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Prostate cancer in elderly patients

Jonathan L Wright, MD, MS
Paul H Lange, MD, FACS
Section Editors
Jerome P Richie, MD, FACS
Nicholas Vogelzang, MD
W Robert Lee, MD, MS, MEd
Deputy Editor
Michael E Ross, MD


Prostate cancer in elderly men is particularly important because of the high incidence and prevalence of disease and mortality in this group of patients:

The incidence of prostate cancer is strongly correlated with age and disproportionately affects the elderly. In the United States, 35 percent of cases from 2003 to 2007 were in men aged 65 to 74, and another 25 percent were in men 75 years or older [1]. Prostate cancer incidence rates rapidly rise with increasing age starting around age 50 years, with the highest rates seen in those aged 70 to 80 years (figure 1). Thus, the estimated prevalence for men aged 75 years or greater is over one million men [1].

Prostate cancer is the third most common cause of cancer death among men aged 80 years and older [2]. Although the case-fatality rate of prostate cancer is quite low, deaths occur disproportionately in the elderly, owing to the long natural history of the disease. Thus, 41 percent of men who die of prostate cancer are between age 75 and 84 years and 30 percent are 85 years or older.

Recommendations for the management of prostate cancer in the elderly are particularly difficult because of issues specific to this group and because clinical trials in prostate cancer often excluded elderly patients.

The initial treatment for elderly men with prostate cancer and the management of advanced disease will be reviewed here. The approach to these issues in younger patients is reviewed separately. (See "Initial approach to low- and very low-risk clinically localized prostate cancer" and "Initial management of regionally localized intermediate, high, and very high-risk prostate cancer" and "Overview of the treatment of disseminated prostate cancer".)


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  1. Horner M, Ries L, Krapcho M, et al. SEER Cancer Statistics Review, 1975-2006, based on November 2008 SEER data submission. In: National Cancer Institute; 2009.
  2. 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/, based on December 2009 SEER data submission, posted to the SEER web site 2008.
  3. Pal SK, Katheria V, Hurria A. Evaluating the older patient with cancer: understanding frailty and the geriatric assessment. CA Cancer J Clin 2010; 60:120.
  4. Droz JP, Aapro M, Balducci L, et al. Management of prostate cancer in older patients: updated recommendations of a working group of the International Society of Geriatric Oncology. Lancet Oncol 2014; 15:e404.
  5. 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.
  6. Bellera CA, Rainfray M, Mathoulin-Pélissier S, et al. Screening older cancer patients: first evaluation of the G-8 geriatric screening tool. Ann Oncol 2012; 23:2166.
  7. Droz JP, Balducci L, Bolla M, et al. Background for the proposal of SIOG guidelines for the management of prostate cancer in senior adults. Crit Rev Oncol Hematol 2010; 73:68.
  8. Senior Adult Oncology. In: NCCN Clinical Practice Guidelines in Oncology; 2010.
  9. Jeldres C, Latouff JB, Saad F. Predicting life expectancy in prostate cancer patients. Curr Opin Support Palliat Care 2009; 3:166.
  10. Walz J, Gallina A, Perrotte P, et al. Clinicians are poor raters of life-expectancy before radical prostatectomy or definitive radiotherapy for localized prostate cancer. BJU Int 2007; 100:1254.
  11. Walz J, Suardi N, Shariat SF, et al. Accuracy of life tables in predicting overall survival in patients after radical prostatectomy. BJU Int 2008; 102:33.
  12. Walz J, Gallina A, Saad F, et al. A nomogram predicting 10-year life expectancy in candidates for radical prostatectomy or radiotherapy for prostate cancer. J Clin Oncol 2007; 25:3576.
  13. Houterman S, Janssen-Heijnen ML, Verheij CD, et al. Greater influence of age than co-morbidity on primary treatment and complications of prostate cancer patients: an in-depth population-based study. Prostate Cancer Prostatic Dis 2006; 9:179.
  14. Konety BR, Cowan JE, Carroll PR, CaPSURE Investigators. Patterns of primary and secondary therapy for prostate cancer in elderly men: analysis of data from CaPSURE. J Urol 2008; 179:1797.
  15. Bubolz T, Wasson JH, Lu-Yao G, Barry MJ. Treatments for prostate cancer in older men: 1984-1997. Urology 2001; 58:977.
