E U R O P E A N U R O L O G Y F O C U S 3 ( 2 0 17 ) 3 8 5 – 3 9 4

available at www.sciencedirect.com
journal homepage: www.europeanurology.com/eufocus

Review – Aging Male

Role of Geriatric Oncologists in Optimizing Care of Urological

Oncology Patients

Jean-Pierre Droz a,*, Helen Boyle b, Gilles Albrand c, Nicolas Mottet d, Martine Puts e
a b
Cancer—Environment Research Unit, Centre Léon-Bérard and Claude-Bernard Lyon1 University, Lyon, France; Department Medical Oncology—Centre
Léon-Bérard, Lyon, France; c Groupement Hospitalier Sud des Hospices Civils de Lyon, Hôpital Antoine Charial, Francheville, France; d Department of Urology,
Saint-Etienne University Hospital, Saint-Priest enJarez, France; e Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada

Article info Abstract

Article history: Context: Urological cancers are common. Since the median age of diagnosis is 60–70 yr,
Accepted October 21, 2017 many patients require geriatric as well as urological evaluation if treatment is to be
tailored to individual health status including comorbidities and frailty.
Associate Editor: Objective: To review the most important features of geriatric assessment and its
Christian Gratzke expected benefits. We also consider ways in which collaboration between urologists
and geriatricians and geriatric teams can benefit patient well-being.
Evidence acquisition: Members of a multidisciplinary International Society of Geriatric
Keywords: Oncology task force reviewed articles published in 2010–2017 using search terms
Urological cancers relevant to urological cancers, the elderly, and geriatric evaluation. The final manuscript
reflects their expert consensus.
Geriatric assessment
Evidence synthesis: Elderly patients should be managed according to their individual
Health evaluation health status and not according to age. As a first step, screening for cognitive impairment
Comorbidities is mandatory to establish patient competence in making decisions. Initial evaluation of
Elderly health status should use a validated screening tool, the G8 screening tool being generally
Multidisciplinary management preferred. Abnormal scores on the G8 should lead to a geriatric assessment that
evaluates comorbid conditions and functional, nutritional, mental, and medicosocial
status. When patients are frail or disabled or have severe comorbidities, comprehensive
geriatric assessment is required. Diagnosis of health status impairment shows the need
for geriatric interventions. This overall approach is realistic in the setting of a depart-
ment of urological oncology and given the involvement of a multidisciplinary team
including trained nurses and other professionals and collaboration with geriatricians.
Mutual education and support of all those involved in managing elderly urological
cancer patients is the key to effective care.
Conclusions: Advances in geriatric evaluation and cancer treatment are contributing to
more appropriate management of elderly patients with urological cancers. Better
understanding of the role of all participants and professional collaboration are vital
to the individualization of care.
Patient summary: Many patients with urological cancers are elderly. In those physically
fit, treatment should generally be the same as that in younger patients. Some elderly
cancer patients are frail and have other medical problems. Treatment in individual
patients should be based on health status and patient preference.
© 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.

* Corresponding author. 24 Allée de Verdun, Bron 69500, France. Tel.: +33 643 178 411.
E-mail address: jpdroz@orange.fr (J.-P. Droz).

https://doi.org/10.1016/j.euf.2017.10.012
2405-4569/© 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.

