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Implications for Senior Adults

with Prostate Cancer in Daily

Practice

Arti Hurria

Duarte, CA, USA

Material for Healthcare Professionals only

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Implications of

CHAARTED, STAMPEDE and RTOG-0521 trials

in daily practice

Droz JP et al. Lancet Oncol 2014;15:e404-14

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SIOG recommendations for

older adults with PCa

• Treatment recommendations for older men with PCa

should be based on:

Droz JP et al. Crit Rev Oncol Hematol 2010;73:68-91; Droz JP et al. BJU Int 2010;106:462-9;

Droz JP et al. Lancet Oncol 2014;15:e404-14

Health status (mainly driven by comorbidities)

Patient preferences

NOT chronological age

AND

“These care decisions should be made while taking into

account patient preference”

PCa: prostate cancer

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Key components for decision making

1. Capacity for decision making

2. Understand the treatment benefits

3. Understand the treatment risks

Making cancer treatment decisions in the context of the

patient’s goals, values, and preferences

Involvement of the multidisciplinary team

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Four components to assess capacity:

1. Understands the relevant information

2. Appreciates their situation

3. Uses reason to make a decision

4. Communicates their choice

Does the patient have decision making

capacity?

Sessums LL et al. JAMA 2011;306:420-7

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Benefits of treatment: CHAARTED trial

• Key considerations:

– Median age: 63 yr (SD not given)

• Oldest patient: 91 yr

• Pre-specified sub-group analysis: age 70+ benefit

– Patient characteristics

• ECOG 0-2 (almost 70% ECOG 0)

• No geriatric assessment data

– Benefit most in high-volume disease

• Visceral metastases

• 4+ bone lesions; ≥1 beyond vertebral body and pelvis

Sweeney C et al. N Engl J Med 2015;373:737-46

Randomized phase III trial in metastatic hormone-naïve PCa

Addition of docetaxel to ADT ���� Improvement of 13.6 months

Median OS: 57.6 vs 44 months

ADT: androgen deprivation therapy; ECOG: Eastern Cooperative Oncology Group;

SD: standard deviation; OS: overall survival

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Benefits of treatment: STAMPEDE trial

• Key considerations:

– Median age: 65 yr (SD not given)

• Oldest patient: 84 yr

– Patient characteristics

• “Fit for therapy:” WHO 0-2– 78% WHO 0

– Only 1% WHO 2

• No geriatric assessment data

James ND et al. J Clin Oncol 2015;33(15S): abstract 5001 (podium presentation ASCO 2015)

Randomized phase III trial in hormone-naïve PCa (M0/M1)

Addition of docetaxel to ADT ���� Improvement of 10 months

Median OS (M0/M1): 77 vs 67 months

Median OS (M1): 65 vs 43 months

WHO: World Health Organization

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Benefits of treatment: RTOG-0521 trial

• Key considerations:

– Median age: 66 yr

• SD and range not given

– High-risk disease:

• 53% Gleason 9-10

• 27% cT3-4

Sandler H et al. J Clin Oncol 2015;33(15S): abstract LBA5002

Randomized phase III trial in high-risk localized PCa

Addition of docetaxel to RT and ADT

4 year OS: 93% vs 89% (favoring chemotherapy arm)

RT: radiation therapy

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Risks of treatment

CHAARTED1: 29.6% ≥ grade 3 toxicity

– 1% grade 3 motor/sensory neuropathy

– 4% grade 3 fatigue

– 6% grade 3-4 febrile neutropenia

– 2.3% grade 3-4 infection with neutropenia

STAMPEDE²: 51% ≥ grade 3 toxicity

– 12% grade 3 febrile neutropenia

– No data on fatigue and neuropathy

RTOG-0521³: 65% ≥ grade 3 toxicity

1. Sweeney C et al. N Engl J Med 2015;373:737-46; 2. James ND et al. J Clin Oncol 2015;33(15S): abstract 5001 (podium

presentation ASCO 2015); 3. Sandler H et al. J Clin Oncol 2015;33(15S): abstract LBA5002

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Who will benefit?

