Prostate cancer (PC) is a leading cause of death in older men. Androgen deprivation therapy (ADT) is considered the standard-of-care for men with locally advanced disease. However, continuous androgen ablation is associated with acute and long-term adverse effects and most patients will eventually develop castration-resistant PC (CRPC). The recent approval of three, second-generation androgen receptor inhibitors (ARIs), apalutamide, enzalutamide, and darolutamide, has transformed the treatment landscape of PC. Treatment with these second-generation ARIs have produced positive trends in metastasis-free survival, progression-free survival, and overall survival. For patients with non-metastatic CRPC, who are mainly asymptomatic from their disease, maintaining quality of life is a major objective when prescribing therapy. Polypharmacy for age-related comorbidities also is common in this population and may increase the potential for drug–drug interactions (DDIs).
This review summarizes the multiple factors that may contribute to the therapeutic burden of patients with CRPC, including the interplay between age, comorbidities, concomitant medications, the use of ARIs, and financial distress.
As the treatment landscape in PC continues to rapidly evolve, consideration must be given to the balance between therapeutic benefits and potential treatment-emergent adverse events that may be further complicated by DDIs with concomitant medications. Patient-centered communication is a crucial aspect of alleviating this burden, and healthcare professionals (HCPs) may benefit from training in effective patient communication. HCPs should closely and frequently monitor patient treatment responses, in order to better understand symptom onset and exacerbation. Patients also should be encouraged to participate in exercise programs, and health information and support groups, which may assist them in preventing or mitigating certain determinants of the therapeutic burden associated with PC and its management.
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United Nations. World population ageing 2019: highlights. https://www.un.org/en/development/desa/population/publications/pdf/ageing/WorldPopulationAgeing2019-Highlights.pdf. Accessed April 17, 2020.
Orimo H. [Reviewing the definition of elderly]. Nihon Ronen Igakkai Zasshi 2006;43:27–34.
Singh S, Bajorek B. Defining ‘elderly’ in clinical practice guidelines for pharmacotherapy. Pharm Pract (Granada) 2014;12:489–89.
Levine ME. Modeling the rate of senescence: can estimated biological age predict mortality more accurately than chronological age? J Gerontol Ser A, Biol Sci Med Sci 2013;68:667–74.
Salinas CA, Tsodikov A, Ishak-Howard M, Cooney KA. Prostate cancer in young men: an important clinical entity. Nat Rev Urol 2014;11:317–23.
Alibhai SM, Krahn MD, Fleshner NE, Cohen MM, Tomlinson GA, Naglie G. The association between patient age and prostate cancer stage and grade at diagnosis. BJU Int 2004;94:303–6.
Pettersson A, Robinson D, Garmo H, Holmberg L, Stattin P. Age at diagnosis and prostate cancer treatment and prognosis: a population-based cohort study. Ann Oncol 2017;29:377–85.
Jones CU, Hunt D, McGowan DG, Amin MB, Chetner MP, Bruner DW, et al. Radiotherapy and short-term androgen deprivation for localized prostate cancer. N. Engl J Med 2011;365:107–18.
Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68:394–424.
Rawla P. Epidemiology of prostate cancer. World J Oncol 2019;10:63–89.
American Cancer Society. Cancer facts & figures 2020. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2020/cancer-facts-and-figures-2020.pdf. Accessed April 20, 2020.
Mottet N, van den Bergh RCN, Briers E, Cornford P, De Santis M, Fanti S, et al. EAU - EANM - ESTRO - ESUR - SIOG guidelines on prostate cancer. https://uroweb.org/guideline/prostate-cancer/. Accessed May 7, 2020.
Luo J, Beer TM, Graff JN. Treatment of nonmetastatic castration-resistant prostate cancer. Oncology 2016;30:336–44.
Coutinho I, Day TK, Tilley WD, Selth LA. Androgen receptor signaling in castration-resistant prostate cancer: a lesson in persistence. Endocr Relat Cancer 2016;23:T179–T97.
Eton DT, Ramalho de Oliveira D, Egginton JS, Ridgeway JL, Odell L, May CR, et al. Building a measurement framework of burden of treatment in complex patients with chronic conditions: a qualitative study. Patient Relat Outcome Meas 2012;3:39–49.
Gallacher K, May CR, Montori VM, Mair FS. Understanding patients’ experiences of treatment burden in chronic heart failure using normalization process theory. Ann Fam Med 2011;9:235–43.
