This is challenging. Officially, in the CHAARTED trial, he would be considered to have low-volume disease. We all know that this is an arbitrary distinction, but the trial was essentially negative in that subgroup. The hazard ratio is similar, but the p-value was nonsignificant. Those patients fared well with hormonal therapy. In general I’m not offering docetaxel to men with low-volume disease.

However, some men still want to receive chemotherapy, and it may confer some benefit, particularly for men with symptomatic disease and large metastases. The number of metastases doesn’t tell much about the volume of disease or symptom status. I will make some exceptions, but in general I offer docetaxel to patients with high-volume disease and decide on a case-by-case basis for patients with low-volume disease.

For an asymptomatic 80-year-old with 3 isolated rib metastases, I would be less inclined to offer docetaxel.

This patient would have low-volume disease according to the CHAARTED criteria, and I would be less inclined to encourage docetaxel. I would discuss the CHAARTED data with the patient, but I would administer goserelin and bicalutamide. Age would not affect my treatment approach, so I would take the same approach for an 80-year-old patient.

At this time we have no clear evidence for the benefit of docetaxel in patients with low-volume metastases, so I would initiate ADT for both of these patients.

This 62-year-old man would receive ADT and docetaxel — the new standard — and I believe that anybody with obvious bone metastases should be considered for bone-strengthening or bone-enhancing therapy. If he were 80 years old, then my treatment approach would depend on his overall performance status, liver function, bone marrow reserve and other criteria. I would not deny him the benefits of the CHAARTED approach based solely on age, but if he didn’t have the reserves, then I would treat with ADT.

I would recommend ADT alone for this patient, with the option for bone-targeted treatment, for which I would choose denosumab in this setting because zoledronic acid is supposedly indicated only for patients with castration-resistant disease. My rationale for not choosing chemotherapy in this case is that this patient does not have high-volume disease by the entry criteria for the CHAARTED trial.

For an 80-year-old, asymptomatic patient with 3 isolated rib metastases, I would also tend to administer ADT and denosumab as an option. In general I do not treat based on performance status or age and tend to treat based more on patients’ physiologic age than on their chronologic age.

I would administer ADT alone to a 62-year-old asymptomatic man with a good performance status and 3 isolated rib metastases, and I would use the same approach for the 80-year-old patient.

My approach for such a patient would be androgen deprivation alone. Although I have not yet used this procedure with any patients, spot radiation for what are called oligometastatic lesions is raising interest, with the hope that such an approach might slow down those metastatic deposits and prolong the patient’s survival. I don’t believe we have any data yet to support this approach, but people are doing it.

Depending on performance status, I might be even more inclined to go with androgen deprivation alone for an 80-year-old and not inflict other agents on him. I would monitor the patient to see how he responded. He might have a prolonged response to androgen deprivation alone.

This 62-year-old patient has fewer than 4 metastases, so I would administer hormone therapy initially. I would have a discussion with the patient about the CHAARTED data, which demonstrated that the median overall survival for patients with low-volume disease has not yet been reached. At this time the evidence does not support administering docetaxel, but that could change in the future. It would be up to the patient to decide.

If the patient were 80 years old and in the same situation, my approach would not differ and I would administer ADT.

This 62-year-old asymptomatic patient doesn’t have high-volume disease, so I would offer ADT alone. I would not recommend bone-targeted therapy as we have no data to support that.

The results of the CHAARTED study showed a clear positive signal for patients with high-volume disease as it was prospectively defined. The hazard ratio for patients with low-volume disease was good, but the data are still immature. As the data mature I will reassess what the best approach is for these patients. We also have to consider the results of the GETUG-AFU 15 study, which demonstrated no benefit with the addition of docetaxel to ADT. We need to see more mature data from this study too.

If the patient were 80 years old I would consider not only performance status but also comorbidities. Some elderly patients are healthy and not on any medications. Other patients may have a history of congestive heart failure or renal failure. Though age and performance status are key drivers, other factors have to be taken into consideration. I would also evaluate the patient’s medical history and then make a decision as to the best approach.

I would offer this patient ADT alone. This patient has low-volume disease and we don’t have strong data to suggest that chemotherapy would be beneficial in that subgroup of patients. I would consider combination therapy with an agonist and antiandrogen or monotherapy with an antagonist such as degarelix. I would monitor the patient, determine the PSA nadir and consider either a clinical trial or close follow-up to detect progression to castration-resistant prostate cancer.

I would consider administering denosumab to this patient with 3 rib metastases. I believe that denosumab is beneficial in delaying time to bone metastasis and prolonging bone metastasis-free survival, as indicated in the 147 trial.

My approach would not change if the patient were 80 years old. The patient population I treat is largely geriatric. Seventy percent of the patients I treat are older than 65, and most of them usually have a good performance status despite being in their eighth or ninth decades.