Zusammenfassung
Durch die Entwicklung der Bevölkerungsstruktur werden die urologischen Tumore als typische Tumore des höheren Lebensalters an Bedeutung zunehmen. Die hauptsächlich betroffene Patientengruppe weist häufig relevante Komorbiditäten und funktionelle Beeinträchtigungen auf, die in der Therapieplanung berücksichtigt werden müssen. In den letzten Jahrzehnten konnten im Bereich der operativen Versorgung urologischer Tumore erhebliche Fortschritte in den perioperativen Komplikationsraten erzielt werden. Dabei kommt vor allem einem interdisziplinärem perioperativem Management eine große Bedeutung zu, da die Prognose-relevanten Komplikationen vor allem nicht-urologische Probleme wie Infektionen, Verwirrtheitszustände, etc. betreffen. Gleichzeitig konnten in der systemischen Therapie des Prostatakarzinoms mit der Einführung der Taxane erstmalig Überlebensvorteile für eine palliative Chemotherapie erzielt werden. Mit Einführung des Gemcitabins in die Therapie der Blasentumore scheinen den bisherigen MVAC-Protokoll äquipotente, aber besser verträgliche Therapieprotokolle möglich. Die Rolle der Wachstumsfaktoren muss in der Therapie der urologischen Tumore noch definiert werden, sei es in der Intensivierung bisheriger Therapieschemata oder in der Verbesserung der Verträglichkeit der Protokolle. Eine interdisziplinäre Zusammenarbeit zwischen Urologen, Internisten und Geriatern ist zur adäquaten Individualisierung des Therapievorgehens sinnvoll und sollte proaktiv erfolgen.
Abstract
Due to demographic developments malignancies of urogenital origin will gain increasing importance. The urologist will face a growing group of patients with co-morbidities and functional disabilities as these neoplasms increase with age. Optimisation of peri-interventional management successfully reduces the risks of surgery. Integration of taxane-based cytostatic regimes achieves a prolongation of survival in hormone-refractory metastatic prostatic cancer. The introduction of gemcitabine in the management of malignancies of the bladder seems to have reduced toxicity while maintaining anti-tumour activity in comparison to MVAC. The role of haematopoetic growth factors remains to be defined in urologic malignancies - increasing dose intensity for better activity or reduction of toxicity. Individualisation of treatment requires early cooperation of the urologist, the oncologist and the geriatrician for an optimal outcome.
Schlüsselwörter
geriatrische Onkologie - Komorbidität - peripoperatives Management - systemische Chemotherapie
Key words
Geriatric oncology - co-morbidities - perioperative management - systemic chemotherapy
Literatur
-
1
Katz S, Branch L G, Branson M H, Papsidero J A, Beck J C, Greer D S.
Active life expectancy.
N Engl J Med.
1983;
309
1218-1224
-
2
Yancik R, Havlik R J. et al .
Cancer and comorbidity in older patients: a descriptive profile.
Ann Epidemiol.
1996;
6
399-412
-
3
Coebergh J W, Janssen-Heijnen M L. et al .
Serious co-morbidity among unselected cancer patients newly diagnosed in the southeastern part of the Netherlands in 1993 - 1996.
J Clin Epidemiol.
1999;
52
1131-1136
-
4
Albertsen P C, Fryback D G. et al .
The impact of co-morbidity on life expectancy among men with localized prostate cancer.
J Urol.
1996;
156
127-132
-
5
Welch H G, Albertsen P C. et al .
Assessing competing risks in treating the elderly.
Hosp Pract (Off Ed).
1996;
31
155-156, 158 - 159, 162, passim
-
6
Newschaffer C J, Bush T L. et al .
Does comorbid disease interact with cancer? An epidemiologic analysis of mortality in a cohort of elderly breast cancer patients.
J Gerontol Biol Sci Med Sci.
1996;
53
372-378
-
7
Kattan M W, Cowen M E. et al .
A decision analysis for treatment of clinically localized prostate cancer.
J Gen Intern Med.
1997;
12
299-305
-
8
Barry M J, Albertsen P C, Bagshaw M A. et al .
Outcomes for men with clinically nonmetastatic prostate carcinoma managed with radical prostatectomy, external beam radiotherapy, or expectant management: a retrospective analysis.
Cancer.
2001;
91
2302-2314
-
9
Froehner M, Koch F R, Litz R. et al .
Comparison of the American Society of Anesthesiologists Physical Status classification with the Charlson score as predictors of survival after radical prostatectomy.
Urology.
2003;
62
698-701
-
10
Froehner M, Koch R, Litz R. et al .
Which conditions contributing to the Charlson score predict survival after radical prostatectomy?.
J Urol.
2004;
171
97-699
-
11
Extermann M.
Measuring comorbidity in older cancer patients.
Eur J Cancer.
2000;
36
453-471
-
12
Wolters U, Wolf T, Stutzer H.
ASA classifications and perioperative variables as predictors of postoperative outcome.
Br J Anesth.
