Understanding the incidence, duration, and severity of symptoms through daily symptom monitoring among frail and non-frail older patients receiving metastatic prostate cancer treatments

INTRODUCTION

Older adults with metastatic prostate cancer (mPC) experience high symptom burden associated with treatment. Frailty may exacerbate treatment toxicity. The aim of this study was to explore short-term treatment toxicity in patients with metastatic prostate cancer.

MATERIALS AND METHODS

Older adults with metastatic prostate cancer starting chemotherapy, androgen-receptor-axis targeted therapies, or radium-223 participated in a prospective, multicentre, observational study. Participants self-reported symptoms daily using the Edmonton Symptom Assessment System for one treatment cycle via internet or telephone. The most common moderate-to-severe symptoms (score≥4), their duration, and the proportion of participants who experienced improvements in symptom severity (score<4) after reporting moderate-to-severe symptoms at baseline were determined using descriptive statistics. Once-weekly symptom questionnaires were administered and analyzed using linear mixed effect models. Symptom incidence, duration, and frailty associations were assessed using t-tests and chi-square tests.

RESULTS

Ninety participants completed the study (mean age=77 years [standard deviation=6.1], 42% frail [Vulnerable Elders Survey≥3]). The most common moderate-to-severe symptoms across cohorts were fatigue (46.8%), insomnia (42.9%), poor wellbeing (41.2%), pain (37.5%), and decreased appetite (37.1%). Poor wellbeing had a higher incidence in frail participants (62.5% in frail vs. 31.4% in non-frail, p=0.039). Symptom duration varied across cohorts and between frail and non-frail participants. Among participants who reported moderate-to-severe symptoms at baseline, no more than 15% improved in any symptom. There were statistically significant improvements in weekly symptoms for fatigue, decreased appetite, and insomnia in the chemotherapy cohort only.

DISCUSSION

Limitations include a short follow-up duration, lack of a control group, and few radium-223 participants. Regular symptom monitoring can help clinicians understand temporal patterns and durations of symptoms and inform supportive care approaches.

Validity of a self-administered G8 screening test for older patients with cancer

INTRODUCTION

The Geriatric 8 (G8) is a brief cancer-specific tool which screens for patients who require a comprehensive geriatric assessment (CGA). The G8 test assesses patients on eight domains such as mobility, polypharmacy, age, and self-rated health. However, the current G8 requires a healthcare professional (nurse or physician) present to conduct the test, which limits its usefulness. The Self-G8 questionnaire (S-G8) is an adaptation of the original G8 test, assessing all the same domains, with questions modified to be appropriate for patients to self-complete. Our objective was to evaluate the performance of S-G8 compared to the G8 and CGA.

MATERIALS AND METHODS

The initial S-G8 was designed by our team through review of the literature and questionnaire design principles, and was optimized through feedback from patients over the age of 70. The questionnaire subsequently underwent further refinement after undergoing pilot testing (N = 14). The diagnostic accuracy of the final iteration of the S-G8 was evaluated along with the standard G8 in a prospective cohort study (N = 52) in an academic geriatric oncology clinic at the Princess Margaret Cancer Centre, Toronto, Canada. Psychometric characteristics were evaluated including internal consistency, sensitivity, and specificity compared to the G8 and to the CGA.

RESULTS

There was strong correlation between the G8 and S-G8 scores, with a Spearman correlation co-efficient of 0.76 (p < 0.001). Internal consistency was acceptable at 0.60. The frequency of abnormality (<14 score) for the G8 and S-G8 was 82.7% and 61.5%, respectively. The mean score for the original G8 and S-G8 was 11.9 and 13.5, respectively. The cut-off of 14 for the S-G8 yielded the best combination of sensitivity of 0.70 ± 0.07 and specificity of 0.78 ± 0.14 when compared to the G8. When compared to two or more abnormal domains on the CGA, the S-G8 performed at least as well as the G8 with a sensitivity of 0.77, specificity of 0.85, and a Youden's index of 0.62.

DISCUSSION

The S-G8 questionnaire appears to be an acceptable alternative to the original G8 in identifying older adults with cancer who will benefit from a CGA. Large scale testing is warranted.

Daily physical activity monitoring in older adults with metastatic prostate cancer on active treatment: Feasibility and associations with toxicity

INTRODUCTION

Physical activity may be associated with cancer treatment toxicity, but generalizability to geriatric oncology is unclear. As many older adults have low levels of physical activity and technology use, this area needs further exploration. We evaluated the feasibility of daily step count monitoring and the association between step counts and treatment-emergent symptoms.

MATERIALS AND METHODS

Adults aged 65+ starting treatment (chemotherapy, enzalutamide/abiraterone, or radium-223) for metastatic prostate cancer were enrolled in a prospective cohort study. Participants reported step counts (measured via smartphone) and symptoms (Edmonton Symptom Assessment Scale) daily for one treatment cycle (i.e., 3-4 weeks). Embedded semi-structured interviews were performed upon completion of the study. The feasibility of daily monitoring was evaluated with descriptive statistics and thematic analysis. The predictive validity of a decline in daily steps (compared to pre-treatment baseline) for the emergence of symptoms was examined using sensitivity and positive predictive value (PPV). Associations between a 15% decline in steps and the emergence of moderate (4-6/10) to severe (7-10/10) symptoms and pain in the next 24 h were assessed using logistic regression.

RESULTS

Of 90 participants, 47 engaged in step count monitoring (median age = 75, range = 65-88; 52.2% participation rate). Daily physical activity monitoring was found to be feasible (94% retention rate; 90.5% median response rate) with multiple patient-reported benefits including increased self-awareness and motivation to engage in physical activity. During the first treatment cycle, instances of a 15% decline in steps were common (n = 37, 78.7%), as was the emergence of moderate to severe symptoms overall (n = 40, 85.1%) and pain (n = 26, 55.3%). The predictive validity of a 15% decline in steps on the emergence of moderate to severe symptoms was good (sensitivity = 81.8%, 95% confidence interval [CI] = 68.7-95.0; PPV = 73.0%, 95% CI = 58.7-87.3), although the PPV for pain was poor (sensitivity = 77.8%, 95% CI = 58.6-97.0; PPV = 37.8%, 95% CI = 22.2-53.5). In the regression models, changes in daily physical activity were not associated with symptoms or pain.

DISCUSSION

Changes in physical activity had modest ability to predict moderate to severe symptoms overall. Although participation was suboptimal, daily activity monitoring in older adults with cancer appears feasible and may have other uses such as improving physical activity levels. Further studies are warranted.

Implementation of clinical recommendations from the geriatric oncology clinic

INTRODUCTION

While evidence on the value of routine geriatric assessment (GA) in cancer care for older patients is growing, there is limited data on the geriatric oncology (GO) clinic's specific recommendations and how they are implemented. In this study, we aimed to assess and evaluate the implementation of recommendations from the GO clinic at Princess Margaret Cancer Center, Toronto, Canada, within six months of the initial visit.

MATERIALS AND METHODS

A retrospective chart review was conducted on 100 consecutive adults age 65+ visiting the GO clinic from 2018 to 2019. For each patient, we evaluated the number and type of recommendations from the GO clinic. Recommendations were grouped based on clinical judgement. Of the recorded recommendations, we measured the rate of implementation within six months of the initial visit including who implemented the recommendations and why recommendations were not implemented. Data were analyzed using descriptive statistics.

RESULTS

One hundred patients visiting the GO clinic (mean age of 80.5 years, 62% male, 52% with planned curative intent, with the genitourinary site being most common) received a median of six recommendations (range of 2-12), regardless of sex, cancer stage, cancer site, and treatment intent. Medication optimization (27%), patient education (26%), and referral to allied health (14%) were the top recommendations from the GO clinic. At six-month follow-up, 83% of all recommendations were implemented, of which 94% were performed by the GO clinic team. Patient education was implemented at a 100% rate by the GO clinic at the time of initial assessment. GO follow-up visit and other diagnostic tests (hearing test, vision test) were the recommendations with the lowest implementation rates, at 51% and 31%, respectively. The most common reasons for recommendations not being implemented were patient transfer to palliative care/death and patient declining recommendations due to busy appointment schedules.

