ASCO 2023: Applying Risk/Benefit Considerations for Elder Patients to Current Treatment Advances in Prostate Cancer

(UroToday.com) The 2023 ASCO annual meeting included a session on the management of prostate cancer in older adults, featuring a presentation by Dr. Alicia Morgans discussing applying risk/benefit considerations for elder patients to current treatment advances in prostate cancer. Dr. Morgans started by emphasizing that when evaluating the patient we need to take a five step approach:

1. Cancer-based prognosis: taking into account traditional cancer staging and treatment considerations
2. Aging-based prognosis: utilizing life expectancy calculators and geriatric screening tools
3. Identification of resources to support patient needs: targeted interventions based on geriatric assessments
4. Assessment of patients’ goals and values: emphasizing quality of life versus cancer control
5. Communication with the patient and caregivers: ensuring shared decision making with all stakeholders involved

To highlight this approach, Dr. Morgans discussed a case presentation of metastatic hormone sensitive prostate cancer. This patient was a 74 year old male who presents from his urologist with a diagnosis of de novo metastatic hormone sensitive prostate cancer. Based on imaging, this patient had high volume disease on bone scan and CT scan, with no visceral organ involvement. There was no new pain or weight loss, but he did have nocturia x3-4 with urinary hesitancy.

Utilizing the five step approach:

1. Cancer-based prognosis: this patient has Gleason 4+5 = 9 disease, his PSA is 57 ng/mL, bone scan shows high volume metastatic hormone sensitive prostate cancer, and CT scan showing only bone metastatic disease. Dr. Morgans notes that we have a plethora of level 1 evidence for improved overall survival in metastatic hormone sensitive prostate cancer:

1. Aging-based prognosis: This patient is 74 years of age, a semi-retired university professor, is very active in his community center, lives with his wife, and continues to work 3 days per week at the university

Aging based prognosis is a very important consideration, as this scenario may be much different if the patient was 74 years old, a retired high school teacher, uncontrolled hypertension, periodic falls, a widower, fixed income, with supportive family but living several hours away.

The International Society of Geriatric Oncology has published guidelines for the management of prostate cancer in elderly patients,¹ providing key guidance. It is important for clinicians to understand the different steps in health status evaluation and the estimated time required to complete these evaluations. Importantly, a mandatory initial step is to perform a G8 and a Mini-COG assessment:

The G8 screening tool highlights 8 specific items that clinicians address, including those pertaining to food intake, weight loss in the last 3 months, mobility, neuropsychological problems, body mass index, number of daily medications, personal consideration of health status, and age:

The benefit of the G8 screening tool is that we can identify patients who are going to do well, and those who will likely do poorly. In a prospective study by Kenis et al. [2], 937 patients with cancer (9% with prostate cancer) were assessed with G8, with a normal screening score significantly associated with improved overall survival (HR 0.38, p < 0.001) versus those with an abnormal G8 score:

The decision tree to determine a patient’s health status is provided by a combination of the G8 and Mini-COG stratifying patients into groups that are fit, frail, or disabled with severe comorbidities. The decision tree for this assessment is as follows:

1. Identification of resources to support patient needs: again, the benefit of the G8 screening tool is it allows resource need to be identified for these patients, such as physical therapy referral, home services, and durable medical equipment. On a more treatment intensified level, perhaps these patients need a neurology or psychology referral, a cognitive rehabilitation program, or pharmacologic management. Additionally, perhaps they need help with medication reconciliation, reduction of polypharmacy, or a pill box organizer.
2. Assessment of patients’ goals and values: for this patient with metastatic hormone sensitive prostate cancer, there are many options for disease management. Dr. Morgans mentioned that we have many options for treating metastatic hormone sensitive prostate cancer, thus for elderly patients, it is particularly important to select the correct option for each patient. Dr. Morgans notes that for abiraterone acetate in LATITUDE and for apalutamide in TITAN, there are age specific subgroup analyses suggesting that each agent has a similar overall survival benefit regardless of age. Additionally, abiraterone quality of life in LATITUDE was preserved over time.
3. Communication with the patient and caregivers: in 2022, Dr. Morgans and Dr. Beltran wrote an editorial piece in Journal of Clinical Oncology [3] assessing factors that contribute to treatment decisions that should be considered when using shared decision making for patients with mHSPC. This includes cancer-related factors, patient-related factors, clinician-related factors, and treatment-related factors as highlighted in the following figure:

Financial toxicity is also an important consideration, given that it has been associated with increased depression, anxiety, distress, and poorer quality of life.

Dr. Morgans concluded her presentation by discussing applying risk/benefit considerations for elder patients to current treatment advances in prostate cancer with the following take-home points:

• Applying considerations specific to older adults in a systematic way can avoid over and under treatment of this vulnerable population
• Steps include cancer assessment, staging the aging, identifying reversible aspects of frailty, understanding patient values, and engaging in shared decisions with patients and their caregivers
• A majority of older adult patients can get some form of treatment intensification in metastatic hormone sensitive prostate cancer 

Presented by: Alicia K. Morgans, MD, MPH, Dana-Farber Cancer Institute, Boston, MA 

Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Associate Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, @zklaassen_md on Twitter during the 2023 American Society of Clinical Oncology (ASCO) Annual Meeting, Chicago, IL, Fri, June 2 – Tues, June 6, 2023. 

References:

1. Droz JP, Albrand G, Gillessen S, et al. Management of prostate cancer in elderly patients: Recommendations of a task force of the International Society of Geriatric Oncology. Eur Urol. 2017 Oct;72(4):521-531.
2. Kenis C, Decoster L, Van Puyvelde K, et al. Performance of two geriatric screening tools in older patients with cancer. J Clin Oncol. 2014 Jan 1;32(1):19-26.
3. Morgans AK, Beltran H. Isn’t Androgen Deprivation Enough? Optimal Treatment for Newly Diagnosed Metastatic Prostate Cancer. J Clin Oncol. 2022 Mar 10;40(8):818-824.