May C, Montori VM, Mair FS. We need minimally disruptive medicine. Br Med J 2009;339:b2803.
Committee on Improving the Quality of Cancer Care: Addressing the challenges of an aging population, Board on Health Care Services, Institute of Medicine. In: Levit L, Balogh E, Nass S, Ganz PA (eds). Delivering high-quality cancer care: charting a new course for a system in crisis. National Academies Press (US): Washington (DC), 2013.
Ernstmann N, Herden J, Weissbach L, Karger A, Hower K, Ansmann L. Prostate-specific health-related quality of life and patient-physician communication - a 3.5-year follow-up. Patient Educ Couns 2019;102:2114–21.
Ayanian JZ, Zaslavsky AM, Guadagnoli E, Fuchs CS, Yost KJ, Creech CM, et al. Patients’ perceptions of quality of care for colorectal cancer by race, ethnicity, and language. J Clin Oncol 2005;23:6576–86.
Freeman HP, Reuben SH. Voices of a broken system: real people, real problems. President’s Cancer Panel Report of the Chairman. 2000;2001.
Lee CN, Chang Y, Adimorah N, Belkora JK, Moy B, Partridge AH, et al. Decision making about surgery for early-stage breast cancer. J Am Coll Surg 2012;214:1–10.
Zikmund-Fisher BJ, Couper MP, Singer E, Ubel PA, Ziniel S, Fowler FJ Jr., et al. Deficits and variations in patients’ experience with making 9 common medical decisions: the DECISIONS survey. Med Decis Mak 2010;30:85s–95s.
Geng H-M, Chuang D-M, Yang F, Yang Y, Liu W-M, Liu L-H, et al. Prevalence and determinants of depression in caregivers of cancer patients: a systematic review and meta-analysis. Medicine 2018;97:e11863.
Harden JK, Sanda MG, Wei JT, Yarandi H, Hembroff L, Hardy J, et al. Partners’ long-term appraisal of their caregiving experience, marital satisfaction, sexual satisfaction, and quality of life 2 years after prostate cancer treatment. Cancer Nurs 2013;36:104–13.
Sambasivam R, Liu J, Vaingankar JA, Ong HL, Tan ME, Fauziana R, et al. The hidden patient: chronic physical morbidity, psychological distress, and quality of life in caregivers of older adults. Psychogeriatrics 2019;19:65–72.
Ritchie CS, Kvale E, Fisch MJ. Multimorbidity: an issue of growing importance for oncologists. J Oncol Pract 2011;7:371–4.
Carrera PM, Kantarjian HM, Blinder VS. The financial burden and distress of patients with cancer: understanding and stepping-up action on the financial toxicity of cancer treatment. CA Cancer J Clin 2018;68:153–65.
de Souza JA, Yap BJ, Wroblewski K, Blinder V, Araujo FS, Hlubocky FJ, et al. Measuring financial toxicity as a clinically relevant patient-reported outcome: the validation of the COmprehensive Score for financial Toxicity (COST). Cancer 2017;123:476–84.
Catt S, Starkings R, Shilling V, Fallowfield L. Patient-reported outcome measures of the impact of cancer on patients’ everyday lives: a systematic review. J Cancer Surviv 2017;11:211–32.
Stokes ME, Ishak J, Proskorovsky I, Black LK, Huang Y. Lifetime economic burden of prostate cancer. BMC Health Serv Res 2011;11:349.
Sanyal C, Aprikian AG, Chevalier S, Cury FL, Dragomir A. Direct cost for initial management of prostate cancer: a systematic review. Curr Oncol 2013;20:e522–31.
Raval AD, Madhavan S, Mattes MD, Sambamoorthi U. Association between types of chronic conditions and cancer stage at diagnosis among elderly Medicare beneficiaries with prostate cancer. Popul Health Manag 2016;19:445–53.
Walker V, Perret-Guillaume C, Kesse-Guyot E, Agrinier N, Hercberg S, Galan P, et al. Effect of multimorbidity on health-related quality of life in adults aged 55 years or older: results from the SU.VI.MAX 2 cohort. PLoS ONE 2016;11:e0169282.
Droz JP, Albrand G, Gillessen S, Hughes S, Mottet N, Oudard S, et al. Management of prostate cancer in elderly patients: recommendations of a task force of the International Society of Geriatric Oncology. Eur Urol 2017;72:521–31.
