancer. Version 4.2022 - May 10, 2022. https://www.nccn.org/professionals/physician_gls/pdf/prostate.pdf
2. Mottet N, van den Bergh RCN, Briers E, Van den Broeck T, Cumberbatch MG, De Santis M, Fanti S, Fossati N, Gandaglia G, Gillessen S, Grivas N, Grummet J, Henry AM, van der Kwast TH, Lam TB, Lardas M, Liew M, Mason MD, Moris L, Oprea-Lager DE, van der Poel HG, Rouvière O, Schoots IG, Tilki D, Wiegel T, Willemse PM, Cornford P. EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer-2020 Update. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol. 2021;79(2):243-262.
3. Boyle HJ, Alibhai S, Decoster L, Efstathiou E, Fizazi K, Mottet N, Oudard S, Payne H, Prentice M, Puts M, Aapro M, Droz JP. Updated recommendations of the International Society of Geriatric Oncology on prostate cancer management in older patients. Eur J Cancer. 2019;116:116-136.
4. Eastham JA, Auffenberg GB, Barocas DA, Chou R, Crispino T, Davis JW, Eggener S, Horwitz EM, Kane CJ, Kirkby E, Lin DW, McBride SM, Morgans AK, Pierorazio PM, Rodrigues G, Wong WW, Boorjian SA. Clinically Localized Prostate Cancer: AUA/ASTRO Guideline, Part II: Principles of Active Surveillance, Principles of Surgery, and Follow-Up. J Urol. 2022;208(1):19-25
5. Marotte D, Chand-Fouche ME, Boulahssass R, Hannoun-Levi JM. Irradiation of localized prostate cancer in the elderly: A systematic literature review. Clin Transl Radiat Oncol. 2022;35:1-8.
6. Marotte D, Gal J, Schiappa R, Gautier M, Boulahssass R, Chand-Fouche ME, Hannoun-Levi JM. High-dose-rate brachytherapy boost for elderly patients with intermediate to high-risk prostate cancer: 5-year clinical outcome of the PROSTAGE cohort. Clin Transl Radiat Oncol. 2022;35:104-109.