1996;
77
217-222
-
13
Charlson M E, Pompei P, Ales K L. et al .
A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
J Chronic Dis.
1987;
40
373-383
-
14
Greenfield S, Blanco D M. et al .
Patterns of care related to age of breast cancer patients.
J Am Med Assoc.
1987;
257
2766-2770
-
15
Kaplan M H, Feinstein A R.
The importance of classifying initial co-morbidity in evaluating the outcome of diabetes mellitus.
J Chronic Dis.
1974;
27
387-404
-
16
Cohen H J.
Cancer and the functional status of the elderly.
Cancer.
1997;
80
1883-1886
-
17
Monfardini S, Balducci L.
A comprehensive geriatric assessment (CGA) is necessary for the study and the management of cancer in the elderly.
Eur J Cancer.
1999;
35
1771-1772
-
18
Serraino D, Fratino L, Zagonel V.
Prevalence of functional disability among elderly patients with cancer.
Crit Rev Oncol Hematol.
2001;
39
269-273
-
19
Krege S, Friedrich C. et al .
Geriatrisches Assessment: Sinnvolle Hilfe bei der Auswahl älterer Tumorpatienten für eine belastende Therapie?.
Urol A.
2004;
43
922-929
-
20
Friedrich C, Pientka L, Kolb G. et al .
Comprehensive geriatric assessment in the elderly cancer patient.
Onkologie.
2003;
26
355-360
-
21
Thomas D M, Riddle P R.
Morbidity and mortality in 100 consecutive radical cystectomies.
Br J Urol.
1982;
54
716-719
-
22
Rosario D J, Becker M, Anderson J B.
The changing pattern of mortality and morbidity from radical cystectomy.
Br J Urol.
2000;
85
427-430
-
23
Peyromaure M, Guerin F, Debre B, Zerbib M.
Surgical management of infiltrating bladder cancer in elderly patients.
Eur Urol.
2004;
45
147-154
-
24
Figueroa A, Stein J P, Dickinson M. et al .
Radical cystectomy for elderly patients with bladder carcinoma.
Cancer.
1998;
83
141-147
-
25
Chang S S, Alberts G, Cookson M S, Smith J A.
Radical cystectomy is safe in elderly patients at high risk.
J Urol.
2001;
166
938-941
-
26
Lance R S, Dinney C P, Swanson D. et al .
Radical cystectomy for invasive cancer in the octogenarian.
Oncol Rep.
2001;
8
723-726
-
27
Stroumbakis N, Herr H W, Cookson M S, Fair W R.
Radical cystectomy in the octogenarian.
J Urol.
1997;
158
2113-2117
-
28
Game' X, Soulie M, Seguin P. et al .
Radical cystectomy in patients older than 75 years: Assessment of morbidity and mortality.
Eur Urol.
2001;
39
525-529
-
29
Frazier H A, Robertson J E, Paulson D F.
Complication of radical cystectomy and urinary diversion: a retrospective study of 675 cases in 2 decades.
J Urol.
1992;
148
1401-1404
-
30
Hautmann R E, Petriconi R de, Gottfried H W. et al .
The ileal neobladder: complications and functional results in 363 patients after 11 years of followup.
J Urol.
1999;
61
422-427
-
31
Stein J P, Liesskowsky G, Cote R. et al .
Radical cystectomy in the treatment of invasive bladder cancer: longterm results in 1054 patients.
J Clin Oncol.
2001;
19
666-675
-
32
Leibovitch I, Avigad I, Ben-Chaim J. et al .
Is it justified to avoid radical cystoprostatectomy in elderly patients with invasive transitional cell carcinoma of the bladder?.
Cancer.
1993;
71
3098-3101
-
33
Takashi S, Bunzo S, Tadashi M. et al .
Orthotopic neobladder reconstruction in elderly bladder cancer patients.
Int J Urol.
2001;
8
533-538
-
34
Gschwend J E, Hautmann R E, Volkmer B G.
Radikale Zystektomie und Harnableitung beim älteren Patienten mit erhöhter Komorbidität.
Urol A.
2004;
43
930-934
-
35
Clark P E, Stein J P, Groshen S G. et al .
Radical cystectomy in the elderly: comparison of survival between younger and older patients.
Cancer.
2005;
103
546-552
-
36
Balducci L, Parker M, Sexton W, Tantranond P.
Pharmacology of antineoplastic agents in the elderly patient.
Semin Oncol.
1989;
16
76-84
-
37
Lindemann R D.
Overview: renal physiology and pathophysiology of aging.
Am J Kidney Diss.
1990;
16
275-282
-
38 Enright P L. Aging of the Respiratory System. In: Hazzard WR et al. (eds.) Principles of Geriatric Medicine & Gerontology. New York: McGraw-Hill 2003: 511-515
-
39
Wei J Y.
Cardiovascular comorbidity in the older cancer patient.
Semin Oncol.
1995;
22
9-10
-
40
Balducci L, Hardy C L, Lyman G H.
Hematopoietic growth factors in the older cancer patient.