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386 E U R O P E A N U R O L O G Y F O C U S 3 ( 2 0 17 ) 3 8 5 – 3 9 4
1. Introduction
In 2013, people aged 65 yr and above represented 16% of the
population in high-income countries and 4% in low-income
countries [1]. Although people aged 65 yr and older repre-
sent <10% of the world’s population overall, they account
for 48% of new cancer cases and 58% of cancer-related
deaths [2]. Cancer is a disease of aging, and most diagnoses
and deaths occur in older adults. The median ages at diag-
nosis of prostate, bladder, and renal cancer are 70, 65 and
60 yr, respectively [2].
We review the most important characteristics of the
health status tools used in geriatrics and their expected
benefits. We also consider how urologists and geriatricians
can collaborate for the benefit of their patients.
2. Evidence acquisition
Members of a multidisciplinary International Society of
Geriatric Oncology (SIOG) task force reviewed articles pub-
lished in 2010–2017 using search terms relevant to urologi-
cal cancers, the elderly, and geriatric evaluation. The final
manuscript reflects their expert consensus.
3. Evidence synthesis
3.1. Major concepts in geriatric oncology
In geriatric oncology, the “health status” of patients is an
important concept. This includes different domains, the
most widely known being functional status, nutritional
status, and comorbidities [3]. However, it is also important
to consider cognition, psychological status, risk of falls, and
sociomedical aspects such as access to a caregiver; financial,
legal, and socioeconomic status; where the patient lives;
and the possibility of neglect and abuse [4].
Comprehensive geriatric assessment (CGA) provides a
systematic means of assessing all health domains. It also
suggests tailored geriatric interventions to optimize func-
tion and well-being by addressing any issues identified.
However, the CGA is generally viewed as a time-consuming
procedure requiring multidisciplinary input that makes it
difficult to use in routine practice, outside a geriatric
department, and in clinical trials. In these situations—which
constitute the majority of settings—different tools are gen-
erally used to detect health impairments. We term this
“geriatric screening,” and the aim is to identify patients
at high risk or those with geriatric problems who could
benefit from full assessment [5,6].
Many geriatric screening tools are available [7]. Table 1
summarizes the principal ones, the health professionals
who can use these tools, and an estimate of the time taken
based on data from the Geneva University Hospital
[8]. Most can be administered by trained registered nurses
though some require medical specialists and, ultimately,
geriatricians. Recently, Hamaker et al [9] have emphasized
that such geriatric assessment (GA) is feasible in routine
practice and clinical trials [10]. In terms of nurses’ time
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(and US salaries), use of these assessments compared
favorably in cost with that of other elements of oncological
workup [9].
It should be understood that the process we illustrate
involves different steps. For example, use of the Mini-
Mental State Examination (MMSE) [11] can detect cognitive
impairment but does not provide a diagnosis of Alzheimer’s
disease, for example, and it does not help decide
management.
Figure 1 shows the International Classification of Func-
tioning, Disability and Health model [12]. It illustrates how
contextual factors, both environmental and personal, inter-
act with body structure and function in influencing the
presentation of disorder or disease.
3.1.1. Heterogeneity in life expectancy
Life expectancy varies greatly, depending on health status
[13] (Fig. 2). Hence, a “fit” 80-yr-old man (in the upper
tertile for his age group) may expect a longer life than a
70-yr-old man with poor health status (in the lower tertile
for his age group). CGA permits a detailed evaluation of
the health status of individual patients and helps predict
the probability of survival based on specific health status
criteria [4]. Available tools can predict 1 or 5 yr survival of
patients living at home, hospital, or nursing home settings
[14].
This has been demonstrated in general populations of
elderly people, but has been demonstrated neither in popu-
lations of patients with cancer, nor in specific cancer popu-
lations such as those with urological tumors.
3.1.2. Components of health status
3.1.2.1. Functional status. This can be evaluated using a number
of different scales, the most important being the Instru-
mental Activities of Daily Living (IADL) [15] and the Activi-
ties of Daily Living (ADL) scales [16]. The ADL rates the
patient’s ability to accomplish basic activities: bathing,
dressing, toileting, ambulation, continence, and feeding.
The IADL rates activities that require a higher level of
cognition and judgment, such as the preparation of meals,
shopping, light housework, financial management, medica-
tion management, use of transportation, and use of the
telephone. Falls and risk of falling are other components
of dependence, and may be caused by a number of condi-
tions including polypharmacy [17]. Risk of falling can also
be assessed by self-reports [18]. This is important, for
example, in prostate cancer patients treated by androgen
deprivation therapy [19].
3.1.2.2. Comorbidities. The impact of comorbidities on patient
outcome has widely been studied, particularly in urology
[3]. The strongest and most widely studied predictor of
noncancer death is the Charlson comorbidity index
[20]. The Charlson index focuses on 19 major comorbid
conditions that significantly affect survival. However, it
provides only a partial evaluation of comorbidity since
many diseases that have a lesser impact on survival (eg,
hypertension) are not rated. For this reason, the Cumulative
Illness Score Rating-Geriatrics (CISR-G) [21], which also
 E U R O P E A N U R O L O G Y F O C U S 3 ( 2 0 17 ) 3 8 5 – 3 9 4 387