DISCUSSION

A median of six recommendations were made per patient. The vast majority of recommendations were implemented, predominantly by the GO team. Overall, the study helps evaluate recommendations provided to patients visiting GO clinics, identify potential gaps, and assist with resource planning for optimal cancer care for older adults.

Applying Quality Indicators to Examine Quality of Care During Active Surveillance in Low-Risk Prostate Cancer: A Population-Based Study

BACKGROUND

Although a few studies have reported wide variations in quality of care in active surveillance (AS), there is a lack of research using validated quality indicators (QIs). The aim of this study was to apply evidence-based QIs to examine the quality of AS care at the population level.

METHODS

QIs were measured using a population-based retrospective cohort of patients with low-risk prostate cancer diagnosed between 2002 and 2014. We developed 20 QIs through a modified Delphi approach with clinicians targeting the quality of AS care at the population level. QIs included structure (n=1), process of care (n=13), and outcome indicators (n=6). Abstracted pathology data were linked to cancer registry and administrative databases in Ontario, Canada. A total of 17 of 20 QIs could be applied based on available information in administrative databases. Variations in QI performance were explored according to patient age, year of diagnosis, and physician volume.

RESULTS

The cohort included 33,454 men with low-risk prostate cancer, with a median age of 65 years (IQR, 59-71 years) and a median prostate-specific antigen level of 6.2 ng/mL. Compliance varied widely for 10 process QIs (range, 36.6%-100.0%, with 6 [60%] QIs >80%). Initial AS uptake was 36.6% and increased over time. Among outcome indicators, significant variations were observed by patient age group (10-year metastasis-free survival was 95.0% for age 65-74 years and 97.5% in age <55 years) and physician average annual AS volume (10-year metastasis-free survival was 94.5% for physicians with 1-2 patients with AS and 95.8% for those with ≥6 patients with AS annually).

CONCLUSIONS

This study establishes a foundation for quality-of-care assessments and monitoring during AS implementation at a population level. Considerable variations appeared with QIs related to process of care by physician volume and Qis related to outcome by patient age group. These findings may represent areas for targeted quality improvement initiatives.

Feasibility and acceptability of remote symptom monitoring (RSM) in older adults during treatment for metastatic prostate cancer

INTRODUCTION

Emerging data support multiple benefits of remote symptom monitoring (RSM) during chemotherapy to improve outcomes. However, these studies have not focused on older adults and do not include treatments beyond chemotherapy. Although chemotherapy, androgen receptor axis-targeted therapies (ARATs), and radium-223 prolong survival, toxicities are substantial and increased in older adults with metastatic prostate cancer (mPC). We aimed to assess RSM feasibility among older adults receiving life-prolonging mPC treatments.

MATERIALS AND METHODS

Older adults aged 65+ starting chemotherapy, an ARAT, or radium-223 for mPC were enrolled in a multicentre prospective cohort study. As part of the RSM package, participants completed the Edmonton Symptom Assessment Scale (ESAS) daily and detailed questionnaires assessing mood, anxiety, fatigue, insomnia, and pain weekly online or by phone throughout one treatment cycle (3-4 weeks). Alerts were sent to the clinical oncology team for severe symptoms (ESAS ≥7). Participants also completed an end of study questionnaire that assessed study burden and satisfaction. Descriptive statistics were used to determine recruitment and retention rates, participant response rates to daily and weekly questionnaires, clinician responses to alerts, and participant satisfaction rates. An inductive descriptive approach was used to categorize open-ended responses about study benefits, challenges, and recommendations into relevant themes.

RESULTS

Ninety males were included (mean age 77 years, 48% ARAT, 38% chemotherapy, and 14% radium-223). Approximately 38% of patients preferred phone-based RSM. Patients provided RSM responses in 1216 out of 1311 daily questionnaires (93%). Over 93% of participants were satisfied (36%), very satisfied (43%), or extremely satisfied (16%) with RSM, although daily reporting was reported by several (8%) as burdensome. Nearly 45% of patients reported severe symptoms during RSM. Most symptom alerts sent to the oncology care team were acknowledged (97%) and 53% led to follow-ups with a nurse or physician for additional care.

DISCUSSION

RSM is feasible and acceptable to older adults with mPC, but accommodation needs to be made for phone-based RSM. The optimal frequency and duration of RSM also needs to be established.

Impact of patients' sex in assessments and treatment recommendations in an older adult cancer clinic

INTRODUCTION

In multiple settings, sex disparities have been seen in diagnosis, treatment, and outcomes. This study sought to determine whether there are sex differences in a geriatric oncology clinic concerning results of the comprehensive geriatric assessment (CGA) and treatment recommendations.

MATERIALS AND METHODS

This is a retrospective cohort study including patients ≥65 years old referred for consultation on cancer treatment decision-making who underwent a CGA between July 2015 and December 2020, in a single Canadian academic geriatric oncology (GO) clinic. We examined differences by sex, stratified by disease site, stage, treatment intent, CGA results by domain, final treatment plan, and referrals for abnormal CGA findings. Differences were assessed using chi-square, Fisher's exact, or t-test as appropriate. Multivariate logistic regression was performed to examine whether sex impacted recommendations to reduce treatment intensity.

RESULTS

In the study period, 328 patients were assessed in the GO clinic (mean age 81 years). The most common cancer types were gastrointestinal (42.1%), hematologic (18.3%), and head and neck (17.3%). More males than females were assessed in the GO clinic (62.2% versus 37.8%, respectively). This proportion did not change over time (p = 0.58). The GO clinic recommended to reduce treatment intensity in 140 cases (42.7%), with no difference between sexes in adjusted models (43.6% of females and 42.2% of males, p = 0.80). There were no differences in any CGA domain by sex. There were also no differences in referrals made by the GO clinic to optimize abnormal CGA domains by sex.

DISCUSSION

Sex itself did not impact treatment decision-making, nor referrals to optimize abnormal CGA domains in our GO clinic using CGA-based care.

Long-term Outcomes Following Active Surveillance of Low-grade Prostate Cancer: A Population-based Study Using a Landmark Approach

PURPOSE

Active surveillance is widely used to manage low-risk prostate cancer, but population-level long-term outcomes are limited. Our objective was to determine long-term population-level oncological outcomes in active surveillance patients. A secondary objective examined the active surveillance discontinuation rate.

MATERIALS AND METHODS

In this retrospective, population-based study using linked administrative databases from Ontario, Canada, we identified low-grade prostate cancer patients managed with active surveillance or initial treatment between 2002-2014. The 10- and 15-year metastasis-free survival, overall survival, and cancer-specific survival were compared between active surveillance and initial treatment. A landmark of 24 months was selected for the primary analysis. Long-term outcomes were examined using multivariable proportional hazards models and a propensity-based approach.

RESULTS

The cohort consisted of 21,282 low-grade prostate cancer patients with a median follow-up of 9.8 years. At 10-year follow-up the survival rate of remaining on active surveillance was 39%, metastasis-free survival was 94.2%, overall survival 88.7%, and cancer-specific survival 98.1%. In adjusted models active surveillance was associated with higher risk of metastasis (HR 1.34, 95%CI 1.15-1.57), overall mortality (HR 1.12, 95%CI 1.01-1.24), and prostate cancer-specific mortality (HR 1.66, 95%CI 1.15-2.39) compared to initial treatment. Survival analysis using 7,525 propensity-matched pairs was consistent with the primary analysis for metastasis-free survival, overall survival and cancer-specific survival.

