- Email: [email protected]
Prostate Cancer Management in an Ageing Population
EURURO-7341; No. of Pages 2 EUROPEAN UROLOGY XXX (2017) XXX–XXX
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Opinion
Prostate Cancer Management in an Ageing Population Jeremy P. Grummet a,*, Karin Plass b, James N’Dow c,d a
Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia;
b
European Association of Urology, Guidelines Office, Arnhem,
The Netherlands; c Academic Urology Unit, University of Aberdeen, Aberdeen, UK; d Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
We are all aware of the world’s ageing population, a trend that is set to continue for decades ahead. The United Nations 2015 revision of their World Population Prospects report predicts that ‘‘globally, the number of persons aged 80 or over is projected to increase from 125 million in 2015 to 434 million in 2050’’ [1], representing a more than threefold increase. The number of people aged 65 yr in the European Union is expected to grow from approximately 84 million in 2008 to 141 million by 2050 [2]. We are also well aware that prostate cancer is a disease for which incidence increases with age. This combination means that prostate cancer among older men will represent an ever-increasing massive disease burden. It is therefore critical that the issue of how to manage prostate cancer in older men is properly addressed. Many fit and healthy older men are at risk of undertreatment because of an underestimation of their longevity, but others are equally at risk of overtreatment when comorbidities that predict a greater health risk than their prostate cancer are not taken into account. In this issue of European Urology, Droz et al [3] present a clinically practical update on the International Society of Geriatric Oncology (SIOG) guidelines for prostate cancer in men aged >70 yr. Previous SIOG guidelines on prostate cancer management for older men have been endorsed by the European Association of Urology (EAU) [4] and are incorporated in Section 6.7 of the EAU prostate cancer guidelines, which are freely available online. Perhaps the most important addition to these updated guidelines is the recommendation for cognitive function screening in this age group via the mini-COG test. This screening test is similar in diagnostic performance to the Mini Mental State Examination (MMSE) but is far less timeconsuming. Patients scoring <3 out of 5 require referral for a full assessment for dementia.
The updated guidelines also provide practical tools for evaluation of overall health status that could be realistically performed in the clinic. Like the mini-COG test, G8 screening takes just 5 min to conduct, and for the G8 test a score of <15 out of 17 is considered abnormal. The G8 screening test has the dual purpose of determining if referral for a comprehensive geriatric assessment (CGA) is needed to identify possible reversible conditions, and of subsequently helping to choose the most appropriate management of the patient’s prostate cancer. Both the G8 and mini-COG tests are provided for use in the article. Notwithstanding the immense clinical utility of these recommendations, it should be remembered that they are based on informal expert consensus only, underpinned by a traditional narrative review of the evidence rather than a formal, robust, systematic review. Furthermore, the authors make clear that there are large gaps in knowledge in this area. Examples cited include validation of G8 screening in this patient population and nomograms to predict outcomes when using health status assessment tools. However, it is notable that little mention is made of focal therapy for localised disease. Perhaps the older age group, for which trade-offs between cancer morbidity and treatment morbidity are arguably even tighter than for younger patients, would be ideally suited for further study of the role of focal therapy in their management care pathway. In our exponentially ageing population, the field of prostate cancer management among older men is ripe for vigorous prospective clinical research. Until these research questions are answered, the updated guidelines should serve as a timely and highly practical clinical tool. As part of their strategy to address appropriate health care provision to the growing elderly population, the European Union adopted a communication in 2012 [5,6] for which funding was provided through European
* Corresponding author. Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia. Tel. +61 293 628644; Fax: +61 293 621433. E-mail address: [email protected] (J.P. Grummet). http://dx.doi.org/10.1016/j.eururo.2017.04.010 0302-2838/# 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Grummet JP, et al. Prostate Cancer Management in an Ageing Population. Eur Urol (2017), http:// dx.doi.org/10.1016/j.eururo.2017.04.010
EURURO-7341; No. of Pages 2 2
EUROPEAN UROLOGY XXX (2017) XXX–XXX
Commission funding programmes (initially FP7, and continued through Horizons2020). Innovative trial models involving all relevant stakeholders, including patients and industry, addressing the inclusion of patients with multiple morbidities are under development [7]. Conflicts of interest: The authors have nothing to disclose.