  16. Cooperberg MR, Carroll PR. Trends in Management for Patients With Localized Prostate Cancer, 1990-2013. JAMA 2015; 314:80.
  17. Lu-Yao GL, Albertsen PC, Moore DF, et al. Fifteen-year Outcomes Following Conservative Management Among Men Aged 65 Years or Older with Localized Prostate Cancer. Eur Urol 2015; 68:805.
  18. Daskivich TJ, Fan KH, Koyama T, et al. Effect of age, tumor risk, and comorbidity on competing risks for survival in a U.S. population-based cohort of men with prostate cancer. Ann Intern Med 2013; 158:709.
  19. http://www.uroweb.org/gls/pdf/1607%20Prostate%20Cancer_LRV3.pdf (Accessed on September 17, 2014).
  20. Bill-Axelson A, Holmberg L, Garmo H, et al. Radical prostatectomy or watchful waiting in early prostate cancer. N Engl J Med 2014; 370:932.
  21. Wong YN, Mitra N, Hudes G, et al. Survival associated with treatment vs observation of localized prostate cancer in elderly men. JAMA 2006; 296:2683.
  22. Sun L, Caire AA, Robertson CN, et al. Men older than 70 years have higher risk prostate cancer and poorer survival in the early and late prostate specific antigen eras. J Urol 2009; 182:2242.
  23. Magheli A, Rais-Bahrami S, Humphreys EB, et al. Impact of patient age on biochemical recurrence rates following radical prostatectomy. J Urol 2007; 178:1933.
  24. Siddiqui SA, Sengupta S, Slezak JM, et al. Impact of patient age at treatment on outcome following radical retropubic prostatectomy for prostate cancer. J Urol 2006; 175:952.
  25. Malaeb BS, Rashid HH, Lotan Y, et al. Prostate cancer disease-free survival after radical retropubic prostatectomy in patients older than 70 years compared to younger cohorts. Urol Oncol 2007; 25:291.
  26. Pierorazio PM, Humphreys E, Walsh PC, et al. Radical prostatectomy in older men: survival outcomes in septuagenarians and octogenarians. BJU Int 2010; 106:791.
  27. Jeldres C, Suardi N, Walz J, et al. Poor overall survival in septa- and octogenarian patients after radical prostatectomy and radiotherapy for prostate cancer: a population-based study of 6183 men. Eur Urol 2008; 54:107.
  28. Tewari A, Johnson CC, Divine G, et al. Long-term survival probability in men with clinically localized prostate cancer: a case-control, propensity modeling study stratified by race, age, treatment and comorbidities. J Urol 2004; 171:1513.
  29. Kundu SD, Roehl KA, Eggener SE, et al. Potency, continence and complications in 3,477 consecutive radical retropubic prostatectomies. J Urol 2004; 172:2227.
  30. Stanford JL, Feng Z, Hamilton AS, et al. Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes Study. JAMA 2000; 283:354.
  31. Hoffman RM, Barry MJ, Stanford JL, et al. Health outcomes in older men with localized prostate cancer: results from the Prostate Cancer Outcomes Study. Am J Med 2006; 119:418.
  32. Mohamad BA, Marszalek M, Brössner C, et al. Radical prostatectomy in Austria: a nationwide analysis of 16,524 cases. Eur Urol 2007; 51:684.
  33. Hu JC, Elkin EP, Pasta DJ, et al. Predicting quality of life after radical prostatectomy: results from CaPSURE. J Urol 2004; 171:703.
  34. Shikanov S, Desai V, Razmaria A, et al. Robotic radical prostatectomy for elderly patients: probability of achieving continence and potency 1 year after surgery. J Urol 2010; 183:1803.
  35. Greco KA, Meeks JJ, Wu S, Nadler RB. Robot-assisted radical prostatectomy in men aged > or =70 years. BJU Int 2009; 104:1492.
  36. Cooperberg MR, Broering JM, Carroll PR. Time trends and local variation in primary treatment of localized prostate cancer. J Clin Oncol 2010; 28:1117.
  37. Gilbert SM, Kuo YF, Shahinian VB. Prevalent and incident use of androgen deprivation therapy among men with prostate cancer in the United States. Urol Oncol 2011; 29:647.
  38. D'Amico AV, Cote K, Loffredo M, et al. Advanced age at diagnosis is an independent predictor of time to death from prostate carcinoma for patients undergoing external beam radiation therapy for clinically localized prostate carcinoma. Cancer 2003; 97:56.
