The main new thing in the pathway, in the guidelines, is the very early introduction of the cognitive evaluation with Mini-Cog initially. The previous guidelines said you have to stratify based on G8 score, which is a screening score for comorbidity, a need for a better understanding, a better check for comorbidity. We strongly suggest that Mini-Cog should be used upfront because patients have to be involved in the decision making process if their cognitive function allows that. It’s fine if it doesn’t; it has to be known from the beginning so the simplest way to do it is to use Mini-Cog. All the other things are almost unchanged with three groups of patients that are fit, frail and too sick.
Are there any updates with respect to prostate cancer?
The points I highlighted yesterday are, first of all, that most men with low risk disease probably don’t need to have anything, especially in senior adults. Probably a large proportion of intermediate risk patients also don’t need to be treated at all. This is based on a very large UK randomised controlled trial, the PROTECT trial, with more than 1,600 men randomised between a form of light active surveillance, called active monitoring, or radical prostatectomy or radiotherapy and at ten years the specific survival in the three groups was almost exactly the same, almost around 99%. So to be better than that is almost impossible in terms of specific survival, so clearly highlighting the fact that low risk and probably most intermediate risk at ten years probably just watch them.
The aggressive disease, the high risk patients based on Gleason score above 7 or a PSA above 20 or DRA with a T3 or higher, clearly the lethal disease, it’s not a rapid lethal disease but it is a lethal disease that deserves a form of active treatment. The second main message was that ADT monotherapy for those kinds of patients is probably not the best way to go. Again, based on a randomised trial that was published by EORTC several years ago showing that upfront ADT in those men versus symptom deferred ADT, there is a very minimal OS benefit for those treated immediately but surprisingly there was absolutely no specific survival benefit, which is quite surprising. There was a suggestion that it was less non-prostate related deaths with ADT, which is absolutely contra-intuitive so we have to be very careful about that. But probably the most important thing is that a third of the patients not treated immediately died without nver receiving any form of ADT, clearly suggesting that this form of ADT should be reserved for the man with the most advanced disease with a lot of symptoms that require a form of treatment. All the others should be treated in a different way, probably with a local form of treatment.
The third message is if you consider dealing with local treatment for senior adults you have to be aware that there are at least two validated strategies, the first one is surgery, the second one is external beam. Both are very valid except the fact that if you’re operating on a senior adult man he must be aware that there is an increased risk of incontinence and an increased risk of impotency compared to younger patients. But it’s a valid option provided the patient is fit enough to have that and in need to receive it. These are the three messages from yesterday’s talk.
How can we implement these?
Probably the most important thing is to have an in depth discussion with patients because every time we say cancer the patient has got a fear – I will have pain and I will die. Clearly we must reassure that those men with a low Gleason score, based on biopsy, clearly they will never die from the prostate cancer, at least up to ten years. Remember PROTECT – 99% specific survival. On the other way, clearly locally advanced diseases are under-treated. Clearly they are under-treated; if you consider only ADT it’s a problem. The urologists and the radiotherapists must be aware that it’s not because you are old that you must be treated with only palliative care. Provided you are fit enough you benefit from it and that’s where the geriatric evaluation comes.
So it’s a matter of education, you have to educate the urologist, the medical oncologist, the radiotherapist and probably the best people to do that are the nurses, provided they are trained, trained by a geriatrician team, that the best way to incorporate. So probably the most important limitation is time and learning to work together with geriatricians that have to be incorporated and involved very early in the process.