Table 1 – Domains of health status, relevant screening tools, and time and personnel needed for evaluation.

Domain Tools Who can do it? Estimated time required (min)a

Basic screening: all patients (10 min)

Cognitive impairment Mini-COGTM TRN and MD 5
Frailty G8 TRN 5
Geriatric assessment: if G8 < 15/17b (20–80 min + clinical synthesis)
Demographic and social status Living situation, marital status, education level, TRN/social worker 5–15
financial resources, caregiver
Comorbidities Charlson index MD + TRN 15
CISR-G MD + TRN 15
Clinical examination MD 
Specialist consultation Specialist 
Functional status IADL TRN 2–5
ADL TRN 2–5
Cognition MMSE TRN 5–10
Mini-COG TRN 5
Depression GDS TRN 1–5
Nutrition MNA TRN/nutritionist 10
Weight loss TRN 1
BMI TRN 1
Albumin level –
Polypharmacy Clinical evaluation TRN and MD 5
Geriatric syndromes Self-reported falls TRN 2
Time to get up and go TRN 5–7
Incontinence TRN 1
Neglect and abuse TRN/social worker 2
Sensory impairments TRN 1–6
Dementia Cognition clinic 
Clinical synthesis Frailty = intervention MD + TRN 
Anesthesiologist?
Geriatric consultation if needed Complex patients Geriatrician and TRN 60

ADL = Activities of Daily Living; BMI = body mass index; CISR-G = Cumulative Illness Score Rating-Geriatrics; GDS = Geriatric Depression Scale;
IADL = Instrumental Activities of Daily Living; MD = medical doctor; MMSE = Mini-Mental State Examination; MNA = Mini Nutritional Assessment;
TRN = trained registered nurse.
Tools are referenced in the text.
a
Based on information from the Geneva University Hospital.
b
This represents 20–30% of patients.

rates diseases such as hypertension according to their is also important in order to detect possible drug interac-
severity and level of control by treatment, may show better tions and drug side effects [23].
discrimination.
The CISR-G has been validated in senior adults with 3.1.2.3. Nutrition. Malnutrition is a strong prognostic factor
cancer, and its prognostic performance compares well with for poor outcome [24]. It is often screened for using the
the Charlson index [22]. Although the CISR-G has improved Mini-Nutritional Assessment tool that grades the nutri-
clinical applicability, this tool too has limitations since it tional state of senior adult patients [25]. Other important
does not allow two comorbidities of the same organ to be and easily assessed variables are weight loss during the last
separately identified [21]. The evaluation of polypharmacy 3 mo, body mass index, and serum albumin level.
[(Fig._1)TD$IG]
Health condition
(disorder or disease)

Body functions Activity Participation

& structure

Environmental Personal
factors factors
Contextual factors

Fig. 1 – International Classification of Functioning, Disability and Health model.

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388 E U R O P E A N U R O L O G Y F O C U S 3 ( 2 0 17 ) 3 8 5 – 3 9 4
[(Fig._2)TD$IG]
Top 25th percentile

50th percentile
25 Lowest 25th percentile
20
Life expentancy (yr)
20
15 16
15
12
11
10 9 8 9
6 5 6
5 4 4 4
3 2 3
1
0
70 75 80 85 90 95
Age (yr)
Fig. 2 – Heterogeneity in life expectancy (modified from Walter and Schonberg [13]).