CONCLUSIONS

In this large population-based study of long-term outcomes in men with low-grade prostate cancer, active surveillance is associated with excellent long-term metastasis-free survival and overall survival. However, long-term cancer-specific survival was slightly inferior (1% worse at 10 years with active surveillance), and this must be balanced against known harms of overtreatment.

The role of frailty in modifying physical function and quality of life over time in older men with metastatic castration-resistant prostate cancer

INTRODUCTION

As treatment options for metastatic castration-resistant prostate cancer (mCRPC) expand and its patient population ages, consideration of frailty is increasingly relevant. Using a novel frailty index (FI) and two common frailty screening tools, we examined quality of life (QoL) and physical function (PF) in frail versus non-frail men receiving treatment for mCRPC.

MATERIALS AND METHODS

Men aged 65+ starting docetaxel chemotherapy, abiraterone, or enzalutamide for mCRPC were enrolled in a multicenter prospective cohort study. QoL, fatigue, pain, and mood were measured with the Functional Assessment of Cancer Therapy-General scale, the Edmonton Symptom Assessment System tiredness and pain subscales, and the Patient Health Questionnaire-9. PF was evaluated with grip strength, four-meter gait speed, five times Sit-to-Stand Test, and instrumental activities of daily living. Frailty was determined using the Vulnerable Elders Survey (VES-13), the Geriatric 8 (G8), and an FI constructed from 36 variables spanning laboratory abnormalities, geriatric syndromes, functional status, social support, as well as emotional, cognitive, and physical deficits. We categorized patients as non-frail (FI ≤ 0.2, VES < 3, G8 > 14), pre-frail (FI > 0.20, ≤0.35), or frail (FI > 0.35, VES ≥ 3, G8 ≤ 14); assessed correlation between the three tools; and performed linear mixed-effects regression analyses to examine longitudinal differences in outcomes (0, 3, 6 months) by frailty status. A sensitivity analysis with worst-case imputation was conducted to explore attrition.

RESULTS

We enrolled 175 men (mean age 74.9 years) starting docetaxel (n = 71), abiraterone (n = 37), or enzalutamide (n = 67). Our FI demonstrated moderate correlation with the VES-13 (r = 0.607, p < 0.001) and the G8 (r = -0.520, p < 0.001). Baseline FI score was associated with worse QoL (p < 0.001), fatigue (p < 0.001), pain (p < 0.001), mood (p < 0.001), PF (p < 0.001), and higher attrition (p < 0.01). Over time, most outcomes remained stable, although pain improved, on average, regardless of frailty status (p = 0.007), while fatigue (p = 0.045) and mood (p = 0.015) improved in frail patients alone.

DISCUSSION

Among older men receiving care for mCRPC, frailty may be associated with worse baseline QoL and PF, but over time, frail patients may experience largely similar trends in QoL and PF as their non-frail counterparts. Further study with larger sample size and longer follow-up may help elucidate how best to incorporate frailty into treatment decision-making for mCRPC.

Impact of treatment on elder-relevant physical function and quality of life outcomes in older adults with metastatic castration-resistant prostate cancer

INTRODUCTION

Understanding physical function (PF) and quality of life (QoL) treatment effects are important in treatment decision-making for older adults with cancer. However, data are limited for older men with metastatic castration-resistant prostate cancer (mCRPC). We evaluated the effects of treatment on PF and QoL in older men with mCRPC.

MATERIALS AND METHODS

Men aged 65+ with mCRPC were enrolled in this multicenter prospective observational study. PF measures included instrumental activities of daily living, grip strength, chair stands, and gait speed. QoL measures included fatigue, pain, mood, and Functional Assessment of Cancer Therapy (FACT)-General total and sub-scale scores. Outcomes were collected at baseline, three, and six months. Linear mixed effects regression models were used to examine PF and QoL differences over time across various treatment cohorts.

RESULTS

We enrolled 198 men starting chemotherapy (n = 71), abiraterone (n = 37), enzalutamide (n = 67), or radium-223 (n = 23). At baseline, men starting chemotherapy had worse measures of PF, QoL, pain, and mood than the other groups. Over time, all PF measures remained stable, pain improved, but functional wellbeing (FWB) and mood worsened significantly for all cohorts. However, change over time in all outcomes was not appreciably different between treatment cohorts. Worst-case sensitivity analyses identified attrition (ranging from 22 to 42% by six months) as a major limitation of our study, particularly for the radium-223 cohort.

DISCUSSION

FWB and mood were most prone to deterioration over time, whereas pain improved with treatment. Although patients initiating chemotherapy had worse baseline PF and QoL, chemotherapy was not associated with significantly greater worsening over time compared to other common therapies for mCRPC. These findings may assist in treatment discussions with patients. However, given the modest sample size, attrition, and timeframe of follow-up, the impact of treatment on PF and QoL outcomes in this setting requires further study, particularly for radium-223.

Remote symptom monitoring (RSM) during treatment for metastatic prostate cancer (mPC) in older men: Feasibility and efficacy

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Background: Emerging data support multiple benefits of RSM during chemotherapy to improve outcomes. These studies do not focus on older adults and do not include non-chemotherapy strategies. mPC represents a major burden in older men. Although both chemotherapy and androgen receptor axis-targeted therapies (ARATs) prolong survival, toxicities are substantial and increased in older men. Understanding the feasibility of RSM and key symptoms experienced by men with mPC on treatment is crucial to designing appropriate supportive care interventions. We aimed to assess RSM feasibility and understand key symptoms during treatment with chemotherapy or an ARAT among older men. Methods: Older adults aged 65+ starting chemotherapy, an ARAT, or Radium-223 for mPC were enrolled in a prospective observational multicentre study. Participants completed the Edmonton Symptom Assessment Scale (ESAS) on weekdays online or by phone. Weekly detailed questionnaires assessed mood, anxiety, fatigue, insomnia, and pain. Notifications were sent to the clinical oncology team with severe symptoms (ESAS 7 or higher). Study duration was the first treatment cycle (̃3-4 weeks). Feasibility data were analyzed descriptively. Linear mixed effects models examined symptoms over time and by cohort. Clinician responses were assessed descriptively. Results: A total of 90 men were included (mean age 76.5y, 48% ARAT, 38% chemotherapy, and 14% Radium-223, 42% frail by Vulnerable Elders Survey-13 cutoff of 3+). Approximately half the patients preferred phone-based RSM. Patients provided RSM responses in 1,874 of approximately 2,000 (94%) instances. In the combined cohort, the most common symptoms of moderate to severe intensity (ESAS 4 or higher) occurring at least once were poor well-being (66%), fatigue (62%), reduced appetite (56%), insomnia (54%), and pain (46%). Symptom patterns were similar between chemotherapy and ARAT groups. Moderate to severe symptoms were more common and lasted longer among frail than non-frail men. Symptoms tended to remain stable or improve over the course of 3-4 weeks of RSM. 89% of participants were satisfied or very satisfied with RSM, although daily reporting was reported by several as burdensome. 45% had severe symptoms from RSM leading to informing the oncology care team, 79% of whom were followed up by a nurse or physician, and 12% of treatments were modified. Conclusions: RSM is feasible, acceptable to older adults, and identifies clinically relevant symptoms, but accommodation needs to be made for phone and the optimal frequency of RSM needs to be established. Poor well-being, fatigue, reduced appetite, and insomnia occurred in over half of participants. Longer-term follow up will be important.

National consensus quality indicators to assess quality of care for active surveillance in low-risk prostate cancer: An evidence-informed modified Delphi survey of Canadian urologists/radiation oncologists

INTRODUCTION

Although many low-risk prostate cancer (PCa) patients worldwide currently receive active surveillance (AS), adherence to clinical guidelines on AS and variations in care at the population level remain poorly understood. We sought to develop system-level quality indicators (QIs) and performance measures for benchmarking the quality of care during AS.