International Society of Geriatric Oncology. Eur Urol. In press. http://dx.doi.org/10.1016/j.eururo.2016.12.025. [4] Mottet N, Bellmunt J, Bolla M, et al. EAU-ESTRO-SIOG guidelines on prostate cancer. part 1: screening, diagnosis, and local treatment with curative intent. Eur Urol 2017;71:618–29. [5] European Commission. Taking forward the strategic implementation plan of the European Innovation Partnership on Active and Healthy Ageing. Communication from the Commission to the
References [1] UN Population Division. World population prospects: the 2015 revision. United Nations; 2015. https://esa.un.org/unpd/wpp/ [2] EUROSTAT. Statistics in focus. March 1999. http://ec.europa.eu/ eurostat/documents/3433488/5278217/CA-DN-99-004-EN.PDF/ 0f91fe65-e0ce-4948-8c2f-7d8ad48c9f64. [3] Droz J-P, Albrand G, Gillessen S, et al. Management of prostate cancer in elderly patients: recommendations of a task force of the
European Parliament and the Council. Brussels, Belgium: European Commission; 2012. p. 16. [6] European Commission. Growing the European silver economy. http://ec.europa.eu/research/innovation-union/pdf/activehealthy-ageing/silvereco.pdf. [7] Committee for Medicinal Products for Human Use. Points to consider on frailty: evaluation instruments for baseline characterisation of clinical trial populations. London, UK: European Medicines Agency; 2015. p. 18.
Please cite this article in press as: Grummet JP, et al. Prostate Cancer Management in an Ageing Population. Eur Urol (2017), http:// dx.doi.org/10.1016/j.eururo.2017.04.010
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Opinion
Prostate Cancer Management in an Ageing Population Jeremy P. Grummet a,*, Karin Plass b, James N’Dow c,d a
Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia;
b
European Association of Urology, Guidelines Office, Arnhem,
The Netherlands; c Academic Urology Unit, University of Aberdeen, Aberdeen, UK; d Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
We are all aware of the world’s ageing population, a trend that is set to continue for decades ahead. The United Nations 2015 revision of their World Population Prospects report predicts that ‘‘globally, the number of persons aged 80 or over is projected to increase from 125 million in 2015 to 434 million in 2050’’ [1], representing a more than threefold increase. The number of people aged 65 yr in the European Union is expected to grow from approximately 84 million in 2008 to 141 million by 2050 [2]. We are also well aware that prostate cancer is a disease for which incidence increases with age. This combination means that prostate cancer among older men will represent an ever-increasing massive disease burden. It is therefore critical that the issue of how to manage prostate cancer in older men is properly addressed. Many fit and healthy older men are at risk of undertreatment because of an underestimation of their longevity, but others are equally at risk of overtreatment when comorbidities that predict a greater health risk than their prostate cancer are not taken into account. In this issue of European Urology, Droz et al [3] present a clinically practical update on the International Society of Geriatric Oncology (SIOG) guidelines for prostate cancer in men aged >70 yr. Previous SIOG guidelines on prostate cancer management for older men have been endorsed by the European Association of Urology (EAU) [4] and are incorporated in Section 6.7 of the EAU prostate cancer guidelines, which are freely available online. Perhaps the most important addition to these updated guidelines is the recommendation for cognitive function screening in this age group via the mini-COG test. This screening test is similar in diagnostic performance to the Mini Mental State Examination (MMSE) but is far less timeconsuming. Patients scoring <3 out of 5 require referral for a full assessment for dementia.
