Management of Prostate Cancer in Elderly Patients
Even though significant progress has been made in the standard of care, with more and more therapies available that target specific kinds of tumors, the greatest successes have been limited to only a few types of cancers. According to Global cancer statistics 2018 (GLOBOCAN estimates of incidence and mortality worldwide), prostate is reported to be one of the most frequently diagnosed cancer in 105 countries. With regard to mortality, it is the leading cause of deaths in 46 countries. Sanofi is among the frontrunners that have forged new paths for the treatment of prostate cancer. With a generous sponsorship from Sanofi, in 2010 SIOG established a taskforce that issued guidelines on the management of prostate cancer in older patients. SIOG has issued in 2014, 2017 and in 2019 updates of these guidelines. Recent advancements in the field brings SIOG to propose an update of its recommendations and the corresponding case based expert interviews.
Co-Chairs: Helen Boyle, France & Ravindran Kanesvaran, Singapore
Members:
Lore Decoster, Belgium
Karim Fizazi, France
Nicolas Mottet, France
Shane O’Hanlon, Ireland
Stéphane Oudard, France
Martine Puts, Canada
2019
Updated recommendations of the International Society of Geriatric Oncology on prostate cancer management in older patients. Boyle HJ, Alibhai S, Decoster L, Efstathiou E, Fizazi K, Mottet N, Oudard S, Payne H, Prentice M, Puts M, Aapro M, Droz JP. Eur J Cancer. 2019 Jul;116:116-136. doi: 10.1016/j.ejca.2019.04.031. Epub 2019 Jun 10.
2017
Management of prostate cancer in elderly patients: recommendations of a Task Force of the International Society of Geriatric Oncology (SIOG). Jean-Pierre Droz, Gilles Albrand, Silke Gillessen, Simon Hughes, Nicolas Mottet, Stephane Oudard, Heather Payne, Martine Puts, Gilbert Zulian, Lodovico Balducci, Matti Aapro. Eur Urol. 2017 Jan 11. pii: S0302-2838(17)30001-5. doi: 10.1016/j.eururo.2016.12.025. [Epub ahead of print]
2014
Management of prostate cancer in older patients: updated recommendations of a working group of the International Society of Geriatric Oncology. Droz JP, Aapro M, Balducci L, Boyle H4, Van den Broeck T, Cathcart P, Dickinson L, Efstathiou E, Emberton M, Fitzpatrick JM, Heidenreich A, Hughes S, Joniau S, Kattan M, Mottet N, Oudard S, Payne H, Saad F, Sugihara T. Lancet Oncol. 2014 Aug;15(9):e404-e414. doi: 10.1016/S1470-2045(14)70018-X.
2010
Background for the proposal of SIOG guidelines for the management of prostate cancer in senior adults. Droz JP, et al. Crit Rev Oncol Hematol 2010; 73: 68-91
Complete guidelines: Management of prostate cancer in older men: recommendations of a working group of the International Society of Geriatric Oncology. Droz JP, Balducci L, Bolla M, Emberton M, Fitzpatrick JM, Joniau S, Kattan MW, Monfardini S, Moul JW, Naeim A, van Poppel H, Saad F, Sternberg CN. BJU Int 2010;106:462-9
This project is supported by unrestricted grants from Astellas and Sanofi.
Treatment of Ovarian cancer in older adults – Development of treatment algorithms and educational program
There are many reviews for the treatment of ovarian cancer in older patients. Despite this, there are problems associated with treatment such as inadequate staging, less aggressive surgery and chemotherapy treatments not according to standard guidelines. Many medical oncology training programs do not expose fellows to gynecologic cancers as the surgeons and radiation oncologists treat the bulk of patients. Therefore, there is a critical educational gap. This is particularly present in the older patients. A SIOG taskforce can contribute to fill this education gap by providing a comprehensive treatment review and educational program. The advent of genetic testing and Parp therapy has added a new dimension requiring more educational initiatives.
Chair: Gabor Liposits, Denmark
Members:
Aminah Ahmed, US
Claire Falandry, France
Aminah Jatoi, US
Vincent Lavoué, France
Stuart M. Lichtman, US
Martine Puts, Canada
William Tew, US
This project is supported by an unrestricted grant from Clovis.
The management of elderly metastatic Renal Cell Carcinoma (mRCC) patients
Treatment of metastatic renal cell carcinoma (mRCC) has evolved tremendously over the past decade since the advent of targeted therapies. In line with this, SIOG had established a task force in 2008 to come up with treatment recommendations for the elderly mRCC patient, an important group that has often been overlooked in terms of recruitment into clinical trials1. In that guideline which was published in a high impact journal in 2009, the task force not only analyzed the evidence regarding the state of art management in mRCC in the elderly but was also able to apply that knowledge by taking into consideration factors unique to an elderly population. These factors include physiological, pathological, pharmacological, and psychological factors that distinguish the older mRCC patients from those younger.
Increased life expectancy has led to a significant expansion in the elderly population. By the year 2020, it is estimated that between one-fifth and one-quarter of the population in the Western world will be aged 65 years or more (Yancik R, Ries LA. Aging and cancer in America. Demographic and epidemiological perspectives. Hematol Oncol Clin North Am 2000; 14 (1): 17–23).
According to the National Cancer Institute, >60% of all incident cancers and 70% of all cancer-related deaths occur in patients >65 years of age and so there are a significant and rapidly increasing number of older patients who need appropriate cancer care (Ries L, Kosary C, Hankey B (eds). SEER Cancer Statistics Review, 1975–1995. Bethesda, MA: National Cancer Institute 1998)
Physiological changes associated with aging, such as declining renal function and decreasing reserve in multiple organ systems, predispose the elderly to cancer drug toxic effects.