Wefel JS, Vardy J, Ahles T, Schagen SB. International cognition and cancer task force recommendations to harmonise studies of cognitive function in patients with cancer. Lancet Oncol 2011;12:703–08.
Chiumento C, Fiorentino A, Cozzolino M, Caivano R, Clemente S, Pedicini P, et al. Impact of comorbidity in elderly prostate cancer patients treated with brachytherapy. Chin J Cancer Res 2013;25:274–80.
Wei MY, Kawachi I, Okereke OI, Mukamal KJ. Diverse cumulative impact of chronic diseases on physical health-related quality of life: implications for a measure of multimorbidity. Am J Epidemiol 2016;184:357–65.
Chandrasekar T, Yang JC, Gao AC, Evans CP. Mechanisms of resistance in castration-resistant prostate cancer (CRPC). Transl Androl Urol 2015;4:365–80.
Heinlein CA, Chang C. Androgen receptor in prostate cancer. Endocr Rev 2004;25:276–308.
Janssen Ortho LLC ZYTIGA (abiraterone acetate) US prescribing information. http://www.janssenlabels.com/package-insert/product-monograph/prescribing-information/ZYTIGA-pi.pdf. Accessed July 22, 2019.
Rathkopf D, Scher HI. Androgen receptor antagonists in castration-resistant prostate cancer. Cancer J 2013;19:43–9.
Astellas Pharma US Inc. Xtandi (enzalutamide) US prescribing information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/203415s014lbl.pdf. Accessed June 11, 2019.
Bayer HealthCare Pharmaceuticals Inc. Nubeqa (darolutamide) US prescribing information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/212099Orig1s000lbl.pdf. Accessed December 13, 2019.
Food and Drug Administration. Prescribing information: ERLEADA. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/210951s000lbl.pdf. Accessed June 11, 2019.
Gul A, Garcia JA, Barata PC. Treatment of non-metastatic castration-resistant prostate cancer: focus on apalutamide. Cancer Manag Res 2019;11:7253–62.
McKay RR, Ye H, Xie W, Lis R, Calagua C, Zhang Z, et al. Evaluation of intense androgen deprivation before prostatectomy: a randomized phase II trial of enzalutamide and leuprolide with or without abiraterone. J Clin Oncol 2019;37:923–31.
Ryan C, Wefel JS, Morgans AK. A review of prostate cancer treatment impact on the CNS and cognitive function. Prostate Cancer Prostatic Dis 2020;23:207–19.
Nguyen PL, Alibhai SM, Basaria S, D’Amico AV, Kantoff PW, Keating NL, et al. Adverse effects of androgen deprivation therapy and strategies to mitigate them. Eur Urol 2015;67:825–36.
Hussain M, Fizazi K, Saad F, Rathenborg P, Shore N, Ferreira U, et al. Enzalutamide in men with nonmetastatic, castration-resistant prostate cancer. N Engl J Med 2018;378:2465–74.
Sternberg CN, Fizazi K, Saad F, Shore ND, De Giorgi U, Penson DF, et al. Enzalutamide and survival in nonmetastatic, castration-resistant prostate cancer. N. Engl J Med 2020;382:2197–206.
Beer TM, Tombal B. Enzalutamide in metastatic prostate cancer before chemotherapy. N. Engl J Med 2014;371:1755–6.
Scher HI, Fizazi K, Saad F, Taplin ME, Sternberg CN, Miller K, et al. Increased survival with enzalutamide in prostate cancer after chemotherapy. N. Engl J Med 2012;367:1187–97.
Smith MR, Saad F, Chowdhury S, Oudard S, Hadaschik BA, Graff JN, et al. Apalutamide treatment and metastasis-free survival in prostate cancer. N. Engl J Med 2018;378:1408–18.
Smith MR, Saad F, Chowdhury S, Oudard S, Hadaschik BA, Graff JN, et al. Apalutamide and overall survival in prostate cancer. Eur Urol. 2021; 79:150–158.
Fizazi K, Shore N, Tammela TL, Ulys A, Vjaters E, Polyakov S, et al. Darolutamide in nonmetastatic, castration-resistant prostate cancer. N. Engl J Med 2019;380:1235–46.
Fizazi K, Shore N, Tammela TL, Ulys A, Vjaters E, Polyakov S, et al. Nonmetastatic, castration-resistant prostate cancer and survival with darolutamide. N. Engl J Med 2020;383:1040–49.