METHODS

Convenient sampling method was used to identify an expert panel among practicing urologists and radiation oncologists across Canada. QI development involved two phases: 1) proposed QIs were identified through a literature search and published clinical guidelines on AS; and 2) indicators were selected through a modified Delphi process during which each panelist independently rated each indicator based on clinical importance. QI items were chosen as appropriate measures for quality of AS care if they met prespecified criteria (disagreement index <1 and median importance of 7 or greater on a nine-point scale).

RESULTS

Among 42 invited expert panel members, the response rate was 45% (n=19). Expert panel members were well-represented by type of physician (84% urologists, 16% radiation oncologists) and practice setting (79% academic, 21% non-academic). The expert panel endorsed 20 of 27 potential indicators as appropriate for measuring quality of AS care.

CONCLUSIONS

We developed a set of QIs to measure AS care using published guidelines and clinical experts. Use of the indicators will be assessed for feasibility in healthcare databases. Reporting quality of care with these AS indicators may enhance adherence, reduce variation in care, and improve patient outcomes among low-risk PCa patients on AS.

A cost-utility analysis of apalutamide for metastatic castration-sensitive prostate cancer

INTRODUCTION

Earlier application of oral androgen receptor-axis-targeted therapies in patients with metastatic castration-sensitive prostate cancer (mCSPC) has established improvements in overall survival, as compared to androgen deprivation therapy (ADT) alone. Recently, the use of apalutamide plus ADT has demonstrated improvement in mCSPC-related mortality, vs. ADT alone, with an acceptable toxicity profile. However, the cost-effectiveness of this therapeutic option remains unknown.

METHODS

We used a state-transition model with probabilistic analysis to compare apalutamide + ADT, as compared to ADT alone for mCSPC patients over a time horizon of 20 years. Primary outcomes included expected life-years (LY), quality-adjusted life-years (QALY), lifetime cost (2020 Canadian dollars), and incremental cost-effectiveness ratio (ICER). Parameter and model uncertainties were assessed through scenario analyses. Health outcomes and cost were discounted at 1.5%, as per Canadian guidelines.

RESULTS

For the base-case analysis, expected LY for ADT and apalutamide plus ADT were 4.11 and 5.56, respectively (incremental LY 1.45). Expected QALYs were 3.51 for ADT and 4.84 for apalutamide plus ADT (incremental QALYs 1.33); expected lifetime cost was $36 582 and $255 633, respectively (incremental cost $219,051). ICER for apalutamide plus ADT, as compared to ADT alone, was $164 700/QALY. Through scenario analysis, price reductions >50% were required for apalutamide in combination with ADT to be considered cost-effective, at a cost-effectiveness threshold of $100 000/QALY.

CONCLUSIONS

Apalutamide plus ADT is unlikely to be cost-effective from the Canadian healthcare perspective unless there are substantial reductions in the price of apalutamide treatment.

Association of Chemotherapy, Enzalutamide, Abiraterone, and Radium 223 With Cognitive Function in Older Men With Metastatic Castration-Resistant Prostate Cancer

IMPORTANCE

Older adults are at greater risk of cognitive decline with various oncologic therapies. Some commonly used therapies for advanced prostate cancer, such as enzalutamide, have been linked to cognitive impairment, but published data are scarce, come from single-group studies, or focus on self-reported cognition.

OBJECTIVE

To longitudinally examine the association between cognitive function and docetaxel (chemotherapy), abiraterone, enzalutamide, and radium Ra 223 dichloride (radium 223) in older men with metastatic castration-resistant prostate cancer.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter, prospective, observational cohort study was conducted across 4 academic cancer centers in Ontario, Canada. A consecutive sample of 155 men age 65 years or older with metastatic castration-resistant prostate cancer starting any treatment with docetaxel, abiraterone acetate, enzalutamide, or radium Ra 223 dichloride (radium 223) were enrolled between July 1, 2015, and December 31, 2019.

EXPOSURES

First-line chemotherapy (docetaxel), abiraterone, enzalutamide, or radium 223.

MAIN OUTCOMES AND MEASURES

Cognitive function was measured at baseline and end of treatment using the Montreal Cognitive Assessment, the Trail Making Test part A, and the Trail Making Test part B to assess global cognition, attention, and executive function, respectively. Absolute changes in scores over time were analyzed using univariate and multivariable linear regression, and the percentages of individuals with a decline of 1.5 SDs in each domain were calculated.

RESULTS

A total of 155 men starting treatment with docetaxel (n = 51) (mean [SD] age, 73.5 [6.2] years; 34 [66.7%] with some postsecondary education), abiraterone (n = 29) (mean [SD] age, 76.2 [7.2] years; 18 [62.1%] with some postsecondary education), enzalutamide (n = 54) (mean [SD] age, 75.7 [7.4] years; 33 [61.1%] with some postsecondary education), and radium 223 (n = 21) (mean [SD] age, 76.4 [7.2] years; 17 [81.0%] with some postsecondary education) were included. Most patients had stable cognition or slight improvements during treatment. A cognitive decline of 1.5 SDs or more was observed in 0% to 6.5% of patients on each measure of cognitive function (eg, 3 of 46 patients [6.5%; 95% CI, 2.2%-17.5%] in the group receiving chemotherapy [docetaxel] had a decline of 1.5 SDs for Trails A and Trails B). Although patients taking enzalutamide had numerically larger declines than those taking abiraterone, differences were small and clinically unimportant.

CONCLUSIONS AND RELEVANCE

These findings suggest that most older men do not experience significant cognitive decline in attention, executive function, and global cognition while undergoing treatment for advanced prostate cancer regardless of the treatment used.

Examining the ability of the Cancer and Aging Research Group tool to predict toxicity in older men receiving chemotherapy or androgen-receptor-targeted therapy for metastatic castration-resistant prostate cancer

BACKGROUND

Because multiple treatments are available for metastatic castrate-resistant prostate cancer (mCRPC) and most patients are elderly, the prediction of toxicity risk is important. The Cancer and Aging Research Group (CARG) tool predicts chemotherapy toxicity in older adults with mixed solid tumors, but has not been validated in mCRPC. In this study, its ability to predict toxicity risk with docetaxel chemotherapy (CHEMO) was validated, and its utility was examined in predicting toxicity risk with abiraterone or enzalutamide (A/E) among older adults with mCRPC.

METHODS

Men aged 65+ years were enrolled in a prospective observational study at 4 Canadian academic cancer centers. All clinically relevant grade 2 to 5 toxicities over the course of treatment were documented via structured interviews and chart review. Logistic regression was used to identify predictors of toxicity.

RESULTS

Seventy-one men starting CHEMO (mean age, 73 years) and 104 men starting A/E (mean age, 76 years) were included. Clinically relevant grade 3+ toxicities occurred in 56% and 37% of CHEMO and A/E patients, respectively. The CARG tool was predictive of grade 3+ toxicities with CHEMO, which occurred in 36%, 67%, and 91% of low, moderate, and high-risk groups (P = .003). Similarly, grade 3+ toxicities occurred among A/E users in 23%, 48%, and 86% with low, moderate, and high CARG risk (P < .001). However, it was not predictive of grade 2 toxicities with either treatment.

CONCLUSIONS

There is external validation of the CARG tool in predicting grade 3+ toxicity in older men with mCRPC undergoing CHEMO and demonstrated utility during A/E therapy. This may aid with treatment decision-making.

