Treatment of Prostate Cancer in Elderly Males

Initial Health Status Assessment

The European Society for Medical Oncology recommends that treatment decisions for elderly men with prostate cancer be based on health status and disease risk stratification rather than chronological age alone, with fit elderly patients receiving the same aggressive treatment as younger patients for intermediate- and high-risk disease 1
The National Comprehensive Cancer Network recommends estimating life expectancy using validated tools that account for health quartile, not just age—a 65-year-old in the healthiest quartile has a 24-year life expectancy versus 8 years in the unhealthiest quartile 2
The American Urological Association recommends avoiding PSA testing in asymptomatic men over age 70 years 1, 3

The European Association of Urology classifies disease as low, intermediate, or high risk based on PSA, Gleason score, and clinical stage 1, 4
The American Urological Association defines low risk as PSA ≤10 ng/mL AND Gleason ≤6 AND stage T1c-T2a 5
The European Association of Urology defines intermediate risk as PSA 10-20 ng/mL OR Gleason 7 OR stage T2b (but not meeting high-risk criteria) 5
The National Comprehensive Cancer Network defines high risk as PSA >20 ng/mL OR Gleason 8-10 OR stage ≥T2c 5

The European Society for Medical Oncology recommends active surveillance as the preferred option for fit elderly men with low-risk disease, involving close monitoring with PSA, repeat biopsies, and/or MRI, reserving curative treatment for progression 1, 4
The American Urological Association recommends watchful waiting with delayed hormone therapy for men with severe comorbidities or limited life expectancy who are unsuitable for curative treatment 1, 4
The National Comprehensive Cancer Network recommends avoiding radical treatment in low-risk disease when life expectancy is limited, as only 13% develop metastases at 15 years and 11% die from prostate cancer 6
The European Association of Urology recommends external beam radiotherapy (EBRT) plus androgen deprivation therapy (ADT) for 24-36 months for high-risk disease 7, 1, 4
The American Society of Clinical Oncology recommends neoadjuvant and concurrent ADT for 4-6 months for intermediate-risk disease receiving radical radiotherapy 1, 4
The European Society for Medical Oncology recommends radical prostatectomy plus pelvic lymphadenectomy as an alternative for high-risk disease in fit elderly patients 1, 4

The National Comprehensive Cancer Network recommends bone health monitoring due to increased fracture risk in elderly patients receiving ADT 7
The American Urological Association recommends denosumab (60 mg subcutaneously every 6 months), zoledronic acid (5 mg intravenously annually), or alendronate (70 mg orally weekly) for patients with high fracture risk 2
The European Association of Urology recommends screening for and intervening to prevent/treat diabetes and cardiovascular disease in men receiving ADT 2

The European Society for Medical Oncology recommends PSA measurement every 3 months during year 1, then every 6 months, with digital rectal examination at follow-up visits 7
The American Urological Association recommends bone scan and imaging if PSA rises or symptoms develop 7
The National Comprehensive Cancer Network recommends salvage radiotherapy to the prostate bed for PSA failure after radical prostatectomy, starting early (PSA <0.5 ng/mL) 1, 4