3.1.2.4. Mental health. Depression contributes to frailty and [27] compared the validity of cognitive screening tools in
can be screened for using the geriatric depression scale [26]. 102 studies that used the MMSE as reference, which is time
Cognition is crucial since impaired patients may not be consuming to complete. Of 10 alternative tests, the mini-
able to participate in decision making. Impaired cognition COG [28] matched most closely scores obtained using the
may also indicate mental illness associated with a poor MMSE and was chosen. The mini-COG tool is shown in
outcome and is generally assessed using the MMSE Table 2. A cutoff point of 3/5 indicates the need to refer
[11]. Complete understanding of the patient’s mental status a patient for full evaluation of potential dementia.
requires a full neuropsychological evaluation. Recent investigations suggest that oncology patients
The SIOG task force on management of elderly prostate with dementia are not always described as such by family
cancer patients [3] considered that cognitive evaluation was physicians, and there is a need to agree a means of assess-
mandatory to assess the patient’s capacity to evaluate ment and definition of mild cognitive impairment in the
information and make informed decisions. A meta-analysis oncology setting [29]. A recent review of cognitive

Table 2 – Mini-COG screening tool.

Step 1: three-word registration

Look directly at person and say, “Please listen carefully. I am going to say three words that I want you to repeat back to me now and try to remember. The words
are [select a list of words from the versions below]. Please say them for me now.” If the person is unable to repeat the words after three attempts, move on to Step
2 (clock drawing).
The following and other word lists have been used in one or more clinical studies. For repeated administrations, use of an alternative word list is recommended.
Version 1 Version 2 Version 3 Version 4 Version 5 Version 6
Banana Leader Village River Captain Daughter
Sunrise Season Kitchen Nation Garden Heaven
Chair Table Baby Finger Picture Mountain
Step 2: clock drawing
Say: “Next, I want you to draw a clock for me. First, put in all of the numbers where they go.” When that is completed, say: “Now, set the hands to 10 past 11.”
Use preprinted circle (see next page) for this exercise. Repeat instructions as needed as this is not a memory test. Move to Step 3 if the clock is not complete
within three minutes.
Step 3: three-word recall
Ask the person to recall the three words you stated in Step 1. Say: “What were the three words I asked you to remember?” Record the word list version number
and the person’s answers.
Scoring
Word Recall: ______ (0–3 points)
= 1 point for each word spontaneously recalled without cueing.
Clock Draw: ______ (0 or 2 points)
= Normal clock: 2 points. A normal clock has all numbers placed in the correct sequence and approximately correct position (e.g., 12, 3, 6 and 9 are in anchor
positions) with no missing or duplicate numbers. Hands are pointing to the 11 and 2 (11:10). Hand length is not scored.
Inability or refusal to draw a clock (abnormal) = 0 points.
Total Score: ______ (0–5 points)
= Total score: Word Recall score + Clock Draw score.
A cut point of <3 on the Mini-COGTM has been validated for dementia screening, but many individuals with clinically meaningful cognitive impairment will score
higher. When greater sensitivity is desired, a cut point of <4 is recommended as it may indicate a need for further evaluation of cognitive status.

From Borson S, with permission.