The potential role of frailty in modifying quality-of-life related outcomes in metastatic castration-resistant prostate cancer (mCRPC) patients receiving docetaxel, abiraterone, enzalutamine, and radium 223

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Background: As the arsenal of therapeutic agents for mCRPC expands, frailty-informed care is emerging as a strategy for tailoring management decisions. Yet, data to guide this approach and to ascertain its impact on the mood, fatigue, pain, and quality of life (QoL) experienced by older men with mCRPC remain lacking. We examined patient-reported outcomes, stratified by a validated frailty index (FI), for mCRPC treatment with docetaxel chemotherapy (CHEMO), abiraterone (ABI), enzalutamide (ENZA), or radium 223 (RAD). Methods: Older (aged 65+) men starting one of four approved therapies for mCRPC were enrolled in a multicenter prospective cohort study. Assessing their mood, fatigue, pain, and QoL with PHQ-9, ESAS tiredness, ESAS pain, and FACT-G total as well as subscale scores, we used linear mixed effect models to determine change in each outcome over time (0, 3, 6 months). At end of treatment, we administered the Decisional Regret Scale. We then constructed a FI from 34 variables that span laboratory abnormalities, geriatric syndromes, instrumental activities of daily living, social support, as well as emotional, cognitive, and physical deficits. Following established cut-offs, we categorized patients as non-, pre-, and frail, then performed stratified linear mixed effects regression analyses to identify differences in outcomes by frailty status. Results: A total of 198 men (mean age 75.1) starting CHEMO (n = 70), ABI (n = 38), ENZA (n = 67), and RAD (n = 29) were included, of which 9.6%, 1.5%, 5.6%, and 2.5%, respectively, were determined frail. Frailty correlated only modestly with age (Pearson r = 0.27). Independent of frailty status, patients across treatment cohorts were similar in terms of baseline QoL-related measures, with the exceptions of mood (p = 0.033) and pain (p = 0.034). Over time, no significant change in QoL was reported, although all four therapies resulted in generally low levels of decisional regret and similar trends of improved pain but worsened mood (p = 0.006 and 0.02, respectively). At baseline, frailty status correlated with worse FACT-G total (p < 0.001) and functional well-being (p < 0.001), as well as worse depression scores (p < 0.001). According to FI-stratified analysis, frail patients experienced similar QoL-related outcomes to fit patients for all measures aside from mood (p < 0.001). Contrary to our hypotheses, frailty was not associated with significant worsening in emotional well-being or functional well-being in response to mCRPC treatment. Conclusions: Of the older men receiving care for mCRPC, frail patients may experience generally similar trends in QoL as fit patients. Interestingly, frailty status, rather than treatment modality, may play more of a contributory role to changes in QoL-related outcomes over time.

Impact of treatment and frailty on elder-relevant physical function outcomes in older adults with metastatic castration-resistant prostate cancer (mCRPC)

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Background: Maintenance of physical function is a key consideration in treatment decision-making for older adults with metastatic cancer, many of whom are frail. However, physical function outcomes with treatment, and effects of frailty, have not been adequately explored in the mCRPC setting. We evaluated the effects of frailty status and treatment with docetaxel (CHEMO), abiraterone (ABI), enzalutamide (ENZA), and radium 223 (RAD) on elder-relevant physical function outcomes in older men with mCRPC. Methods: Men aged 65+ were enrolled in this multicenter prospective observational cohort study. Daily function was evaluated with the OARS instrumental activities of daily living (IADL). Objective physical function was assessed by grip strength and the Short Physical Performance Battery (SPPB). Falls were documented during interviews. We also collected FACT-G physical well-being (PWB) and functional well-being (FWB) subscales. Assessments were performed at baseline, 3 months, and 6 months. We identified frailty status with a validated frailty index. Mixed effects regression models were used to examine the difference in primary outcomes over time by treatment group or frailty status adjusted for baseline characteristics. Factors associated with falls within 6 months of treatment initiation were determined with logistic regression. Results: A total of 70, 38, 67, and 23 men starting CHEMO, ABI, ENZA, and RAD were included. Mean age, education, race, number of medications, and BMI were similar at baseline between treatment groups. In treatment-stratified analyses without considering frailty, no significant changes over time were reported for any physical function outcome. Frailty was significantly associated with lower IADL function (p < 0.0001), worse grip strength (p < 0.0001), worse SPPB score (p < 0.0001), worse PWB (p < 0.0001), and worse FWB (p < 0.0001) at baseline. In frailty-stratified analyses, grip strength (p = 0.0345) worsened, but SPPB (p = 0.0147) improved significantly over time. Also, changes in SPPB (p = 0.0394) and PWB scores (p = 0.0269) over time differed by frailty status, where frail cohorts had greater improvement over time in both scores. Frailty and treatment type were not predictors of falls whereas prior falls history (OR: 3.52, 95% CI: 1.40-8.86) and age (OR: 1.07, 95% CI: 1.01-1.14) were significant predictors. Conclusions: Frail older men receiving treatment for mCRPC have worse IADL function, grip strength, SPPB scores, PWB, and FWB at baseline. Although grip strength worsened over time, they had greater improvement in SPPB scores and PWB over time than fit patients. Contrary to our hypothesis, most older adults do not experience significant worsening in elder-relevant physical function outcomes over time regardless of treatment. The impact of frailty requires further study.

Role of the vulnerable elders survey-13 screening tool in predicting treatment plan modification for older adults with cancer

BACKGROUND

The Vulnerable Elders Survey (VES-13) is commonly used to identify older patients who may benefit from Comprehensive Geriatric Assessment (CGA) prior to cancer treatment. The optimal cut point of the VES-13 to identify those whose final oncologic treatment plan would change after CGA is unclear. We hypothesized that patients with high positive VES-13 scores (7-10)have a higher likelihood of a change in treatment compared to low positive scores (3-6).

METHODS

Retrospective review of a customized database of all patients seen for pre-treatment assessment in an academic geriatric oncology clinic from June 2015 to June 2019. Various VES-13 cut points were analyzed to identify those individuals whose treatment was modified after CGA. Area under the curve (AUC) was calculated and subgroups of patients treated locally or systemically were also examined to determine if performance varied by treatment modality.

RESULTS

We included 386 patients with mean age 81, 58% males. Gastrointestinal cancer was the most common site (31%) and 60% were planned to receive curative treatment. The final treatment plan was modified in 59% overall, with 52.7% modified with VES-13 scores 7-10, 50.8% with scores 3-6 and 28.1% with scores <3 (P = 0.002). VES-13 performance in predicting treatment modification was similar for cut points 3 (AUC 0.58), 4 (0.59), 5 (0.59), and 6 (0.59) and in those considering local treatment vs. chemotherapy.

CONCLUSIONS

A positive VES-13 score was associated with final oncologic treatment plan modification. A high positive score was not superior to the conventional cut point of ≥3.

Predictive role of Vulnerable Elders Survey-13 screen tool for elder cancer patients in final oncology treatment plan

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Background: The Vulnerable Elders Survey (VES-13) is one of several tools that can identify older patients who are vulnerable (if the score is ≥ 3 out of 10) and more likely to benefit from Comprehensive Geriatric Assessment (CGA) prior to cancer treatment. The optimal cutpoint of the VES-13 to identify those whose final oncologic treatment plan would change after CGA is unclear. We hypothesized that patients with high positive scores (7-10) will have a higher likelihood of a change in the final oncologic treatment plan compared to low positive patients (score 3-6). Methods: Retrospective review of a customized database of all patients seen for pre-treatment assessment (solid tumor and lymphoma) in the geriatric oncology clinic at the Princess Margaret Cancer Centre from June 2015 to June 2019. Various VES-13 score cutpoints were compared with the final treatment plan to identify those individuals whose treatment was modified after CGA. Area under the curve was calculated and subgroups of patients treated locally or systemically were also examined to determine if performance varied by type of patient. Results: 386 patients with mean age 81, 58% males were included. Gastrointestinal cancer was the most common site 31% and 60% were planned to receive curative treatment. The final treatment plan was modified in 50% with VES-13 scores 7-10, 46.7% with scores 3-6 and 26.8 % for scores < 3 (P = 0.002; Table). The optimal VES-13 cutoff was between 3-6 (C-statistics 0.57-0.59).The VES-13 performed similarly in those considering local treatment (surgery with/without radiation) vs. chemotherapy. Modified final treatment for local therapy with VES-13 scores < 3 was 11.4 % compared to 42.9% with scores ≥ 3 was 42.9% (p-value < 0.001), whereas for systemic therapy it was 32.4% and 62.5%, respectively (p-value = 0.002). Conclusions: Although high positive VES-13 scores (7-10) had slightly higher likelihood of having the final oncologic treatment plan modified, there was no strong advantage compared to the conventional cutpoint of 3 or higher. The VES-13 performed similarly in predicting treatment change after CGA for local and systemic treatment plans. Further studies are required to identify the optimal frailty screening tool and cutpoint. [Table: see text]