Mateo J, Fizazi K, Gillessen S, Heidenreich A, Perez-Lopez R, Oyen WJG, et al. Managing nonmetastatic castration-resistant prostate cancer. Eur Urol 2019;75:285–93.
Graff JN, Baciarello G, Armstrong AJ, Higano CS, Iversen P, Flaig TW, et al. Efficacy and safety of enzalutamide in patients 75 years or older with chemotherapy-naive metastatic castration-resistant prostate cancer: results from PREVAIL. Ann Oncol 2016;27:286–94.
Pilon D, Behl AS, Ellis LA, Robitaille MN, Lefebvre P, Dawson NA. Assessment of real-world central nervous system events in patients with advanced prostate cancer using abiraterone acetate, bicalutamide, enzalutamide, or chemotherapy. Am Health Drug Benefits 2017;10:143–53.
Scher HI, Beer TM, Higano CS, Anand A, Taplin ME, Efstathiou E, et al. Antitumour activity of MDV3100 in castration-resistant prostate cancer: a phase 1-2 study. Lancet 2010;375:1437–46.
Williams S, Mazibuko N, O’Daly O, Zurth C, Patrick F, Woolridge C, et al. Significant localized reduction in cerebral blood flow (CBF) in regions relevant to cognitive function with enzalutamide (ENZA) compared to darolutamide (DARO) and placebo (PBO) in healthy volunteers. J Clin Oncol 2020;38:abstr 326.
Sandmann S, Trummel D, Seidel D, Nubbemeyer R, Gieschen H, Zurth C Higher blood-brain barrier penetration of [14C]apalutamide and [14C]enzalutamide compared to [14C]darolutamide in rats using whole-body autoradiography. ASCO Genitourinary Cancers Symposium; 14–16 February; San Francisco.
Zurth C, Sandmann S, Trummel D, Seidel D, Gieschen H. Blood-brain barrier penetration of [14C]darolutamide compared with [14C]enzalutamide in rats using whole body autoradiography. J Clin Oncol 2018;36:345.
Moilanen AM, Riikonen R, Oksala R, Ravanti L, Aho E, Wohlfahrt G, et al. Discovery of ODM-201, a new-generation androgen receptor inhibitor targeting resistance mechanisms to androgen signaling-directed prostate cancer therapies. Sci Rep. 2015;5:12007.
van Haastregt JC, Zijlstra GA, van Rossum E, van Eijk JT, Kempen GI. Feelings of anxiety and symptoms of depression in community-living older persons who avoid activity for fear of falling. Am J Geriatr Psychiatry 2008;16:186–93.
Galvao DA, Taaffe DR, Spry N, Joseph D, Turner D, Newton RU. Reduced muscle strength and functional performance in men with prostate cancer undergoing androgen suppression: a comprehensive cross-sectional investigation. Prostate Cancer Prostatic Dis 2009;12:198–203.
Network NCC. National Comprehensive Cancer Network clinical practice guidelines in oncology: cancer-related fatigue. https://www.nccn.org/professionals/physician_gls/pdf/fatigue.pdf. Accessed July 6, 2020.
Galvao DA, Taaffe DR, Spry N, Newton RU. Exercise can prevent and even reverse adverse effects of androgen suppression treatment in men with prostate cancer. Prostate Cancer Prostatic Dis 2007;10:340–6.
Taaffe DR, Newton RU, Spry N, Joseph D, Chambers SK, Gardiner RA, et al. Effects of different exercise modalities on fatigue in prostate cancer patients undergoing androgen deprivation therapy: a year-long randomised controlled trial. Eur Urol 2017;72:293–99.
Winters-Stone KM, Dobek JC, Bennett JA, Dieckmann NF, Maddalozzo GF, Ryan CW, et al. Resistance training reduces disability in prostate cancer survivors on androgen deprivation therapy: evidence from a randomized controlled trial. Arch Phys Med Rehabil 2015;96:7–14.
Joly F, Giffard B, Rigal O, De Ruiter MB, Small BJ, Dubois M, et al. Impact of cancer and its treatments on cognitive function: advances in research from the Paris International Cognition and Cancer Task Force symposium and update since 2012. J Pain Symptom Manag 2015;50:830–41.
Cherrier MM, Anderson K, David D, Higano CS, Gray H, Church A, et al. A randomized trial of cognitive rehabilitation in cancer survivors. Life Sci 2013;93:617–22.
