What is the recommended treatment for an 83-year-old man with metastatic prostate cancer?

Treatment Recommendations for an 83-year-old Man with Metastatic Prostate Cancer

For an 83-year-old man with metastatic prostate cancer, continuous androgen deprivation therapy (ADT) is the recommended first-line treatment, with additional therapy options determined by symptom burden, disease extent, and patient fitness. 1

Initial Treatment Approach

First-Line Therapy

• Continuous ADT should be maintained indefinitely as the backbone of treatment 1
• Treatment decisions should be based on performance status and overall health, not age alone 2

Treatment Intensification Options

For patients who are fit enough for additional therapy:

1. For hormone-naïve disease:

   • ADT plus docetaxel (75 mg/m² every 3 weeks) is recommended for patients fit enough for chemotherapy 1, 3
   • ADT plus an androgen receptor pathway inhibitor (abiraterone or enzalutamide) is an alternative option 4

2. For castration-resistant disease (CRPC):

   • Asymptomatic/mildly symptomatic patients:

     • Abiraterone plus prednisone or enzalutamide is recommended 1
     • Sipuleucel-T may be considered (though benefits are modest) 1

   • Symptomatic patients:

     • Docetaxel plus prednisone is recommended if fit enough 1
     • Radium-223 for bone-predominant disease without visceral metastases 1

Post-Docetaxel Options for CRPC

If disease progresses after docetaxel:

• Abiraterone plus prednisone 1
• Enzalutamide 1
• Cabazitaxel (with discussion of toxicity risks) 1
• Radium-223 (for bone-predominant disease without visceral metastases) 1
• 177Lu-PSMA-617 (for PSMA-expressing mCRPC after both docetaxel and a novel androgen receptor inhibitor) 2

Supportive Care Measures

• Pain management: Single fraction external beam radiation therapy for painful bone metastases 1
• Bone health: Denosumab or zoledronic acid for patients at high risk of skeletal-related events 1
• Regular exercise should be recommended to reduce fatigue and improve quality of life 1
• MRI of spine is recommended for patients with vertebral metastases to detect subclinical cord compression 1

Special Considerations for Elderly Patients

• Docetaxel treatment in elderly patients (≥65 years) is associated with higher rates of anemia (71% vs 59%), infection (37% vs 24%), nail changes (34% vs 23%), anorexia (21% vs 10%), and weight loss (15% vs 5%) compared to younger patients 3
• Avoid docetaxel in patients with liver dysfunction (bilirubin >ULN or AST/ALT >1.5 × ULN with alkaline phosphatase >2.5 × ULN) 3
• Regular monitoring for treatment-specific toxicities is essential 2

Treatment Sequencing

The optimal sequence of therapies is not definitively established 1. Treatment decisions should be guided by:

• Distribution and extent of disease
• Pace of disease progression
• Patient comorbidities
• Previous treatments received
• Patient preferences
• Drug availability

Despite significant advances in treatment options, metastatic prostate cancer remains incurable 5, 6. The goal of therapy is to extend survival while maintaining quality of life.