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Most men diagnosed with prostate cancer are older than 65. In clinical trials, however, the participants tend to be younger and more fit than real-world patients, noted authors of a review in the .

"Therefore, despite the incidence of prostate cancer peaking in older age, it is not known whether older men derive the same benefit from the treatment strategies used in younger men," said Alicia Morgans, MD, MPH of Dana-Farber Cancer Institute and Harvard Medical School in Boston, and co-authors.

Given this, geriatric assessments to determine a patient's frailty or fitness and inform treatment decisions are important in prostate cancer patients older than 65. These assessments can help avoid overtreating frailer men or undertreating fitter ones, the authors explained.

In their review, the team covered evidence-based risk-assessment tools for older men with prostate cancer as well as intervention strategies to improve treatment tolerance.

In the following interview, Morgans, medical director of the Survivorship Program, discussed some of these tools and strategies.

Life-expectancy calculators are important for older men with prostate cancer. Can you tell us about one of the available life-expectancy calculators that may be useful?

Morgans: Many life-expectancy calculators are available online to help physicians determine how long their patient may live, with the newer ones incorporating specific comorbidities and detail to try to improve precision of the estimate. The from the University of California, San Francisco, is one such calculator that incorporates important patient characteristics, such as age, comorbidities, and lifestyle and health characteristics into the calculation.

The most important thing for clinicians is to find a calculator that is comfortable for their practice and patient population, and use it consistently when seeing older adults.

For geriatric assessment, you highlight the Geriatric 8 and the Mini-Cog as useful validated tools. Can you briefly describe these?

Morgans: The Geriatric 8, or G8, is an eight-question survey instrument that assesses nutrition, weight loss, mobility, neuropsychiatric symptoms, polypharmacy, and overall health status. The scale ranges from 0 to 17, and patients who score less than 14 are identified as potentially being frail and at risk for shorter life expectancy.

The Mini-Cog is a screening tool for cognitive impairment that includes a three-question word recall and clock drawing exercise. Scores range from 0 to 5, with a score of 3 or less identifying patients who need a more in-depth neurologic assessment for dementia. Importantly, both of these are tools that have been recommended for use in older prostate cancer populations, and they can be administered relatively quickly and easily with minimal training.

What tools are available to help identify older patients at increased risk for chemotherapy toxicity?

Morgans: The Cancer and Aging Research Group (CARG) toxicity tool was specifically designed to identify patients who may be at higher risk of experiencing chemotherapy toxicity. This 11-item tool can be administered over 5 minutes and is available free on the . The chemotherapy risk-assessment scale for high-age patients (also known as the CRASH tool) is also available for .

A growing body of evidence suggests that frailty assessments may improve mortality when used to guide intraoperative care. Can you briefly tell us about one of these studies and what it found?

Morgans: One thought-provoking evaluated over 9,000 patients using a preoperative frailty-risk assessment. If patients had a heightened Risk Analysis Index score of 21 or higher that was confirmed by physician assessment, a multidisciplinary team was notified to review plans and have additional shared decisions regarding whether to proceed with surgery or not, or change the surgical or anesthesia plan. This reduced 30-day, 6-month, and 1-year mortality.

One intervention strategy to address frailty perioperatively is prehabilitation. What does this entail?

Morgans: Prehabilitation has been studied in several settings in GU oncology, and it involves trying to enhance patient nutrition and physical function before surgery. Because we routinely have weeks of time between diagnosis and surgery for prostate cancer, this can be a time when patients can emphasize these kinds of routines that include physical therapy for overall function, pelvic floor physical therapy, and nutritional support.

Although these strategies make sense on face value, ongoing investigation is needed to demonstrate effectiveness and enable these programs to become more widespread.

Read the review here and expert commentary about it here.