Curr Opin Hematol.
2001;
8
170-187
-
41
Bokemeyer C, Honecker F, Wedding U. et al .
Use of hematopoietic growth factors in elderly patients receiving cytotoxic chemotherapy.
Onkologie.
2002;
25,1
32-39
-
42
Lichtman S M, Skirvin J A, Vernulapalli S.
Pharmacology of antineoplastic agents in older cancer patients.
Crit Rev Oncol Hematol.
2003;
46,2
101-114
-
43
Wit R de.
Shifting paradigms in prostate cancer; docetaxel plus low-dose prednisone - finally an effective chemotherapy.
Eur J Cancer.
2005;
41
502-507
-
44
Tannock I F, Wit R de, Berry W R. et al .
Docetaxel plus prednisone or mitoxantrone plus prednisone for advanced prostate cancer.
N Engl J Med.
2004;
351,15
1502-1512
-
45
Petrylak D P, Tangen C M, Hussain M H. et al .
Docetaxel and extramustine compared with mitoxantrone and prednisone for advanced refractory prostate cancer.
N Engl J Med.
2004;
351,15
1513-1520
-
46
Abratt R P, Brune D, Dimopoulos M A. et al .
Randomised phase III study of intravenous vinorelbine plus hormone therapy versus hormone therapy alone in hormone-refractory prostate cancer.
Ann Oncol.
2004;
15
1613-1621
-
47
Sternberg C N, Whelan P, Hetherington J. et al .
Phase III trial of satraplatin, an Oral platinum plus prednisone vs. prednisone alone in patients with hormone-refractory prostate cancer.
Oncology.
2005;
68
2-9
-
48
Bhandari M S, Petrylak D P, Hussain M.
Clinical trials in metastatic prostate cancer - Has there been real progress in the past decade?.
Eur J Cancer.
2005;
41
941-953
-
49
Smith M R, Nelson J B.
Future therapies in hormone-refractory prostate cancer.
Urology.
2005;
65: (Suppl 5A)
9-17
-
50
Bamias A, Efstathiou E, Moulopoulos L A.
The outcome of elderly patients with advanced urothelial carcinoma after platinum-based combination chemotherapy.
Ann Oncology.
2005;
16
307-313
-
51
Fossa S D, Sternberg C, Scher H I. et al .
Survival of patient with advanced urothelial cancer treated with cisplatin-based chemotherapy.
Br J Cancer.
1996;
74
1655-1659
-
52
Bajorin D F, Dodd P M, Mazumdar M. et al .
Long-term survival in metastatic transitional-cell carcinoma and prognostic factors predicting outcome of therapy.
J Clin Oncol.
1999;
17
3173-3181
-
53
Roychowdhury D F, Hayden A, Liepa A M.
Health-related quality of life parameters as independent prognostic factors in advanced or metastatic bladder cancer.
J Clin Oncol.
2003;
21
673-678
-
54
Millikan R, Dinney C, Swanson D. et al .
(2001) Integrated therapy for locally advanced bladder cancer: final report of a randomised trial of cystectomy plus adjuvant MVAC versus cystectomy with both preoperative and postoperative MVAC.
J Clin Oncol.
2003;
19
4005-4013
-
55
Nogue-Aliguer M, Carles J, Arrivi A. et al .
Gemcitabine and carboplatin in advanced transitional cell carcinoma of the urinary tract: an alternative therapy.
Cancer.
2003;
97
2180-2186
-
56
Vaughn D J, Manola J, Dreicer R. et al .
Phase II study of paclitaxel plus carboplatin in patients with advanced carcinoma of the urothelium and renal dysfunction: a trial of the Eastern Co-operative Oncology Group.
Cancer.
2002;
95
1022-1027
-
57
Hussain M, Vaishampayan U, Du W. et al .
Combination carboplatin, paclitaxel and gemcitabine is an active treatment for advanced urothelial carcinoma.
J Clin Oncol.
2001;
19
2527-2533
-
58
Castagneto B, Zai S, Marenco D. et al .
Single agent gemcitabine in previously untreated elderly patients with advanced bladder carcinoma: response to treatment and correlation with the comprehensive geriatric assessment.
Oncology.
2004;
67
27-32
-
59
Aparicio A M, Elkhouiery A B, Quinn D I.
The Current and Future Application of Adjuvant Systemic Chemotherapy in Patients with Bladder Cancer Following Cystectomy.
Urol Clin N Am.
2005;
32
217-230
-
60
Goffin J R, Rajan R, Souhami L.
Tolerance of radiotherapy and chemotherapy in elderly patients with Bladder cancer.
Am J Clin Oncol.
2004;
27
172-177
-
61
Post P, Kil P, Hendrikx A. et al .
Comorbidity in patients with prostate cancer and its relevance to treatment choice.
BJU Int.
1999;
84
652-656
Dr. med. S. Krege
Urologische Universitätsklinik Essen
Hufelandstr. 55
45147 Essen ·
Email: susanne.krege@uni-essen.de
