Receipt of definitive therapy in elderly patients with unfavorable‐risk prostate cancer

Yang, David D.; Mahal, Brandon A.; Muralidhar, Vinayak; Boldbaatar, Ninjin; Labe, Shelby A.; Nezolosky, Michelle D.; Vastola, Marie E.; Beard, Clair J.; Martin, Neil E.; Mouw, Kent W.; Orio, Peter F.; King, Martin T.; Nguyen, Paul L.

doi:10.1002/cncr.30948

Cited by 24 publications

(20 citation statements)

References 32 publications

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“…A recent publication of data from the National Cancer Database (NCDB) that captures approximately 70% of newly diagnosed cancers in the United States, documented that increasing age was significantly associated with a decreased likelihood of curative treatment in patients with intermediate and high-risk PC. Interestingly, despite the evidence of undertreatment, the study showed that more than half of patients older than 80 years had received some form of local treatment, mostly radiotherapy [19]. This stands in contrast with treatment policies in Norway: In 2004 less than 5% of patients aged 75-79 years had received local treatment, with gradually increasing treatment numbers during the course of the following 12 years ($50% local treatment in 2016).…”

Section: Discussionmentioning

confidence: 85%

Non-metastatic prostate cancer: rationale for conservative treatment and impact on disease-related morbidity and mortality in the elderly

Löffeler

Halland

Fawad

et al. 2020

Scandinavian Journal of Urology

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Purpose: To determine the rationale for not offering local treatment to prostate cancer patients with non-metastatic disease at diagnosis who later died of prostate cancer and to document local and systemic complications caused by disease progression. Material and Methods: In this population-based, retrospective study we reviewed the medical records of all patients who died of prostate cancer in 2009-2014 in Vestfold County (Vestfold Mortality Study), who were non-metastatic at diagnosis and who had received no local treatment to the prostate (n ¼ 117). Results: A review of patient records demonstrated that the chronological age of 75 years or older was the main rationale for not offering local treatment to the prostate (37%, n ¼ 43). No consideration was given to the functional status and patient health. These elderly patients stood for almost one-fifth of the total PC mortality in Vestfold County. In addition to dying from PC, 86% of patients developed local complications attributable to PC progression. Observation of strict limits for local treatment with regard to tumor characteristics contributed further to the underuse of local treatment. Conclusions: Our study demonstrated systematic undertreatment of elderly patients with aggressive, nonmetastatic PC with regard to local treatment based on chronological age alone. The patients in this study died of prostate cancer and the majority experienced significant morbidity caused by local tumor growth.

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Section: Discussionmentioning

confidence: 85%

Non-metastatic prostate cancer: rationale for conservative treatment and impact on disease-related morbidity and mortality in the elderly

Löffeler

Halland

Fawad

et al. 2020

Scandinavian Journal of Urology

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“…Taking the most commonly diagnosed cancer in men, prostate cancer, as an example, one study in locally advanced disease, found that the likelihood of patients receiving radical treatment was more than halved with every 10 year age increase [7] . Similarly, Yang et al (2017) examined the receipt of definitive treatments, including radiotherapy, in intermediate and high-risk older patients with prostate cancer [8] . Age stratification revealed that 83% of those aged 75–79, and only 63% aged ≥80, intermediate-risk patients, received definitive therapy, while 81% aged 70–75 and 55% aged ≥80 high-risk patients underwent definitive treatment.…”

Section: Introductionmentioning

confidence: 99%

Personalised treatment for older adults with cancer: The role of frailty assessment

O’Donovan

Leech

2020

Technical Innovations & Patient Support in Radiation Oncolo

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It is widely accepted in clinical practice that chronological age is a poor predictor of treatment tolerance and outcomes in older adults with cancer. Intrinsic vulnerability is more a function of underlying frailty, rather than chronological age. Frailty is a state of increased vulnerability to stressors, such as cancer and its treatment, which can lead to adverse health outcomes for patients. Capturing this heterogeneity in reserve capacity is the cornerstone of management in geriatricmedicine, but remains poorly understood or adopted in radiation oncology. A two-step approach, using a shorter screening tool, followed by full assessment for those who need it, is the mostresourceful way of implementing frailty assessment in radiotherapy departments. It is important for radiation oncology professionals to identify frailty and to use this information in multidisciplinary decision making in order to develop a personalised radiotherapy approach for the older person. There are many ways we can effectively use this information, such as considering treatment fractionation schedules that would limit the burden of travel for those with social frailty, or reviewing the range of modalities at our disposal, which might limit toxicity in the older person at high risk of deterioration during treatment. Frailty assessment is not carried out in many radiotherapy departments presently, but there are many international models to use as exemplars as to how it may be implemented in clinical practice. There are many opportunities for further research and role development in this field at the current time.