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 E U R O P E A N U R O L O G Y F O C U S 3 ( 2 0 17 ) 3 8 5 – 3 9 4
impairments in the setting of prostate cancer [30] con-
cluded that there was a need for agreement on the defini-
tion of cognitive impairment and standardizing of measures
to aid accurate assessment.
3.1.2.5. Other medicosocial aspects. Important information that
should be collected includes marital status, whether the
patient is living alone, the presence or otherwise of a
caregiver, nature of the accommodation (including toilet
facilities and stairs), potential support from family and
friends, education level and former occupation, and—criti-
cally—sources of finance. It is also important to consider the
possibility of neglect and abuse, and the influence of dental
health and visual and auditory impairments: can patients
hear about their treatment plan, and are they able to acquire
and take their medications safely?
The range of health status evaluations has been
described in depth [4,7,18,31], and geriatric screening tools
are accessible on the SIOG website [32]. The paper “How to
implement a GA in clinical practice” gives practical tips for
implementing screening and assessment [33].
3.2. Comprehensive geriatric assessment
The CGA is the gold standard in the assessment of health
status since it comprises a “multidisciplinary evaluation in
which the multiple problems of older persons are uncov-
ered, described, and explained if possible, and in which the
resources and strengths of the person are catalogued, need
for services assessed, and a coordinated care plan developed
to focus interventions on the person’s problems” [34].
Several randomized, controlled trials of CGA in senior
adult patients have demonstrated a beneficial effect on
survival, quality of life, and rates of institutionalization.
These findings have been confirmed by meta-analyses
[35,36]. Since the mid-1990s [37], attempts have been made
to integrate CGA into oncology. However, the best form of
CGA to use and exactly how it should be integrated into
current practice remain unclear [4,31]. Studies have exam-
ined the benefit of CGA in geriatric oncology specifically [18]
and generally support its efficacy. In patients with cancer,
CGA identifies conditions—for example, depression or mal-
nutrition—which can decrease a patient’s ability to tolerate
cancer therapy and which can be reversed by appropriate
treatment.
Following a systematic review, a SIOG task force devel-
oped recommendations on the use of CGA and screening
tools in senior adult patients with cancer [4,38]. These
guidelines were updated in 2014 [4] and 2015 [7].
The 2005 task force [38] recommended that a CGA, with
follow-up, should be used in cancer patients of 70 yr and
older to detect unaddressed problems, improve functional
status, and possibly also improve survival. At that time,
there was insufficient evidence to recommend any specific
tool or approach, and the advice was that general geriatric
experience should be used. The SIOG task force documented
strong evidence that a CGA detects problems missed by
standard assessment both in the general geriatric popula-
tion and in cancer patients. There was also strong evidence
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389
that a CGA improved function and reduced the hospitaliza-
tion rate of senior adults. There was no firm evidence that a
CGA improved survival and was cost effective. These con-
clusions remained unchanged in 2015 [4].
3.3. Health status screening tools
These include the physical performance test [39], Gronin-
gen Frailty Index [40], Vulnerable Elders Survey-13 (VES-13)
[41], Preoperative Assessment of Cancer in the Elderly [42],
Fried Frailty Index [5], and G8 [43].Other tools have also
been described and validated [7]. In busy clinical practice,
we recommend that a screening tool is used to identify
patients in need of further evaluation by CGA.
Currently, the G8 seems the most robust, since data show
high sensitivity with acceptable specificity and prognostic/
predictive value for outcome measures. The G8 was devel-
oped specifically for older cancer patients and can be com-
pleted in less than 5 min. Its eight components cover food
intake, weight loss, body mass index, mobility, neuropsy-
chological problems, polypharmacy, self-perceived health
status, and age. The questionnaire is shown in Table 3. In a
prospective noninterventional study of 1435 evaluable
patients aged 70 yr or older, Geriatric Assessment, G8,
and VES-13 were used [43]. An abnormal score on the G8
(14 on a scale of 0–17) strongly predicted 1-yr mortality.
Reproducibility of the two questionnaires was good. G8
appeared more sensitive (76.5% vs 68.7%, p = 0.0046),
whereas VES-13 was more specific (74.3% vs 64.4%,
p < 0.0001) in predicting 1-yr mortality. Abnormal G8 score
(hazard ratio [HR] = 2.72), advanced stage (HR = 3.30), male
sex (HR = 2.69), and poor performance status (HR = 3.28)
were independent prognostic factors for 1-yr survival [43].
Following studies showing the G8 to be a good way of
identifying patients requiring a CGA, the European Organi-
zation for Research and Treatment of Cancer made G8
screening compulsory for all patients aged 70 yr and older
who are included in the organization’s trials. Its use is also
recommended in European Association of Urology (EAU)
guidelines [44].
It should be noted that the objective of these tools is
different from that of tools used to predict treatment tox-
icity in elderly cancer patients [45–48]. This is the case even
if certain items are used in both instances.
The SIOG task force [7] stated in 2014 that “the perfor-
mance of different screening tools may depend on the
setting and the preferred screening tool may depend on
the clinical situation. For this reason, no specific screening
tool can be recommended or discouraged.” However, the
expert consensus of the authors of the EAU–ESTRO–ESUR–
SIOG guidelines (see below) and the updated SIOG guide-
lines on elderly prostate cancer is that the G8 should be
used.
3.3.1. Health status screening tools in urology: SIOG, EAU, and
National Cancer Center Network recommendations
Since 2014, the SIOG recommendations on elderly prostate
cancer have been fully endorsed by the EAU and are now
referred to as the EAU/ESTRO/SIOG guidelines [44]. The
390 E U R O P E A N U R O L O G Y F O C U S 3 ( 2 0 17 ) 3 8 5 – 3 9 4

