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Although prostate cancer predominantly affects older men, clinical trial cohorts are disproportionately younger and more fit than the real-world patients typically seen in clinical practice. Therefore, it is unknown whether the optimal approach to prostate cancer management is the same for older men as it is for those who are younger and have better performance status. In a review in the , Graham and colleagues outline contemporary evidence-based risk-assessment and decision tools for older men with prostate cancer, as well as proposing strategies to improve treatment tolerance.

In addition to cancer-based assessment prognosis, the initial step is to develop a tailored approach to assess a patient's overall health status to align treatment recommendations mostly appropriately with each patient's goals and ability to tolerate treatment. Traditional performance assessments such as the ECOG performance status or Karnofsky performance status are inadequate in an older population.

It is recommended that all men diagnosed with prostate cancer age ≥75 years should have non-cancer-related life expectancy assessed using instruments such as the Social Security Administration life table, Lee Index, Schonberg Index, or . A Geriatric Assessment (GA) refers to assessing domains where older patients frequently have needs to characterize overall health status.

Several shorter screening tools are available that can be used to screen patients for those most likely to benefit from a comprehensive GA. These can be performed easily in the clinic and include the Geriatric-8 screening tool (4-5 minutes) or the Vulnerable Elders Survey-13 (4-5 minutes).

In addition, there are numerous assessments for identifying and reducing frailty in patients contemplating radical prostatectomy (i.e., Risk Analysis Index Score), androgen-deprivation therapy (ADT), particularly in relation to bone health management (e.g., FRAX calculator and DEXA scan on commencing ADT) as well as estimating chemotherapy toxicity (CARG toxicity, CRASH tool).

Older adults diagnosed with prostate cancer have many integrated domains that require consideration or intervention when contemplating treatment. The use of non-cancer-related life expectancy, in addition to geriatric screening assessment tools can improve prognostication and tailoring of care to avoid both undertreatment as well as excess toxicity.

Finally, careful assessment of financial toxicity, social determinants of health, and barriers to care because of the potential vulnerability in older age also need to be considered.

Peter E. Lonergan, MD, FRCS (Urol.) is a consultant urologist for the Department of Urology, St. James's Hospital; and clinical senior lecturer at Trinity College in Dublin, Ireland.

Read the review here and an interview about it here.