A cost-utility analysis of apalutamide for the treatment of patients with metastatic castration-sensitive prostate cancer (mCSPC)

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Background: The therapeutic landscape for patients with mCSPC has evolved over the last decade given the growing body of evidence demonstrating efficacy for the earlier application of oral androgen receptor signaling inhibitors, such as with abiraterone and enzalutamide. Recently the success of the TITAN trial established the superior efficacy of apalutamide combined with androgen deprivation therapy (ADT), with a 33% reduction in mortality versus ADT alone, and a tolerable toxicity profile. However, with substantially higher costs than ADT alone, the cost-effectiveness of this combination is critical to evaluate. Methods: A cost-utility analysis of apalutamide+ADT versus ADT alone was conducted from the Canadian healthcare perspective. A state-transition model with probabilistic analysis was used to compare the two strategies over a lifetime horizon. Model inputs were informed by the TITAN trial (transition probabilities, adverse events [AE], subsequent therapy), published literature (utilities) and Canadian costing resources (systemic therapy [initial and subsequent], routine care [physician visits, imaging], AE, end-of-life care costs). Primary outcomes included expected life-year gains (LYG), quality-adjusted life-years (QALY), lifetime cost (in 2018 Canadian dollars), and the incremental cost-effectiveness ratio (ICER). Multiple scenario analyses were conducted to assess parameter and model uncertainty. Cost and effectiveness were discounted at 1.5% as per Canadian guidelines. Results: From the base-case analysis expected LYG and QALY for ADT and apalutamide+ADT were 4.11, 5.57 and 3.50, 4.85, respectively. Expected cost over a lifetime horizon was $37,553 and $254,205, respectively. The ICER for apalutamide+ADT as compared to ADT alone was $160,483/QALY. Through scenario analysis, cost-effectiveness of apaluatmide+ADT was achieved with apalutamide price reductions of >50%, relative to a cost-effectiveness threshold (CET) of $100,000/QALY. Scenario analysis of alternative long-term survival expectations with apalutamide+ADT demonstrated cost-effectiveness (relative to CET $100,000/QALY) with expected improvements in the 5-year survival rate of 29% as compared to ADT (versus base-case expected improvement in 5-year survival of 15%). Conclusions: Apalutamide+ADT is unlikely to be cost-effective from the Canadian healthcare perspective at current list prices. Improvement in cost-effectiveness is most likely to be achieved through price reductions in apalutamide drug costs.

The effect of docetaxel, enzalutamide, abiraterone, and radium-223 on cognitive function in older men with metastatic castrate-resistant prostate cancer (mCRPC)

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Background: Older adults are at greater risk of cognitive decline with various oncologic therapies. Emerging data suggest cognitive effects of various therapies for mCRPC but study populations are highly selected and published data are limited and focus mostly on self-reported cognitive function. We evaluated the effects of treatment with docetaxel chemotherapy (CHEMO), abiraterone (ABI), enzalutamide (ENZA), and radium 223 (Ra223) on cognitive function in older men with mCRPC. Methods: Men age 65+ with mCRPC starting any of the 4 treatments for mCRPC were enrolled in this multicenter prospective cohort study. Three short yet reliable and sensitive measures in older adults were administered at baseline and final visit (6 months with CHEMO and Ra223, mean 14-16 months with ENZA and ABI) using the Montreal Cognitive Assessment (MoCA), Trails A, and Trails B to assess global cognition, attention, and executive function, respectively. Absolute changes in cognitive scores over time were analyzed using multivariable linear regression, and the percentage of individuals with a decline of 1.5 SD in each domain were calculated. Higher scores on MoCA are better but worse for Trails A/B. Results: A total of 51, 26, 49, and 21 men starting CHEMO, ABI, ENZA, and Ra223 with complete data were included. Mean age, education, and baseline cognition were similar between groups (Table). Most patients demonstrated stable cognition or slight reductions. Executive function was the most sensitive of the 3 cognitive domains, and declined by at least 1.5 SD in about one-fifth of each cohort. Although ABI had numerically smaller declines than ENZA, differences were generally small and clinically unimportant. Conclusions: Most older men do not experience significant cognitive decline while on treatment for mCRPC regardless of treatment used.[Table: see text]

Does screening for frailty with the vulnerable elders survey (VES-13) identify older adults with GU malignancy who benefit most from a consultation in a geriatric oncology clinic?

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Background: The VES-13 is a well-studied brief frailty screening tool for ≥ 65 older adults (OAs) in the oncology setting. Vulnerable patients (scoring ≥ 3) are at higher risk for adverse outcomes and will benefit from a Comprehensive Geriatric assessment (CGA) and cancer treatment decision optimization. Whether the VES-13 is effective specifically in patients with Genitourinary (GU) malignancies remains to be established. Primary objective: to determine if the VES-13 can predict which OAs with GU cancer (Bladder, Prostate, Kidney) had subsequent treatment modification after CGA. Secondary objective: to investigate if there is any association between VES-13 score with comorbidity and chemotherapy toxicity prediction tool (CARG). Methods: The VES-13 was administered to consecutive patients referred to the geriatric oncology (GO) clinic from GU site at the Princess Margaret Cancer Centre, Canada. All patients underwent CGA. CGA assess 8 domains including cognition, comorbidities, function, falls risk. Among patients referred for pre-treatment assessment, we examined whether the VES-13 predicted changes in the final treatment plan after CGA. Descriptive statistics were used to describe the VES-13 scores and final treatment impact. Results: From July 2015-October 2019, 77 were included in this analysis. The VES-13 ≥ 3 group were 52/77 (67.5%), and significantly associated with higher comorbidities (P = 0.003) and worse CARG scores (P = 0.005). The final treatment plan was modified in 36/77 (47%). In univariate analysis, the odds ratio (OR) for VES-13 ≥3 was 1.92 (95% CI 0.72-5.12) for change in final treatment, which was not statistically significant likely due to modest sample size. Interestingly in the same univariate analysis, there was a strong association between final treatment plan with falls risk (OR 2.63, 95% CI 1.03-6.72), physical performance (OR 2.51, 95% CI 0.98-6.45) and cognition (OR 3.95, 95% CI 1.19-13.19). Conclusions: The VES-13 identified vulnerable GU patients who will benefit from CGA and may predict treatment optimization by identifying patients at higher risk of chemotherapy toxicity and higher comorbidity.

The long-term outcomes of Gleason grade groups 2 and 3 prostate cancer managed by active surveillance: Results from a large, population-based cohort

INTRODUCTION

Active surveillance (AS) is an accepted management strategy for low-risk prostate cancer (PCa), but its role in the management of favorable intermediate-risk PCa remains controversial. Most reports studying the role of AS for these men generally lack long-term followup and include small numbers of patients. Our objective was to report the outcomes of men diagnosed with Gleason grade groups (GGG) 2 and 3 PCa who were managed expectantly.

METHODS

Using administrative datasets and pathology reports, we identified all men who were diagnosed with GGG 2 and 3 PCa and managed expectantly between 2002 and 2011 in Ontario, Canada. Outcomes and associated factors were estimated using cumulative incidence function methods and multivariable Cox regression models, respectively.

RESULTS

We identified 926 men who were managed expectantly (AS [n=374] or watchful waiting [n=552]). The eight-year cancer-specific survival was 94% and 89% for the AS and watchful waiting cohorts, respectively. Among AS men, 266 (71%) received treatment after a followup of approximately eight years. Cumulative AS discontinuation rates at one and five years were 30.5% and 65.1%, respectively.