  39. Dosoretz AM, Chen MH, Salenius SA, et al. Mortality in men with localized prostate cancer treated with brachytherapy with or without neoadjuvant hormone therapy. Cancer 2010; 116:837.
  40. Jani AB, Gratzle J. Analysis of impact of age and race on biochemical control after radiotherapy in different prostate cancer settings. Urology 2005; 66:124.
  41. Johnstone PA, Riffenburgh RH, Moul JW, et al. Effect of age on biochemical disease-free outcome in patients with T1-T3 prostate cancer treated with definitive radiotherapy in an equal-access health care system: a radiation oncology report of the Department of Defense Center for Prostate Disease Research. Int J Radiat Oncol Biol Phys 2003; 55:964.
  42. D'Amico AV, Chen MH, Renshaw AA, et al. Androgen suppression and radiation vs radiation alone for prostate cancer: a randomized trial. JAMA 2008; 299:289.
  43. D'Amico AV, Chen MH, Renshaw A, et al. Long-term Follow-up of a Randomized Trial of Radiation With or Without Androgen Deprivation Therapy for Localized Prostate Cancer. JAMA 2015; 314:1291.
  44. Giacalone NJ, Wu J, Chen MH, et al. Prostate-Specific Antigen Failure and Risk of Death Within Comorbidity Subgroups Among Men With Unfavorable-Risk Prostate Cancer Treated in a Randomized Trial. J Clin Oncol 2016.
  45. Nanda A, Chen MH, Moran BJ, et al. Predictors of prostate cancer-specific mortality in elderly men with intermediate-risk prostate cancer treated with brachytherapy with or without external beam radiation therapy. Int J Radiat Oncol Biol Phys 2010; 77:147.
  46. Hoffman KE, Chen MH, Moran BJ, et al. Prostate cancer-specific mortality and the extent of therapy in healthy elderly men with high-risk prostate cancer. Cancer 2010; 116:2590.
  47. Nanda A, Chen MH, Braccioforte MH, et al. Hormonal therapy use for prostate cancer and mortality in men with coronary artery disease-induced congestive heart failure or myocardial infarction. JAMA 2009; 302:866.
  48. Widmark A, Klepp O, Solberg A, et al. Endocrine treatment, with or without radiotherapy, in locally advanced prostate cancer (SPCG-7/SFUO-3): an open randomised phase III trial. Lancet 2009; 373:301.
  49. Warde P, Mason M, Ding K, et al. Combined androgen deprivation therapy and radiation therapy for locally advanced prostate cancer: a randomised, phase 3 trial. Lancet 2011; 378:2104.
  50. Fossa SD, Wiklund F, Klepp O, et al. Ten- and 15-year prostate cancer-specific mortality in patients with nonmetastatic locally advanced or aggressive intermediate prostate cancer, randomized to lifelong endocrine treatment alone or combined with radiotherapy: final results of the Scandinavian Prostate Cancer Group-7. Eur Urol 2016.
  51. Bekelman JE, Mitra N, Handorf EA, et al. Effectiveness of androgen-deprivation therapy and radiotherapy for older men with locally advanced prostate cancer. J Clin Oncol 2015; 33:716.
  52. Jani AB, Parikh SD, Vijayakumar S, Gratzle J. Analysis of influence of age on acute and chronic radiotherapy toxicity in treatment of prostate cancer. Urology 2005; 65:1157.
  53. Geinitz H, Zimmermann FB, Thamm R, et al. 3D conformal radiation therapy for prostate cancer in elderly patients. Radiother Oncol 2005; 76:27.
  54. Villa S, Bedini N, Fallai C, Olmi P. External beam radiotherapy in elderly patients with clinically localized prostate adenocarcinoma: age is not a problem. Crit Rev Oncol Hematol 2003; 48:215.
  55. Liu L, Glicksman AS, Coachman N, Kuten A. Low acute gastrointestinal and genitourinary toxicities in whole pelvic irradiation of prostate cancer. Int J Radiat Oncol Biol Phys 1997; 38:65.
  56. Schultheiss TE, Hanks GE, Hunt MA, Lee WR. Incidence of and factors related to late complications in conformal and conventional radiation treatment of cancer of the prostate. Int J Radiat Oncol Biol Phys 1995; 32:643.
