Prostate Cancer Diagnosis and Treatment in Elderly Patients: A Cross-Sectional Survey Exploring Practice Patterns and Preferences of Uro-Oncologists in Northeast Italy

Abstract

Background: The optimal diagnostic and therapeutic strategies for prostate cancer (PCa) in patients aged ≥75 years (mild-old and oldest-old) are still contentious. Resource allocation and ideal treatment for older patients are challenges, mainly due to their comorbidities and reduced life expectancy. This survey aims to assess current clinical practices and the experiences of healthcare providers in the diagnosis and management of elderly patients with PCa. Materials and Methods: In Northeast Italy, members of the Gruppo Uro-Oncologico del Nord-Est (GUONE) conducted a survey involving 104 physicians of different specialties (Nuclear Medicine, Medical Oncology, Radiation Oncology, Radiology, Urology) between 1 November 2024 and 30 November 2024. The survey encompassed 51 questions, evaluating various diagnostic and therapeutic scenarios. Results: Digital rectal exam (DRE) was recommended by 35.9% of physicians for patients aged 75 or older at risk of PCa. PSA testing was continued in 76.3% of these patients. For 36.5% of the physicians, there should be no age limit for prostate biopsy. Moreover, 42.6% of physicians recommended a magnetic resonance imaging (MRI)-guided prostate biopsy regardless of age. A prostate biopsy was deemed mandatory before initiating any form of hormonal therapy by 57.7% of the participants. For 22.3% and 34.7% of physicians, there should be no age limit for prostate MRI and PET/CT for staging purposes. Interestingly, PET/CT was not recommended in 52% of cases as a staging tool for patients older than 85 years. For patients without comorbidities, the age limit to consider radical prostatectomy (RP) was 75, with 58.6% of physicians in favor. There were no definitive limits for radiotherapy (RT). Chemotherapy had an age limit for 81.6% of the respondents; for 18.4%, 22.5%, and 26.5% of physicians, age limits were 75, 80, and 85 years, respectively. The use of androgen receptor pathway inhibitors (ARPIs) had no definitive age limits for 46.5% of respondents. For patients with no comorbidities and low-volume metastatic PCa, the preferred option was androgen deprivation therapy + ARPIs + RT. The follow-up schedule after RP or RT exhibited heterogeneity with no consensus regarding the frequency of PSA testing or the age at which it should be discontinued. Conclusions: This survey highlights the need for consensus guidelines in diagnosing and managing mild-old and oldest-old elderly PCa patients. With the aging population, standardized protocols are essential to ensure optimal care.

Keywords: PCa; aging population; elderly; old; prostate cancer; survey.

Figure 1

Differences among responders. DRE = digital rectal examination; PSA = prostate-specific antigen; MRI = magnetic resonance imaging; PET/CT = positron emission tomography/computer tomography; PCa = prostate cancer. (a) Frequency of digital rectal examination (DRE) during clinical visits in patients aged ≥75 years. (b) Attitude toward prostate-specific antigen (PSA) testing in patients ≥ 75 years old who have never been tested before. (c) Criteria and timing for stopping PSA testing in patients ≥ 75 years old. (d) Age limit to perform prostate biopsy. (e) Age limit to consider patients for prostate magnetic resonance imaging (MRI). (f) Age limit to consider PET/CT for staging prostate cancer (PCa) in older patients.

Figure 2

Differences among responders; PCa = prostate cancer; PSA = prostate-specific antigen; RP = radical prostatectomy; RT = radiotherapy; ADT = androgen deprivation therapy. (a) Suggested upper age limits for considering radical prostatectomy as a treatment option for the primary tumor. (b) Suggested upper age limits for considering radiotherapy as a treatment option for the primary tumor. (c) Suggested upper age limits for considering chemotherapy as a treatment option. (d) Attitudes toward age thresholds for treatment intensification with androgen receptor pathway inhibitors (ARPIs). (e) Preferred treatment strategies in patients with no comorbidities and low-volume metastatic PCa, stratified by age groups. (f) Opinions on whether PSA testing should be continued in men aged ≥75 years with undetectable PSA more than 10 years after radical prostatectomy.