CONCLUSIONS

Expectant management of GGG 2 and 3 PCa may be an option for certain men. Notably for AS patients, the cancer-specific mortality at eight years was 6%, and over 65% of men underwent treatment within five years. Further studies are required to evaluate which patients, based on disease-specific features and competing health risks, would benefit most from a conservative strategy.

Validating the Cancer and Aging Research Group (CARG) toxicity prediction tool in older men receiving chemotherapy for metastatic castration-resistant prostate cancer (mCRPC) and extending it to androgen receptor targeted agents

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Background: Multiple treatment options are available for mCRPC. Being able to predict toxicity risk for different treatments in older adults can aid treatment decision-making and supportive care. The CARG tool is a promising toxicity risk prediction tool for chemotherapy, but has not been specifically validated in the mCRPC setting for either chemotherapy or androgen receptor targeted agents. We prospectively evaluated the ability of the CARG tool to predict risk of clinically relevant grade 2 and grade 3+ toxicity of treatment with chemotherapy (CHEMO) and abiraterone or enzalutamide (A/E) in older adults with mCRPC. Methods: Men age 65+ were enrolled in this prospective observational study at 3 academic centres, Princess Margaret Cancer Centre, Sunnybrook Health Sciences Centre, and Kingston Health Sciences Centre in Ontario, Canada. All grade 2 and grade 3+ toxicities were documented during cycle 1 of CHEMO or in the first 3 months of A/E via structured interviews and chart review. Lab abnormalities were documented only if resulting in emergency room visits, requiring treatment, or affecting subsequent oncologic treatment. Toxicity was rated using the Common Terminology Criteria for Adverse Events version 4. Logistic regression was performed to identify predictors of toxicity. Results: 64 men starting CHEMO (primarily docetaxel 60-75 mg/m^2, mean age 73y) and 59 men starting A/E (mean age 76y) were included. Clinically important grade 2 toxicities occurred in 86% and 70% of CHEMO and A/E patients, respectively. Grade 3+ toxicities occurred in 48% and 25% of CHEMO and A/E patients, respectively. The CARG tool was predictive of grade 3+ toxicities with CHEMO, which occurred in 22%, 53%, and 71% of low, moderate, and high risk groups (p = 0.017). However, the CARG tool was not predictive of grade 2 toxicities with CHEMO, or grade 2 or 3+ toxicities with A/E (Table). Conclusions: We provide external validation of the CARG tool in predicting grade 3+ toxicity in older men with mCRPC undergoing CHEMO. Grade 2 toxicities are very common with both CHEMO and A/E, and grade 3+ toxicity occurs in 1 in 4 older men on A/E. Additional efforts to identify men at higher risk of toxicity from various mCRPC treatments are warranted. [Table: see text]

A phase II randomized controlled trial of three exercise delivery methods in men with prostate cancer on androgen deprivation therapy

BACKGROUND

Existing evidence demonstrates that 1:1 personal training (PT) improves many adverse effects of androgen deprivation therapy (ADT). Whether less resource-intensive exercise delivery models are as effective remains to be established. We determined the feasibility of conducting a multi-center non-inferiority randomized controlled trial comparing PT with supervised group (GROUP) and home-based (HOME) exercise programs, and obtained preliminary efficacy estimates for GROUP and HOME compared to PT on quality of life (QOL) and physical fitness.

METHODS

Men with prostate cancer on ADT were recruited from one of two experienced Canadian centres and randomized 1:1:1 to PT, GROUP, or HOME. Randomization was stratified by length of ADT use and site. Participants completed moderate intensity aerobic and resistance exercises 4-5 days per week for 6 months with a target 150 min per week of exercise. Exercise prescriptions were individualized and progressed throughout the trial. Feasibility endpoints included recruitment, retention, adherence, and participant satisfaction. The efficacy endpoints QOL, fatigue, and fitness (VO2 peak, grip strength, and timed chair stands) in GROUP and HOME were compared for non-inferiority to PT. Descriptive analyses were used for feasibility endpoints. Between-group differences for efficacy endpoints were examined using Bayesian linear mixed effects models.

RESULTS

Fifty-nine participants (mean age 69.9 years) were enrolled. The recruitment rate was 25.4% and recruitment was slower than projected. Retention was 71.2%. Exercise adherence as measured through attendance was high for supervised sessions but under 50% by self-report and accelerometry. Satisfaction was high and there was no difference in this measure between all three groups. Between-group differences (comparing both GROUP and HOME to PT) were smaller than the minimum clinically important difference on most measures of QOL, fatigue, and fitness. However, two of six outcomes for GROUP and four of six outcomes for HOME had a > 20% probability of being inferior for GROUP.

CONCLUSIONS

Feasibility endpoints were generally met. Both GROUP and HOME interventions in men with PC on ADT appeared to be similar to PT for multiple efficacy outcomes, although conclusions are limited by a small sample size and cost considerations have not been incorporated. Efforts need to be targeted to improving recruitment and adherence. A larger trial is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02046837 . Date of registration: January 20, 2014.

Identification of subgroups of metastatic castrate-resistant prostate cancer (mCRPC) patients treated with abiraterone plus prednisone at low- vs. high-risk of radiographic progression: An analysis of COU-AA-302

INTRODUCTION

Radiographic imaging is used to monitor disease progression for men with metastatic castrate-resistant prostate cancer (mCRPC). The optimal frequency of imaging, a costly and limited resource, is not known. Our objective was to identify predictors of radiographic progression to inform the frequency of imaging for men with mCRPC.

METHODS

We accessed data for men with chemotherapy-naive mCRPC in the abiraterone acetate plus prednisone (AA-P) group of a randomized trial (COU-AA-302) (n=546). We used Cox proportional hazards modelling to identify predictors of time to progression. We divided patients into groups based on the most important predictors and estimated the probability of radiographic progression-free survival (RPFS) at six and 12 months.

RESULTS

Baseline disease and change in prostate-specific antigen (PSA) at eight weeks were the strongest determinants of RPFS. The probability of RPFS for men with bone-only disease and a ≥50% fall in PSA was 93% (95% confidence interval [CI] 87-96) at six months and 80% (95% CI 72-86) at 12 months. In contrast, the probability of RPFS for men with bone and soft tissue metastasis and <50% fall in PSA was 55% (95% CI 41-67) at six months and 34% (95% CI 22-47) at 12 months. These findings should be externally validated.

CONCLUSIONS

Patients with chemotherapy-naive mCRPC treated with first-line AA-P can be divided into groups with significantly different risks of radiographic progression based on a few clinically available variables, suggesting that imaging schedules could be individualized.

Quality of care during active surveillance in low-risk prostate cancer patients: A population-based approach

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Background: Active surveillance (AS) has become a widely accepted management strategy for low-risk (Gleason score ≤6) prostate cancer (PC). Given the large proportion of low-risk PC (60-90%) patients who currently receive AS, adherence to clinical guidelines on AS and variations in care at the population level remain surprisingly poorly understood. Further, it is presently unclear how often patients receive high quality AS care in community settings (almost all published data come from academic centers), yet the majority of AS occurs in community settings. Thus, there is significant interest in developing system-level quality indicators (QIs). We sought to develop structure-process-outcome-based QIs to enable benchmarking during AS follow-up using data available in Canadian administrative databases. Methods: We performed a detailed literature search on QIs in PC as well as broader theoretical concepts on QIs and consulted with clinical leaders from a major cancer centre. Current guidelines on AS and potential quality indicators were identified from a literature search. AS-specific QIs were tested among low-risk PC who were managed with AS between 2002-2011 using population-level cancer registry databases. We assessed adherence to clinical guidelines using QIs, and compared with health care system-related characteristics. Results: 25 indicators were proposed [structure of care (n = 5), process of care (n = 16) and health outcomes (n = 4)]. Overall 39% received AS, with 88% managed by a urologist. Only 43% of low volume (≤3 positive cores) patients underwent AS. Adherence of confirmatory biopsy with guidelines was performed on only 32% of patients, and adherence was better in higher volume institutions, among higher volume physicians, and in cancer centers. 5-and 10-year PC specific survival were significantly better among high volume physicians. Conclusions: We have proposed a set of QIs for measuring AS care. Initial data show that higher volume institution or higher volume physician and cancer center had better adherence to quality of AS care. Long term survival was better among patients treated by high volume physicians. Further validation of these QIs is ongoing.