Ercoli LM, Petersen L, Hunter AM, Castellon SA, Kwan L, Kahn-Mills BA, et al. Cognitive rehabilitation group intervention for breast cancer survivors: results of a randomized clinical trial. Psychooncology 2015;24:1360–7.
Sutton E, Hackshaw-McGeagh LE, Aning J, Bahl A, Koupparis A, Persad R, et al. The provision of dietary and physical activity advice for men diagnosed with prostate cancer: a qualitative study of the experiences and views of health care professionals, patients and partners. Cancer Causes Control 2017;28:319–29.
Kaiser A, Haskins C, Siddiqui MM, Hussain A, D’Adamo C. The evolving role of diet in prostate cancer risk and progression. Curr Opin Oncol 2019;31:222–29.
Li H, Hodgson E, Watson L, Shukla A, Nelson JJ. Comorbidities and concomitant medication use in men with prostate cancer or high levels of PSA compared to matched controls: a GPRD analysis. J Cancer Epidemiol 2012;2012:291704.
Fleshner K, Tin A, Benfante N, Carlsson S, Vickers AJ. Comparison of physician-documented versus patient-reported collection of comorbidities among patients with prostate cancer upon first visit to the urology clinic. JCO Clin Cancer Inform 2018;2:1–10.
Shore N, Zurth C, Fricke R, Gieschen H, Graudenz K, Koskinen M, et al. Evaluation of clinically relevant drug–drug interactions with darolutamide in the phase 3 ARAMIS trial for patients with nonmetastatic castration-resistant prostate cancer. Target Oncol 2019;14:527–39.
Astellas. Xtandi prescribing information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/203415s014lbl.pdf. Accessed September 26, 2018.
Janssen Ortho LLC. Erleada (apalutamide) US prescribing information. Revised 09/2020. http://www.janssenlabels.com/package-insert/product-monograph/prescribing-information/ERLEADA-pi.pdf. Accessed October 21, 2020.
Del Re M, Fogli S, Derosa L, Massari F, De Souza P, Crucitta S, et al. The role of drug-drug interactions in prostate cancer treatment: focus on abiraterone acetate/prednisone and enzalutamide. Cancer Treat Rev 2017;55:71–82.
Pollock Y, Smith M, Saad F, Chowdhury S, Oudard S, Hadaschik B, et al. Predictors of falls and fractures in patients (pts) with nonmetastatic castration-resistant prostate cancer (nmCRPC) treated with apalutamide (APA) plus ongoing androgen deprivation therapy (ADT). J Clin Oncol 2019;37:5025.
Zurth C, Koskinen M, Fricke R, Prien O, Korjamo T, Graudenz K, et al. Drug–drug interaction potential of darolutamide: in vitro and clinical studies. Eur J Drug Metab Pharmacokinet 2019;44:747–59.
Nelson CJ, Lee JS, Gamboa MC, Roth AJ. Cognitive effects of hormone therapy in men with prostate cancer: a review. Cancer 2008;113:1097–106.
Treanor CJ, Li J, Donnelly M. Cognitive impairment among prostate cancer patients: an overview of reviews. Eur J Cancer Care 2017;26:e12642.
Coons SJ, Eremenco S, Lundy JJ, O’Donohoe P, O’Gorman H, Malizia W. Capturing patient-reported outcome (PRO) data electronically: the past, present, and promise of ePRO measurement in clinical trials. Patient 2015;8:301–09.
Lucas SM, Kim TK, Ghani KR, Miller DC, Linsell S, Starr J, et al. Establishment of a web-based system for collection of patient-reported outcomes after radical prostatectomy in a statewide quality improvement collaborative. Urology 2017;107:96–102.
Saad F, Cella D, Basch E, Hadaschik BA, Mainwaring PN, Oudard S, et al. Effect of apalutamide on health-related quality of life in patients with non-metastatic castration-resistant prostate cancer: an analysis of the SPARTAN randomised, placebo-controlled, phase 3 trial. Lancet Oncol 2018;19:1404–16.
Tombal B, Saad F, Penson D, Hussain M, Sternberg CN, Morlock R, et al. Patient-reported outcomes following enzalutamide or placebo in men with non-metastatic, castration-resistant prostate cancer (PROSPER): a multicentre, randomised, double-blind, phase 3 trial. Lancet Oncol 2019;20:556–69.
