Radiation Therapy in the Management of High Risk Nonmetastatic Prostate Cancer in the Geriatric Population - #51Take Quiz
Describes the role of radiation therapy in the management of high risk non-metastatic prostate cancer.
Patients with high risk features of >T3 disease or Gleason Score 8-10 need a metastatic workup including CT abdomen and pelvis and a bone scan.
Treatment decisions for men who present with high risk prostate cancer need to address the risk of morbidity and mortality of the disease, morbidity of treatment, and patient life expectancy based on co-morbid conditions and geriatric assessments.
In high risk patients, androgen depravation therapy (ADT) alone has historically been a treatment option. However, this should be reserved for patients with short anticipated longevity as several clinical trials have demonstrated this to be inferior to more aggressive local therapy such as radiation combined with ADT (2,5,6). In 2007, the American Urological Association (4) recommended that primary androgen depravation not be considered an option for men with localized prostate cancer.
Since the risk of prostate cancer mortality from high risk disease is at least 50% at ten years (3) serious consideration for curative treatment in the elderly is warranted. Several randomized clinical trials have also shown the benefit of hormone therapy (7,8) and specifically long term hormone therapy (9,10) in addition to radiation for patients with high risk disease and thus the elderly should be considered for such pending comorbities.
Concerns for the Elderly
Long term ADT has been shown to cause bone loss, muscle mass loss, metabolic effects and increased risk of falls in the elderly (11). Thus specific attention needs to be paid evaluating the elderly for these risks. Cardiac mortality has not been shown to be increased in patients taking ADT for prostate cancer combined with radiation (12) but attention to the metabolic changes associated with ADT is important especially in the elderly (13).
The society for geriatric oncology has recommended that healthy geriatric patients be treated the same as their younger counterparts. Patients with mild comorbidities should be treated similarly with strong consideration given to radiation therapy and androgen depravation(14).
Prostate cancer risk increases with age and balancing the risks of treatment with the risks of disease progression presents challenges for providers treating patients with this disease.
Determine best course of treatment for patients with high risk prostate cancer.
Increasing age is a risk for the development of prostate cancer (1). Most cases occur in men over age 65 and prostate cancer deaths occur disproportionately in the elderly, owing to the long natural history of the disease.
Describe the role of radiation therapy in the management of high risk nonmetastatic prostate cancer (any > T3 or any GS 8-10) for geriatric patients
Review of Systems (ROS)
- Ries, LAG, Melbert, D, Krapcho, M, et al. SEER Cancer Statistics Review, 1975–2005. Bethesda, MD: National Cancer Institute, 2008. Available at: http://seer.cancer.gov/csr/1975-2005/NCCN guidelines on prostate cancer, version 2.2014
- Albertsen PC, Hanley JA, Fine J. JAMA 2005 293(17): 2095-2101
- Jnl Urol Vol 177, June 2007:2106-2131
- Lancet 373:301-308,2009
- JCO 31,2013 (suppl16;abstr3)
- IJROBP 61(5),1285-1290,2005
- Lancet 360,103-108,2002
- JCO 26 (15), 2497-2504,2008
- NEJM 360(24),2516-2527,2009
- Urology 72 (2),2008
- JCO 27(1);92-99,1/1/09
- Cancer Vol 112, No 10, 5/15/08,2188-2194
- Critical Reviews in Oncology/Hematology 73(2010)68-91
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