Irradiation of localized prostate cancer in the elderly: A systematic literature review

Abstract

Purpose: To analyze the literature that addresses radiation therapy for intermediate and high-risk prostate cancer (PC) in the elderly.

Patients and methods: A PubMed literature search was conducted including articles from 01/01/2000 to 30/06/21, with the following keywords: PC, radiotherapy/brachytherapy and elderly. The analysis mainly focused on the issue of under-treatment in the elderly and the benefit/risk balance of irradiation.

Results: Of the 176 references analyzed, 24 matched the selection criteria. The definition of "elderly patient" varied from 70 to 80 years. The analysis was impacted by the inhomogeneous primary end points used in each cohort. Age was often an obstacle to radical treatment, with a subsequent risk of under-treatment, particularly in patients with a poorer prognosis. However, comparable elderly oncological outcomes were compared to younger patients, both with external beam radiotherapy alone or combined with brachytherapy boost. Late toxicity rates are low and most often comparable to younger populations. However, a urinary over- toxicity was observed in the super-elderly (>80 years) after brachytherapy boost. The use of ADT should be considered in light of comorbidities, and may even be deleterious in some patients.

Conclusion: Due to the increase in life expectancy, the management of PC in the elderly is a challenge for patients, clinicians and health insurance payers. Except for unfit men, elderly patients remain candidates for optimal curative treatment (i.e. regardless of age) after oncogeriatric assessment. More solid data from prospective trials conducted specially in this population will provide better guidance in our daily clinical practice.

Keywords: 3DCT, 3D conformal radiotherapy; ACE-27, Adult Comorbidity Evaluation 27; AD, Alzheimer’s disease; ADT, androgen deprivation therapy; ASCO, American Society of Clinical Oncology; Androgen deprivation therapy; BRFS, biochemical relapse-free survival; BT, brachytherapy; Brachytherapy; CCI, Charlson comorbidity index; EBRT, External beam radiation therapy; Elderly; G, grade; GI, Gastro-intestinal; GI, Genito-urinary; HDR, high dose-rate; IGRT, Image Guided Radiation Therapy; IMRT, intensity modulated radiation therapy; LDR, low dose-rate; LE, life expectancy; MA, median age; MFU, median follow-up; NCCN, National Comprehensive Cancer Network; OS, overall survival; PC, prostate cancer; PCSM, prostate cancer specific mortality; PCSS, Prostate cancer specific survival; Prostate cancer; QoL, quality of life; Radiation therapy; SBRT, stereotactic body radiation therapy; SEER, Surveillance, Epidemiology, and End Results; SIOG, International Society of Geriatric Oncology; bNED, Biological non-evidence of disease.

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Flow chart.