Table 3 – G8 screening tool.

1.– Whether food intake has declined over the past 3 mo due to loss of Severe decrease in food intake 0
appetite, digestive problems, chewing, or swallowing difficulties
Moderate decrease in food intake 1
No decrease in food intake 2
2. Weight loss during the last 3 mo Weight loss >3 kg 0
Does not know 1
Weight loss 1–3 kg 2
No weight loss 3
3. Mobility Bed or chair bound 0
Able to get out of bed/chair but not able to go out 1
Able to go out 2
4.– Neuropsychological problems Severe depression or dementia 0
Mild dementia 1
No psychological problems 2
5. BMI, (weight in kg)/(height in m)2 <19 0
19–<21 1
21–<23 2
23 3
6. Taking more than three prescription drugs per day Yes 0
No 1
7. In comparison with other people of the same age, how the Not as good 0
patient considers his/her health status
Does not know 0.5
As good 1
Better 2
8. Age (yr) 86 0
80–85 1
<80 2

BMI = body mass index.

National Cancer Center Network (NCCN) guidelines [49] on
senior adults are based on a different approach. Instead of
recommending initial use of a screening tool, the NCCN
recommends extensive geriatric evaluation and the CGA.
However, it should be noted that the first step in manage-
ment in these guidelines is to ask “has the patient the ability
to understand the relevant information about proposed
diagnostic tests or treatments and appreciate their situa-
tion” [49]. Even so, the NCCN guidelines do not mention
specific tools to detect cognitive impairment.
Systematic reviews of the management of urological
cancer in elderly patients have been published [50], and
SIOG is preparing guidelines on bladder cancer manage-
ment in the elderly.
In SIOG guidelines, health status has generally been
defined according to the groups described by Balducci
and Extermann [51], and these align with the terminology
used in the geriatric literature [12]. Patients are described as
belonging to one of four groups: healthy or fit, frail, dis-
abled/severe comorbidities, or terminally ill. Cancer treat-
ment decisions should be adapted to each health status
group [3]. This approach has been used, for example, in the
recent SIOG guidelines on prostate cancer in elderly
patients [3].
3.3.2. Geriatric interventions
The various domains of health status impairment, and
corresponding options for intervention, are shown in
Table 4. Decisions should involve the interdisciplinary team
including medical specialists, nurses, psychologists, social
workers, nutritionists, ergotherapists, physiotherapists, and
pharmacists. Those involved in patient support, including
spiritual support, should also be included. Recommenda-
tions to help implement geriatric intervention programs
have been published [52].
3.3.3. Collaboration in screening and decision making
Inappropriate approaches to the management of elderly
people with cancer can result from common mispercep-
tions. These may be expressed in terms such as the follow-
ing: “I know how to treat this sort of cancer, so I know how
to treat the same cancer in an elderly patient”; “this patient
is too sick”; “this patient is too old”; “this old patient is not
suitable for surgery because the complications are too
severe”; and—perhaps most disturbing of all—“this patient
is too old and will die, so why prolong his suffering?”.
Arriving at such conclusions without appropriate evaluation
is wrong—and this is so even if full evaluation subsequently
supports such judgments [53]. There are clearly arguments
to promote GA instead of clinical judgment in cancer
patients, even if these do not derive specifically from the
setting of urological cancers [54,55].
The optimal practical approach that has recently been
developed is a geriatric oncology program based on
collaboration between oncology and geriatrics depart-
ments, particularly when the latter are experienced in
CGA (Fig. 3).
The foundation is the combination of evidence-based
oncological treatment guidelines and geriatric health status
evaluation. The objective of the process is a decision based
on evidence, professional co-operation, and consensus. The
initial step is G8 screening by a trained registered nurse in a
urology/oncology department and a geriatric evaluation, if
required, again by a trained nurse. A geriatric consultation