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“…A growing awareness of iatrogenic harms (e.g., heart attack, osteoporosis, diabetes, loss of sexual function) [ 3 ], coupled with a lack of evidence supporting chemical castration in many cases [ 1 , 4 – 6 ], creates patient safety concerns. Despite this, chemical castration with ADT in low value cases persists as in the case of localized prostate cancer treatment [ 7 ].…”

Section: Introductionmentioning

confidence: 99%

“…The highest levels of evidence for chemical castration with ADT injections to treat prostate cancer occur in two scenarios: (1) high risk localized disease in combination with radiation therapy, and (2) metastatic cancer with spread to bones or other organs causing symptoms such as pain [ 8 – 11 ]. However, a significant amount of castration among patients receiving fee-for-service or integrated health system care occurs outside those instances where high levels of benefit exist [ 1 , 4 – 7 ]. Neither long-term studies nor current guidelines support castration as primary treatment for localized prostate cancer [ 11 ].…”

Section: Introductionmentioning

confidence: 99%

De-implementation of low value castration for men with prostate cancer: protocol for a theory-based, mixed methods approach to minimizing low value androgen deprivation therapy (DeADT)

et al. 2018

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BackgroundMen with prostate cancer are often castrated with long-acting injectable drugs termed androgen deprivation therapy (ADT). Although many benefit, ADT is also used in patients with little or nothing to gain. The best ways to stop this practice are unknown, and range from blunt pharmacy restrictions to informed decision-making. This study will refine and pilot two different de-implementation strategies for reducing ADT use among those unlikely to benefit in preparation for a comparative effectiveness trial.Methods/designThis innovative mixed methods research program has three aims. Aim 1: To assess preferences and barriers for de-implementation of chemical castration in prostate cancer. Guided by the theoretical domains framework (TDF), urologists and patients from facilities with the highest and lowest castration rates across the VA will be interviewed to identify key preferences and de-implementation barriers for reducing castration as prostate cancer treatment. This qualitative work will inform Aim 2 while gathering rich information for two proposed pilot intervention strategies. Aim 2: To use a discrete choice experiment (DCE), a novel barrier prioritization approach, for de-implementation strategy tailoring. The investigators will conduct national surveys of urologists to prioritize key barriers identified in Aim 1 for stopping incident castration as localized prostate cancer treatment using a DCE experiment design. These quantitative results will identify the most important barriers to be addressed through tailoring of two pilot de-implementation strategies in preparation for Aim 3 piloting. Aim 3: To pilot two tailored de-implementation strategies to reduce castration as localized prostate cancer treatment. Building on findings from Aims 1 and 2, two de-implementation strategies will be piloted. One strategy will focus on formulary restriction at the organizational level and the other on physician/patient informed decision-making at different facilities. Outcomes will include acceptability, feasibility, and scalability in preparation for an effectiveness trial comparing these two widely varying de-implementation strategies.DiscussionOur innovative approach to de-implementation strategy development is directly aligned with state-of-the-art complex implementation intervention development and implementation science. This work will broadly advance de-implementation science for low value cancer care, and foster participation in our de-implementation evaluation trial by addressing barriers, facilitators, and concerns through pilot tailoring.Trial registrationClinicalTrials.gov Identifier: NCT03579680, First Posted July 6, 2018.

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Receipt of definitive therapy in elderly patients with unfavorable‐risk prostate cancer

Cited by 24 publications

References 32 publications

Non-metastatic prostate cancer: rationale for conservative treatment and impact on disease-related morbidity and mortality in the elderly

Non-metastatic prostate cancer: rationale for conservative treatment and impact on disease-related morbidity and mortality in the elderly

Personalised treatment for older adults with cancer: The role of frailty assessment

De-implementation of low value castration for men with prostate cancer: protocol for a theory-based, mixed methods approach to minimizing low value androgen deprivation therapy (DeADT)

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