Treatment of metastatic renal cell carcinoma (mRCC) has evolved tremendously over the past decade since the advent of targeted therapies. In line with this, SIOG had established a task force in 2008 to come up with treatment recommendations for the elderly mRCC patient, an important group that has often been overlooked in terms of recruitment into clinical trials1. In that guideline which was published in a high impact journal in 2009, the task force not only analyzed the evidence regarding the state of art management in mRCC in the elderly but was also able to apply that knowledge by taking into consideration factors unique to an elderly population. These factors include physiological, pathological, pharmacological, and psychological factors that distinguish the older mRCC patients from those younger1.
It’s been 6 years since the publication of the above position paper and the treatment landscape has changed a lot since. In the 2009 paper1, the data for targeted therapies for use in mRCC patients were limited to Sunitinib2, Sorafenib3, Temsirolimus4, Everolimus5 and Bevacizumab with Interferon6. However since then we have a number of other drugs that have come to the forefront in the treatment of mRCC; like Pazopanib7 and Axitinib8 and we have better clarity on how best to sequence these drugs as well. Quality of life improvement and patient preference studies9 related to it have made this drug a feasible option for the frail and elderly population. We also have more data now regarding how these drugs work in the elderly population too.
In July 2014, SIOG ( International Society of Geriatric Oncology) organized a major regional meeting covering the Asia Pacific region (SIOG APAC 2014) to highlight the issues afflicting older cancer patient in the most rapidly ageing part of the world. During this meeting, Dr Ravindran Kanesvaran, the host of the SIOG APAC meeting and genitourinary cancer oncologist from the National Cancer Centre Singapore had made a presentation on the “optimal management of metastatic renal cell carcinoma in the elderly”. It was then that the idea of updating the current guideline was conceived. It is hoped that the updated guideline that we are planning will further enhance the care of elderly mRCC patients with the advent of better therapy that have been developed over the past 6 years.
This task force will review the available evidence:
- To incorporate the latest therapies in the care of elderly mRCC in both the first and second line of treatment while taking into account principles of geriatric management
- To provide guidance on how to sequence treatment in elderly mRCC patients
- To assess both clinical trial and real world data on the use of state of the art therapies in older mRCC patients and incorporate them into our guideline
Chair/ co-chair:
Ravindran Kanesvaran (SNG)
Vincent Launay-Vacher (FR; C-KIN representative)
Writing Committee
Robert Motzer (USA)
Florian Scotté (FR)
Toni Choueiri (USA)
Joaquim Bellmunt (SP)
Olivia Le Saux (FR)
Elderly patients with metastatic renal cell carcinoma: position paper from the International Society of Geriatric Oncology. Ravindran Kanesvaran, Olivia Le Saux, Robert Motzer, Toni K Choueiri, Florian Scotté, Joaquim Bellmunt, Vincent Launay-Vacher. Lancet Oncol. 2018 Jun;19(6):e317-e326. doi: 10.1016/S1470-2045(18)30125-6. Epub 2018 Jun 1.
This project was supported by unrestricted grants from Novartis and Pfizer.
Metastatic Renal Cell Cancer (mRCC) in the elderly
The task force completed the first systematic review of the role of targeted agents specifically in the elderly population.
Chair: Joaquim Bellmunt, Spain
Members:
Sylvie Négrier, France
Bernard Escudier, France
Ahmad Awada, Belgium
Matti Aapro, Switzerland
2009
The medical treatment of metastatic renal cell cancer in the elderly: Position paper of a SIOG Taskforce. Bellmunt J, et al. Crit Rev Oncol Hematol 2009; 69: 64-72
Radiopharmaceuticals in the elderly cancer patient
Molecular imaging using radiopharmaceuticals has a clear role in visualising the presence and extent of tumour at diagnosis and monitoring response to therapy. Such imaging provides prognostic and predictive information relevant to management, e.g. by quantifying active tumour mass using positron emission tomography/computed tomography (PET/CT). As these techniques require only pharmacologically inactive doses, age and potential frailty are generally not important. However, this may be different for therapy involving radionuclides because the radiation can impact normal bodily function (e.g. myelosuppression). Since the introduction of Iodine-131 as a targeted therapy in thyroid cancer, several radiopharmaceuticals have been widely used. These include antibodies and peptides targeting specific epitopes on cancer cells. Among therapeutic bone seeking agents, radium-223 (223Ra) stands out as it results in survival gains in patients with castration-resistant prostate cancer and symptomatic bone metastases. The therapeutic use of radiopharmaceuticals in elderly cancer patients specifically has received little attention. In elderly prostate cancer patients, there may be advantages in radionuclides’ ease of use and relative lack of toxicity compared with cytotoxic and cytostatic drugs.
Chair:
John O Prior, Switzerland
Writing Committee
Silke Gillessen, Switzerland
Manfred Wirth, Germany
William Dale, USA
Matti Aapro, Switzerland
Wim J G Oyen, UK
2017
Radiopharmaceuticals in the elderly cancer patient: Practical considerations, with a focus on prostate cancer therapy: A position paper from the International Society of Geriatric Oncology Task Force. John O Prior, Silke Gillessen, Manfred Wirth, William Dale, Matti Aapro, Wim J G Oyen. Eur J Cancer. 2017 May;77:127-139. doi: 10.1016/j.ejca.2017.01.030. Epub 2017 Apr 7.
This project was supported by an unrestricted grant from Bayer. 