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 E U R O P E A N U R O L O G Y F O C U S 3 ( 2 0 17 ) 3 8 5 – 3 9 4 391

Table 4 – Domains of health status impairment and possible geriatric interventions.

Domain Impairment Options

Medicosocial status Poor living circumstances, absence of caregiver, Refer to social worker; consider provision of carer or nursing
insufficient financial resources home place; caregiver management; home safety evaluation
Neglect and abuse Legal protection
Functional status Dependence Physical and occupational therapy
Falls Home safety evaluation
Incontinence Pelvic floor exercise
Sensory impairments Rehabilitation
Transportation assistance
Mental health Depression Refer to psychiatrist/psychologist
Anxiety Medication
Psychological distress Support group
Spiritual distress Spiritual care
Cognitive impairment Assess capacity to understand and accept treatment
Dementia Cognitive testing
Refer to psychiatrist
Caregiver management
Consider nursing home place
Nutrition Malnutrition Specific dietary recommendations
Oral care
Comorbidities Comorbidities of differing severity Management by specialists (diagnosis and treatment)
Polypharmacy Excess number Doctor and pharmacist to review prescriptions, cancel those that
Unclear therapeutic objective are not needed, and adjust where there is risk of adverse interactions
Interactions
Clinical synthesis Frailty = simple geriatric intervention Determining simple geriatric interventions

(with a trained nurse and geriatrician) should be able to and geriatrician) will lead to a decision. In the minority of
solve the most frequent problems identified. patients who would benefit from a CGA in a geriatric
Following this, discussion within the multidisciplinary department, decisions should be made by geriatric oncology
urology–oncology board (including trained registered nurse boards in reference centers.
[(Fig._3)TD$IG]
Urologist + trained registerednurse

Screening of health status

Cancer evaluaon
G8 + Mini-COG

Diagnosis and
Normal G8 > 14 Abnormal G8 ≤ 14
staging Mini-COG abnormal

Decision making:
modulaon Geriatric assessment
of treatment Outpaent clinic

Urology tumor Assessment in

board geriatric groups Comprehensive geriatric
assessement in geriatry
Geriatric
intervenon
Therapy
Oncogeriatric board

Interacon:
urologist &
Oncological Geriatric follow-up geriatrician
follow-up

Fig. 3 – Steps in the treatment pathway that involve collaboration between specialists in urology–oncology and those in geriatrics.