The updated guidelines also provide practical tools for evaluation of overall health status that could be realistically performed in the clinic. Like the mini-COG test, G8 screening takes just 5 min to conduct, and for the G8 test a score of <15 out of 17 is considered abnormal. The G8 screening test has the dual purpose of determining if referral for a comprehensive geriatric assessment (CGA) is needed to identify possible reversible conditions, and of subsequently helping to choose the most appropriate management of the patient’s prostate cancer. Both the G8 and mini-COG tests are provided for use in the article. Notwithstanding the immense clinical utility of these recommendations, it should be remembered that they are based on informal expert consensus only, underpinned by a traditional narrative review of the evidence rather than a formal, robust, systematic review. Furthermore, the authors make clear that there are large gaps in knowledge in this area. Examples cited include validation of G8 screening in this patient population and nomograms to predict outcomes when using health status assessment tools. However, it is notable that little mention is made of focal therapy for localised disease. Perhaps the older age group, for which trade-offs between cancer morbidity and treatment morbidity are arguably even tighter than for younger patients, would be ideally suited for further study of the role of focal therapy in their management care pathway. In our exponentially ageing population, the field of prostate cancer management among older men is ripe for vigorous prospective clinical research. Until these research questions are answered, the updated guidelines should serve as a timely and highly practical clinical tool. As part of their strategy to address appropriate health care provision to the growing elderly population, the European Union adopted a communication in 2012 [5,6] for which funding was provided through European
* Corresponding author. Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia. Tel. +61 293 628644; Fax: +61 293 621433. E-mail address: [email protected] (J.P. Grummet). http://dx.doi.org/10.1016/j.eururo.2017.04.010 0302-2838/# 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Grummet JP, et al. Prostate Cancer Management in an Ageing Population. Eur Urol (2017), http:// dx.doi.org/10.1016/j.eururo.2017.04.010
EURURO-7341; No. of Pages 2 2
EUROPEAN UROLOGY XXX (2017) XXX–XXX
Commission funding programmes (initially FP7, and continued through Horizons2020). Innovative trial models involving all relevant stakeholders, including patients and industry, addressing the inclusion of patients with multiple morbidities are under development [7]. Conflicts of interest: The authors have nothing to disclose.
International Society of Geriatric Oncology. Eur Urol. In press. http://dx.doi.org/10.1016/j.eururo.2016.12.025. [4] Mottet N, Bellmunt J, Bolla M, et al. EAU-ESTRO-SIOG guidelines on prostate cancer. part 1: screening, diagnosis, and local treatment with curative intent. Eur Urol 2017;71:618–29. [5] European Commission. Taking forward the strategic implementation plan of the European Innovation Partnership on Active and Healthy Ageing. Communication from the Commission to the
References [1] UN Population Division. World population prospects: the 2015 revision. United Nations; 2015. https://esa.un.org/unpd/wpp/ [2] EUROSTAT. Statistics in focus. March 1999. http://ec.europa.eu/ eurostat/documents/3433488/5278217/CA-DN-99-004-EN.PDF/ 0f91fe65-e0ce-4948-8c2f-7d8ad48c9f64. [3] Droz J-P, Albrand G, Gillessen S, et al. Management of prostate cancer in elderly patients: recommendations of a task force of the
European Parliament and the Council. Brussels, Belgium: European Commission; 2012. p. 16. [6] European Commission. Growing the European silver economy. http://ec.europa.eu/research/innovation-union/pdf/activehealthy-ageing/silvereco.pdf. [7] Committee for Medicinal Products for Human Use. Points to consider on frailty: evaluation instruments for baseline characterisation of clinical trial populations. London, UK: European Medicines Agency; 2015. p. 18.
Please cite this article in press as: Grummet JP, et al. Prostate Cancer Management in an Ageing Population. Eur Urol (2017), http:// dx.doi.org/10.1016/j.eururo.2017.04.010