  57. Skwarchuk MW, Jackson A, Zelefsky MJ, et al. Late rectal toxicity after conformal radiotherapy of prostate cancer (I): multivariate analysis and dose-response. Int J Radiat Oncol Biol Phys 2000; 47:103.
  58. Chen AB, D'Amico AV, Neville BA, Earle CC. Patient and treatment factors associated with complications after prostate brachytherapy. J Clin Oncol 2006; 24:5298.
  59. Pinkawa M, Fischedick K, Gagel B, et al. Impact of age and comorbidities on health-related quality of life for patients with prostate cancer: evaluation before a curative treatment. BMC Cancer 2009; 9:296.
  60. Sammon JD, Abdollah F, Reznor G, et al. Patterns of Declining Use and the Adverse Effect of Primary Androgen Deprivation on All-cause Mortality in Elderly Men with Prostate Cancer. Eur Urol 2015; 68:32.
  61. Thompson I, Thrasher JB, Aus G, et al. Guideline for the management of clinically localized prostate cancer: 2007 update. J Urol 2007; 177:2106.
  62. NCCN Practice Guidelines in Oncology: Prostate Cancer http://www.nccn.org/professionals/physician_gls/PDF/prostate.pdf (Accessed on August 09, 2010).
  63. Shahinian VB, Kuo YF, Freeman JL, Goodwin JS. Risk of fracture after androgen deprivation for prostate cancer. N Engl J Med 2005; 352:154.
  64. Stoch SA, Parker RA, Chen L, et al. Bone loss in men with prostate cancer treated with gonadotropin-releasing hormone agonists. J Clin Endocrinol Metab 2001; 86:2787.
  65. Bakhireva LN, Barrett-Connor E, Kritz-Silverstein D, Morton DJ. Modifiable predictors of bone loss in older men: a prospective study. Am J Prev Med 2004; 26:436.
  66. Smith MR, Saad F, Egerdie B, et al. Sarcopenia during androgen-deprivation therapy for prostate cancer. J Clin Oncol 2012; 30:3271.
  67. Basaria S, Muller DC, Carducci MA, et al. Hyperglycemia and insulin resistance in men with prostate carcinoma who receive androgen-deprivation therapy. Cancer 2006; 106:581.
  68. Braga-Basaria M, Dobs AS, Muller DC, et al. Metabolic syndrome in men with prostate cancer undergoing long-term androgen-deprivation therapy. J Clin Oncol 2006; 24:3979.
  69. Harle LK, Maggio M, Shahani S, et al. Endocrine complications of androgen-deprivation therapy in men with prostate cancer. Clin Adv Hematol Oncol 2006; 4:687.
  70. Kintzel PE, Chase SL, Schultz LM, O'Rourke TJ. Increased risk of metabolic syndrome, diabetes mellitus, and cardiovascular disease in men receiving androgen deprivation therapy for prostate cancer. Pharmacotherapy 2008; 28:1511.
  71. Leahy Y. Risk of metabolic syndrome, cardiovascular disease, and diabetes in androgen deprivation therapy. Clin J Oncol Nurs 2008; 12:771.
  72. Ford ES, Giles WH, Dietz WH. Prevalence of the metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey. JAMA 2002; 287:356.
  73. Ford ES. Risks for all-cause mortality, cardiovascular disease, and diabetes associated with the metabolic syndrome: a summary of the evidence. Diabetes Care 2005; 28:1769.
  74. Galassi A, Reynolds K, He J. Metabolic syndrome and risk of cardiovascular disease: a meta-analysis. Am J Med 2006; 119:812.
  75. Shahinian VB, Kuo YF, Freeman JL, Goodwin JS. Risk of the "androgen deprivation syndrome" in men receiving androgen deprivation for prostate cancer. Arch Intern Med 2006; 166:465.
  76. Loblaw DA, Virgo KS, Nam R, et al. Initial hormonal management of androgen-sensitive metastatic, recurrent, or progressive prostate cancer: 2006 update of an American Society of Clinical Oncology practice guideline. J Clin Oncol 2007; 25:1596.
  77. Hussain M, Tangen CM, Berry DL, et al. Intermittent versus continuous androgen deprivation in prostate cancer. N Engl J Med 2013; 368:1314.