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392 E U R O P E A N U R O L O G Y F O C U S 3 ( 2 0 17 ) 3 8 5 – 3 9 4
Working side by side, health professionals learn a com-
mon language and ways of establishing interdisciplinary
consensus within a consistent and coherent network. They
can also develop clinical research programs specifically
designed for older patients who are likely to benefit from
geriatric intervention. To assist the process, SIOG has
attempted to build an evidence base and a methodology
for decision making in elderly prostate cancer patients [3].
Detailed practical recommendations for elderly prostate
cancer patients have recently been published by SIOG
[3]. The next step in urology is to also consider bladder
and renal tumors. Each has specific treatment require-
ments, but patient evaluation might be very similar. Such
work is underway.
3.4. Perspectives
3.4.1. Developments in GA
Further research in health evaluation is clearly warranted.
The 2014 SIOG consensus on GA in older patients with
cancer [4] used the Oxford 2011 criteria to grade the quality
of evidence and strength of recommendations in the field
[56]. The following grades were assigned: prediction of
toxicity by CGA, levels 3 and 4; GA and overall survival,
level 4; GA contents (domains and tools), level 5; and
organization and implementation of GA in oncological prac-
tice, level 5. Hence, a great deal needs to be done. However,
worldwide efforts are ongoing [4,31,33,57]. These involve
the full range of health professionals concerned to improve
knowledge and practice in geriatric oncology with the
objective of increasing duration and quality of life.
3.4.2. Concept of global geriatric oncology
The elderly population will rise from 0.2 billion in 2008 to
0.4 billion in 2050 in the more developed countries, whereas
in less developed countries it will rise from 0.4 billion to
1.6 billion [58]. Therefore, geriatric oncology needs a truly
global reach. This will be complicated by differences in culture
and comorbidities, but—above all—by the lack of geriatricians
and education for health professionals [59]. Meeting this
need is crucial if we consider, for example, the prevalence
of bladder cancers in Egypt and Sub-Saharan Africa and that
of prostate cancers in Africa and the Caribbean.
3.4.3. Education of nongeriatrician specialists
Mutual education is key. The process starts with recognizing
the value of a team approach, and continues with a high-
quality systematic review of the evidence and achieving of
consensus on guidelines. Guidelines then need to be dis-
seminated and their application encouraged. Specialists in
oncology must now consider dedicated geriatricians as full
partners in the multidisciplinary team. Improved patient
outcome will be the driving force behind the change.
4. Conclusions
Overall, the approach to urological cancers in the fit elderly
should be the same as that in younger patients and based on
existing international recommendations. Individual elderly
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patients should be managed according to their health status
and not according to age.
Evaluation of health status should include a validated
screening tool and GA. The G8 screening tool is recom-
mended by EAU–ESTRO–ESUR–SIOG guidelines. When
patients are frail or disabled, or have severe comorbidities,
CGA is required. This may indicate the need for additional
geriatric interventions.
Encouraging urologists, medical oncologists, radiothera-
pists, geriatricians, and nursing and allied health profes-
sionals to work together means establishing formal mech-
anisms to achieve effective co-operation.
Author contributions: Jean-Pierre Droz had full access to all the data in
the study and takes responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Droz.
Acquisition of data: Droz, Puts.
Analysis and interpretation of data: Droz, Albrand, Boyle, Mottet, Puts.
Drafting of the manuscript: Droz, Mottet, Puts.
Critical revision of the manuscript for important intellectual content: Droz,
Boyle, Albrand, Mottet, Puts.
Statistical analysis: None.
Obtaining funding: Droz.
Administrative, technical, or material support: Editorial support was pro-
vided Rob Stepney (medical writer, Charlbury, UK) and funded by SIOG
(International Society of Geriatric Oncology).
Supervision: Droz.
Other: None.
Financial disclosures: Jean-Pierre Droz certifies that all conflicts of
interest, including specific financial interests and relationships and
affiliations relevant to the subject matter or materials discussed in the
manuscript (eg, employment/affiliation, grants or funding, consultan-
cies, honoraria, stock ownership or options, expert testimony, royalties,
or patents filed, received, or pending), are the following: J.P. Droz: Ho-Co:
Sanofi. G. Albrand: none. H. Boyle: Ho-Co: Pfizer, Roche, Sanofi, Janssen,
Novartis, BMS, Astellas, Pierre Fabre, and Amgen. N. Mottet: GF: Takeda
Pharmaceutical/Millenium, Astellas, Pierre Fabre, Sanofi, Pasteur; Ho-Co:
Takeda Pharmaceutical/Millenium, Jansen, Astellas, BMS, Bayer, IPSEN,
Ferring, Novartis, Nuclétron, Pierre Fabre, Sanofi, Zeneca. M. Puts: none.
Funding/Support and role of the sponsor: Editorial support was provided
by Rob Stepney (medical writer, Charlbury, UK) and funded by SIOG. Dr.
Puts is supported by a New Investigator Award of the Canadian Institutes
of Health Research.
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