Management of Prostate Cancer in the Older Man Supriya G. Mohile, a Mark Lachs, b and William Dale c Due to the high incidence and prevalence in older men, prostate cancer is best understood as an age-associated disease. Physicians and their older patients commonly face the dilemma of whether or not to initiate treatment for localized disease or early systemic relapse (ie, biochemical recur- rence). Although many older men with symptomatic advanced prostate cancer benefit from hormonal treatments and chemotherapies, treatment complications also may influence outcome. Older prostate cancer patients have a high prevalence of other factors that can limit remaining life expectancy (RLE), quality of life (QOL), and tolerance to treatment. A comprehensive geriatric assessment (CGA) can help identify other health status issues that can predict morbidity or mortality in vulnerable or frail older prostate cancer populations. Despite a growing body of evidence, more research is needed to establish optimal treatment strategies for all disease stages in prostate cancer patients diagnosed later in life. Semin Oncol 35:597-617. Published by Elsevier Inc. P rostate cancer is the leading noncutaneous can- cer diagnosis and the second leading cause of cancer deaths among men in the United States. In 2008, there will be an estimated 186,320 cases and 28,660 deaths from the disease. 1 Prostate cancer is a disease associated with aging. The probability of devel- oping prostate cancer rises from one in 14 in those aged 60 – 69 to one in seven above the age of 70 years. 1 The absolute number of older men diagnosed with prostate cancer is increasing due to higher rates of screening. These numbers are expected to increase further due to the aging of the population. In 2030, 20% of the population will be 65 years of age or older, compared to 13% today. 2 The diagnosis and management of prostate cancer is complex and controversial. Although screening and treatment rates remain high, many older men will never experience complications or a reduced lifespan from prostate cancer even when left untreated. Despite the high incidence, older men are more likely to die from conditions other than from prostate cancer. 3 Care- ful patient selection for screening and aggressive treat- ment is of utmost importance in the older subgroups of the population. Although there is considerable knowl- edge of prostate cancer variables that influence overall survival, decision-making tools and nomograms for pre- dicting risk of death from prostate cancer do not con- sistently incorporate key health status characteristics known to influence life expectancy in the elderly. Ge- riatric assessment can help better estimate life expect- ancy, and thereby help inform the approach to treat- ment, in older men who are deciding whether to be screened or treated for prostate cancer. In this article, we provide an approach to the assess- ment of the older man for prostate cancer screening or treatment along with an overview of management op- tions for prostate cancer treatment along the full clin- ical continuum of the disease. EPIDEMIOLOGY OF PROSTATE CANCER IN THE OLDER MAN Prostate cancer is the most common noncutaneous malignancy among men and is their second leading cause of cancer mortality. 1 Autopsy studies have de- scribed the prevalence of clinically insignificant pros- tate cancer in men who died from other causes. One third of men over 50 years of age will have histologic evidence of prostate cancer on autopsy studies, with more than 80% of cancers measuring less than 0.5 cm in size. 4 At the time of death, close to 70% of men over 80 years of age have prostate cancer on autopsy. 5 These autopsy results suggest that many older persons have clinically insignificant prostate cancers that screening a James Wilmot Cancer Center, University of Rochester, Rochester, NY. b Division of Geriatrics, Weill-Cornell Medical College, New York, NY. c Department of Medicine, Section of Geriatrics, The University of Chi- cago, Chicago, IL. Supported in part by a Hartford Geriatrics Health Outcomes Research Award (S.G.M.) and a Paul Beeson Career Development Award (W.D.). Address correspondence to Supriya Gupta Mohile, MD, MS, 601 Elm- wood Ave, Box 704, Rochester, NY 14642. E-mail: supriya_mohile@ urmc.rochester.edu 0270-9295/00/$ - see front matter © 2008 Published by Elsevier Inc. doi:10.1053/j.seminoncol.2008.08.003 Seminars in Oncology, Vol 35, No 6, December 2008, pp 597-617 597