Perceptions of Study Newsletters for Older Cancer Patients in Longitudinal Studies

To date, no study has examined the value of providing study newsletters in educating and motivating participants taking part in longitudinal intervention studies and reducing attrition in studies. The study team examined perceptions and satisfaction towards study newsletters, and their potential benefits, in a population of older men with prostate cancer participating in two ongoing longitudinal trials. Two study newsletters issues were mailed out 4 months apart to prostate cancer patients participating in a bone health and/or exercise intervention trial. Participants (n = 133) were invited to complete an 18-item custom-designed survey examining perceptions towards and satisfaction with the newsletter, and provide feedback about what makes an ideal study newsletter. Analyses were primarily descriptive. Resources required to produce a study newsletter were also calculated. Of 133 participants, 83 usable surveys were returned (response rate 62.4%). The mean satisfaction rating for the newsletter was 8.5/10 (SD 1.9) (10 = highly satisfied). Seventy eight percent said the newsletter encouraged them to continue to participate in the study, and 93% indicated that providing such study newsletters should be optional (64%) or mandatory (29%). Each newsletter required 31 h of study personnel time (mostly research student) to produce. Study participants were very satisfied with the newsletter and the majority indicated that study newsletters should be a regular practice in all long-term studies and may improve participant retention. Producing a newsletter is a low-cost method of educating participants in longitudinal studies. Its impact on recruitment and retention should be examined in clinical trials.

Effects of a 6-month moderate-intensity exercise program on metabolic parameters and bone mineral density in men on androgen deprivation therapy for prostate cancer

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Background: Androgen deprivation therapy (ADT) is commonly used to treat prostate cancer (PC) but is associated with significant side effects including metabolic abnormalities and bone loss. Although multiple trials have demonstrated that exercise is associated with improvements in multiple side effects of ADT, its effects on metabolic and skeletal outcomes is unclear. We conducted a phase II randomized controlled trial (RCT) comparing three different exercise delivery models. The present analysis examined prespecified endpoints of change in metabolic parameters and bone mineral density. Methods: Men with stage TxNxMx PC starting or continuing ADT for at least 6 months were enrolled and randomized equally to personal training (n = 18), supervised group training (n = 14), or home-based training (n = 16). Participants in all intervention arms underwent moderate to vigorous physical activity with a target of 150 minutes per week for 6 months. Fasting blood work and dual x-ray absorptiometry (DXA) were done at baseline and 6 months (blood work) and 12 months (DXA). Paired t-tests and ANCOVA were used to analyze findings. Results: 48 participants (mean age 69.9 years) were enrolled. The primary analysis demonstrated no significant difference between arms on most quality of life and fitness outcomes so groups were combined for the present analysis. Exercise was not associated with statistically significant changes in hemoglobin, total cholesterol, low density lipoprotein, high density lipoprotein, triglycerides, or fasting blood glucose (p = 0.075 to 0.87). Similarly, exercise was not associated with changes in bone mineral density at lumbar spine, total hip, or femoral neck sites on DXA (p = 0.44 to 0.71). Mean weight change was +0.8 kg. There was no difference between exercise arms on any outcome. Conclusions: Although our study is limited by a small sample size, our results suggest that 6 months of moderate intensity exercise is not associated with improvements in either metabolic or skeletal outcomes in men on ADT. More intensive behavioural interventions and/or pharmacological interventions will be required to reverse the deleterious effects of ADT. Clinical trial information: NCT02046837.

Improving bone health in men with prostate cancer receiving androgen deprivation therapy: Results of a randomized phase 2 trial

BACKGROUND

Strategies to improve bone health care in men receiving androgen deprivation therapy (ADT) are not consistently implemented. The authors conducted a phase 2 randomized controlled trial of 2 education-based models-of-care interventions to determine their feasibility and ability to improve bone health care.

METHODS

A single-center parallel-group randomized controlled trial of men with prostate cancer who were receiving ADT was performed. Participants were randomized 1:1:1 to 1) a patient bone health pamphlet and brief recommendations for their family physician (BHP+FP); 2) a BHP and support from a bone health care coordinator (BHP+BHCC); or 3) usual care. The primary efficacy outcome was receipt of a bone mineral density (BMD) test within 6 months. Secondary efficacy outcomes included guideline-appropriate calcium and vitamin D use and bisphosphonate prescriptions for men at high fracture risk. Feasibility endpoints included recruitment, retention, satisfaction, contamination, and outcome capture. The main analysis used logistic regression with a 1-sided P of .10. The trial is registered at ClinicalTrials.gov (identifier NCT02043236).

RESULTS

A total of 119 men were recruited. The BHP+BHCC strategy was associated with a greater percentage of men undergoing a BMD test compared with the usual-care group (78% vs 36%; P<.001). BMD ordering also was found to be increased with the BHP+FP strategy (58% vs 36%; P = .047). Both strategies were associated with higher percentages of patients using calcium and vitamin D, but only the BHP+FP arm was statistically significant (P = .039). No men were detected to be at high fracture risk. All but one feasibility endpoint was met.

CONCLUSIONS

Educational strategies to improve bone health care appear feasible and are associated with improved BMD ordering in men receiving ADT. Cancer 2018;124:1132-40. © 2017 American Cancer Society.

Oncologic outcomes of radiation therapy following active surveillance for low- and intermediate-risk localized prostate cancer

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Background: To evaluate the oncologic outcomes and potential impact of delayed radical treatment in the form of radiotherapy (RT), in men with localized prostate cancer progressing after active surveillance (AS). Methods: We identified patients on AS subsequently treated with state-of-the-art RT (either dose-escalated image-guided intensity modulated radiotherapy [IG-IMRT] or low-dose-rate brachytherapy [LDR-BT]). Based on the clinical characteristics at time of AS progression, we compared the oncologic outcomes to matched patients treated with upfront RT after diagnose. One to two matching patients per AS case were identified from existing RT databases based on: age (+/- 3 years), clinical prognostic factors (NCCN risk group; PSA +/- 2ng/mL; cT category; primary and secondary Gleason score; percentage of diagnostic cores involved dichotomized at < or > 50%), and treatment modality (IG-IMRT or LDR-BT). We aimed to determine whether patients on AS have potentially compromised outcomes. Results: We identified 215 patients (out of 1070 AS cohort) undergoing RT after a median of 26 months (IQR 16-52.5) on AS. Median follow-up post RT was 4.8 years (IQR 2.9-7.2). No patient died of prostate cancer. At 5-years, the biochemical relapse free-, metastases free- and overall-survival rate were respectively 98.6%, 99.1%, 98.6% in the AS cohort. Matched cohort comprised 400 patients treated with IG-IMRT (71%) or LDR-BT (29%). Adequate matching was confirmed. The median follow-up post RT was 8.2 years (IQR 4.7-10). At 5-years, biochemical relapse free-, metastases free- and overall-survival rates of 98.5%, 98.7%, 93.7% respectively, which were not statistically different compared to those patients treated upon AS progression. Conclusions: Curative-intent radiotherapy (i.e. dose-escalated IG-IMRT or LDR-BT) after a period of AS renders excellent oncologic outcomes at 5 years. Moreover, the delay of therapy after a period of AS does not appear to result in inferior oncologic outcomes compared to patients with similar risk characteristics undergoing upfront radical radiotherapy.