Choice of treatment tactics in elderly patients with non-metastatic prostate cancer

Objective: to compare the results of approaches used in real clinical practice to the treatment of elderly patients with primary non-metastatic prostate cancer (PCa).

Material: a retrospective study based on the EMIAS database included medical information on patients aged 75 years and older with verified non-metastatic PCa who were under observation at the Central Administrative District Clinical Hospital of the Moscow Health Department from July 31, 2000 to January 18, 2024. Patients were included in the study if there was available information on concomitant diseases, the prevalence of the tumor process, treatment tactics, the chronology of the course and outcome of PCa, the date of the last observation or death, as well as the cause of death if it was registered.

Results: The data of 401 patients aged ≥ 75 years with verified non-metastatic prostate cancer were included. The median age was 84.0 (75.0–99.0) years. The median Charlson comorbidity index was 7 (4–12). The median baseline prostate-specific antigen (PSA) level was 12.0 (0.3–182.1) ng / ml. All patients had verified prostate adenocarcinoma (ISUP grade 4–5–87 (21.7 %)). The cT category was assessed as cT3–4 in 91 (22.7 %), the cN1 category was diagnosed in 22 (5.5 %) patients. Patients were classified into intermediate unfavorable, high and very high risk groups in 235 (58.6 %) cases. In 113 (28.2 %) cases, radical treatment was performed (external beam radiotherapy (EBRT) — 113 (28.2 %), radical prostatectomy — 37 (9.2 %), brachytherapy — 14 (3.5 %), ablation — 2 (0.5 %)), in 202 (50.4 %) cases — immediate antitumor therapy, 33 (8.2 %) patients received deferred treatment within the framework of active observation (10 (2.5 %)) or expectant tactics (23 (5.7 %)). The deferred treatment group was incomparable with the immediate radical and drug treatment groups in sample size and had a smaller proportion of patients in the intermediate unfavorable, high and very high risk groups (p < 0.05 for all). For other characteristics, the treatment groups were balanced. The median follow-up for all patients was 54.1 (1.1–275.7) months. In the entire study population, 4-year overall survival (OS) was 95.0 %, specific survival (SS) was 99.4 %, and cardiospecific survival (CSS) was 95.3 %; relapse-free survival (RFS) of radically treated patients was 74.4 %, progression-free survival (PFS) with first-line systemic therapy was 78.3 %, and PFS in patients who did not receive immediate treatment was 46.6 %. No effect of treatment approach was found on OS and CSS in the entire patient population, including those adjusted for risk group (p > 0.05 for all). A decrease in 4-year DFS was noted in the deferred treatment group compared with the radical treatment group (83.1 % vs. 95.2 %, p = 0.036) due to the subgroup with the Charlson comorbidity index ≥ 8 (72.5 % vs. 94.8 %, p = 0.060). RFS in operated patients was lower than in irradiated patients (p = 0.032), which did not affect the DFS and OS indicators (p > 0.05 for all). In the watchful waiting subgroup, DFS was lower than in patients under active surveillance (p = 0.015), but DFS and OS in these cohorts were similar.

Conclusion: in elderly patients with non-metastatic prostate cancer, immediate radical and drug treatment does not lead to an increase in SV and OS compared with delayed treatment.

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