  78. Sweeney C, Chen YH, Carducci MA, et al. Impact on overall survival (OS) with chemohormonal therapy versus hormonal therapy for hormone-sensitive newly metastatic prostate cancer (mPrCa): An ECOG-led phase III randomized trial (abstract LBA2). 2014 American Society of Clinical Oncology (ASCO) meeting.
  79. Onukwugha E, Mullins CD, Hsu VD, et al. Effect of urologists and medical oncologists on treatment of elderly men with Stage IV prostate cancer. Urology 2011; 77:1088.
  80. Berthold DR, Pond GR, Soban F, et al. Docetaxel plus prednisone or mitoxantrone plus prednisone for advanced prostate cancer: updated survival in the TAX 327 study. J Clin Oncol 2008; 26:242.
  81. Anderson J, Van Poppel H, Bellmunt J, et al. Chemotherapy for older patients with prostate cancer. BJU Int 2007; 99:269.
  82. Mourey L, Gravis G, Sevin E, et al. Feasibility of docetaxel-prednisone (DP) in frail elderly (age 75 and older) patients with castration-resistant metastatic prostate cancer (CRMPC): GERICO10-GETUG P03 trial led by Unicancer (abstract). 2014 ASCO Genitourinary Cancer Symposium.
  83. Begg CB, Carbone PP. Clinical trials and drug toxicity in the elderly. The experience of the Eastern Cooperative Oncology Group. Cancer 1983; 52:1986.
  84. Ritz P, Vellas B. Pharmacokinetics and drug toxicity in elderly patients: a case for geriatric core data in clinical trials. J Nutr Health Aging 2007; 11:261.
  85. Beer TM, Berry W, Wersinger EM, Bland LB. Weekly docetaxel in elderly patients with prostate cancer: efficacy and toxicity in patients at least 70 years of age compared with patients younger than 70 years. Clin Prostate Cancer 2003; 2:167.
  86. Italiano A, Ortholan C, Oudard S, et al. Docetaxel-based chemotherapy in elderly patients (age 75 and older) with castration-resistant prostate cancer. Eur Urol 2009; 55:1368.
  87. Fosså SD. A randomized phase II trial comparing weekly taxotere plus prednisolone versus prednisolone alone in androgen-independent prostate cancer. Front Radiat Ther Oncol 2008; 41:108.
  88. de Bono JS, Oudard S, Ozguroglu M, et al. Prednisone plus cabazitaxel or mitoxantrone for metastatic castration-resistant prostate cancer progressing after docetaxel treatment: a randomised open-label trial. Lancet 2010; 376:1147.
  89. Bahl A, Oudard S, Tombal B, et al. Impact of cabazitaxel on 2-year survival and palliation of tumour-related pain in men with metastatic castration-resistant prostate cancer treated in the TROPIC trial. Ann Oncol 2013; 24:2402.
  90. Beer TM, Armstrong AJ, Rathkopf DE, et al. Enzalutamide in metastatic prostate cancer before chemotherapy. N Engl J Med 2014; 371:424.
  91. Ryan CJ, Smith MR, de Bono JS, et al. Abiraterone in metastatic prostate cancer without previous chemotherapy. N Engl J Med 2013; 368:138.
  92. de Bono JS, Logothetis CJ, Molina A, et al. Abiraterone and increased survival in metastatic prostate cancer. N Engl J Med 2011; 364:1995.
  93. Scher HI, Fizazi K, Saad F, et al. Increased survival with enzalutamide in prostate cancer after chemotherapy. N Engl J Med 2012; 367:1187.
  94. Mulders PF, Molina A, Marberger M, et al. Efficacy and safety of abiraterone acetate in an elderly patient subgroup (aged 75 and older) with metastatic castration-resistant prostate cancer after docetaxel-based chemotherapy. Eur Urol 2014; 65:875.
  95. Sternberg CN, de Bono JS, Chi KN, et al. Improved outcomes in elderly patients with metastatic castration-resistant prostate cancer treated with the androgen receptor inhibitor enzalutamide: results from the phase III AFFIRM trial. Ann Oncol 2014; 25:429.
  96. Parker C, Nilsson S, Heinrich D, et al. Alpha emitter radium-223 and survival in metastatic prostate cancer. N Engl J Med 2013; 369:213.
  97. Kantoff PW, Higano CS, Shore ND, et al. Sipuleucel-T immunotherapy for castration-resistant prostate cancer. N Engl J Med 2010; 363:411.