Estimating life expectancy

Walter LC. JAMA 2014;311:1336-47 (eAppendix 3) - Calculation from US 2010 Life Tables 10

20

16

12

9

64

15

11

8

54

3

9

64

32

1

0

5

10

15

20

25

70 year 75 year 80 year 85 year 90 year 95 year

Life

ex

pe

cta

ncy

(y

ea

rs)

Top 25th percentile (FIT seniors)

50th percentile (MEDIAN life expectancy)

Lowest 25th percentile (FRAIL seniors)

Age

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www.eprognosis.org

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ONCODAGE – G8

• Cut-off: abnormal if ≤14

• Sensitivity: 76.6%

• Specificity: 64.4%

• Reproducibility: kappa:

0.65

• Duration of the test:

4.4 minutes

Bellera CA et al. Ann Oncol 2012;23:2166-72; Kenis C et al. J Clin Oncol 2014;32:19-26

http://espacecancer.sante-ra.fr/oncogeriatrie/default.aspx (access Nov 4 2015)

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ONCODAGE – G8 impact on OS

Kenis C et al. J Clin Oncol 2014;32:19-26

Ove

rall

surv

iva

l (p

rob

ab

ility

)

Time (months)

No. at risk

Normal 240 219 202 177 126 67 22

Abnormal 697 517 420 324 208 104 23

1.0

0.8

0.6

0.4

0.2

0 10 20 30 40

Normal

Abnormal

Log-rank P < .001

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Droz JP et al. Lancet Oncol 2014;15:e404-1414

>14

No geriatric

assessment

requested

≤14

Geriatric

assessment

requested

G8 Screening

VULNERABLE FRAILFIT

GERIATRIC INTERVENTIONS

Not reversibleReversible

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Principles of the 2014 guideline

Droz JP et al. Lancet Oncol 2014;15:e404-14 15

Health status evaluation

Geriatric intervention

Standard treatment

as for younger

patients

Standard treatment

as for younger patients

Symptomatic

management including

adapted specific

treatments

Only palliative

treatment

Group 1

(Healthy)

Group 2

(Vulnerable, i.e.

reversible problem

Group 3

(Frail, i.e. non

reversible problem)

Group 4

(Terminal illness)

Geriatric screening with G8 tool

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CRASH score

Extermann M et al. Cancer 2012;118:3377-86

ResultsDescription Score Risk

Heme score 4 Med high

Non heme score 3 Med low

Combined score 6 Med low

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CARG toxicity calculator

Hurria A et al. J Clin Oncol 2011;29:4217-8

http://www.mycarg.org/Chemo_Toxicity_Calculator (access Nov 4 2015)

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Placing decision in the context of

the patient’s goals, values, and preferences

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Functional status

Comorbidities

Finances

Age

Individual’s

treatment decision

Cancer stage

Psychological status

Cancer therapeutics

Organ function

Cognition

Spirituality

Polypharmacy

Social support

Culture Literacy

Key factors contributing to decision

making

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Knowledge gaps:

Opportunities for geriatric oncology

1. Geriatric assessment data needed to weigh the risk and

benefits

• Functional vs chronological age

2. Additional outcomes of relevance:

• Impact of therapy on function

3. Additional data regarding toxicities (including grade 2)

• Neuropathy, fatigue

4. Tolerance of therapy in age 75+

5. Treatment of individuals who did not meet eligibility for

these studies (i.e. vast majority had PS 0)

6. Geriatric assessment guided interventions to improve

treatment tolerancePS: Performance status

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Geriatrics OncologyGeriatric oncology

Thank you!SA

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Evaluation form

• Please fill in the evaluation form and hand it over to

the staff as you leave the room

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?

?

?

QuestionsSA

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