Fizazi K, Shore ND, Tammela T, Kuss I, Le Berre MA, Mohamed AF, et al. Impact of darolutamide (DARO) on pain and quality of life (QoL) in patients (Pts) with nonmetastatic castrate-resistant prostate cancer (nmCRPC). ASCO; May 31–June 4; Chicago, USA.
Protopapa E, van der Meulen J, Moore CM, Smith SC. Patient-reported outcome (PRO) questionnaires for men who have radical surgery for prostate cancer: a conceptual review of existing instruments. BJU Int 2017;120:468–81.
Small EJ, Saad F, Chowdhury S, Oudard S, Hadaschik BA, Graff JN, et al. Final survival results from SPARTAN, a phase III study of apalutamide (APA) versus placebo (PBO) in patients (pts) with nonmetastatic castration-resistant prostate cancer (nmCRPC). J Clin Oncol 2020;38:abstr 5516.
Fizazi K, Shore ND, Tammela T, Ulys A, Vjaters E, Polyakov S, et al. Overall survival (OS) results of phase III ARAMIS study of darolutamide (DARO) added to androgen deprivation therapy (ADT) for nonmetastatic castration-resistant prostate cancer (nmCRPC). J Clin Oncol 2020;38:abstr 5514.
Poquet N, Lin C. The Brief Pain Inventory (BPI). J Physiother 2016;62:52.
Marzouk S, Naglie G, Tomlinson G, Duff Canning S, Breunis H, Timilshina N, et al. Impact of androgen deprivation therapy on self-reported cognitive function in men with prostate cancer. J Urol 2018;200:327–34.
Von Ah D, Jansen CE, Allen DH. Evidence-based interventions for cancer- and treatment-related cognitive impairment. Clin J Oncol Nurs 2014;18(Suppl):17–25.
Yellen SB, Cella DF, Webster K, Blendowski C, Kaplan E. Measuring fatigue and other anemia-related symptoms with the Functional Assessment of Cancer Therapy (FACT) measurement system. J Pain Symptom Manag 1997;13:63–74.
Morris C, Gibbons E, Fitzpatrick R Patient reported outcome measures. http://phi.uhce.ox.ac.uk/pdf/CancerReviews/PROMs_Oxford_Prostate%20Cancer_012011.pdf. Accessed December 18, 2018.
Okuyama T, Akechi T, Kugaya A, Okamura H, Shima Y, Maruguchi M, et al. Development and validation of the cancer fatigue scale: a brief, three-dimensional, self-rating scale for assessment of fatigue in cancer patients. J Pain Symptom Manag 2000;19:5–14.
Hinz A, Mehnert A, Kocalevent RD, Brähler E, Forkmann T, Singer S, et al. Assessment of depression severity with the PHQ-9 in cancer patients and in the general population. BMC Psychiatry. 2016;16:22.
Teng E, Becker BW, Woo E, Knopman DS, Cummings JL, Lu PH. Utility of the functional activities questionnaire for distinguishing mild cognitive impairment from very mild Alzheimer’s disease. Alzheimer Dis Assoc Disord 2010;24:348–53.
Marshall GA, Zoller AS, Lorius N, Amariglio R, Locascio J, Johnson K, et al. Functional activities questionnaire items that best discriminate and predict progression from clinically normal to mild cognitive impairment. Curr Alzheimer Res 2015;12:493–502.
Pickard AS, Ray S, Ganguli A, Cella D. Comparison of FACT- and EQ-5D–based utility scores in cancer. Value Health 2012;15:305–11.
Devlin N, Herdman M, Pavesi M, Phung, Naidoo S, Beer TM, et al. Health-related quality of life effects of enzalutamide in patients with metastatic castration-resistant prostate cancer: an in-depth post hoc analysis of EQ-5D data from the PREVAIL trial. Health Qual Life Outcomes 2017;15:130.
Medical writing support was provided by Farzana Miah, MSc, of Scion, London, UK. Editorial support, including referencing, and proofreading was provided by Annabel Ola, MSc, of Scion, London, UK. All medical writing and editorial services were funded by Bayer HealthCare Pharmaceuticals, Inc. (Whippany, NJ, USA) according to Good Publication Practice guidelines (Link). However, the ultimate responsibility for opinions, conclusions, and data interpretation lies with the authors.
Conflict of interest
DS has received grants from Janssen and personal fees from Janssen, Blue Earth, and AstraZeneca. NS has received personal fees from Amgen, Astellas, AstraZeneca, Bristol-Myers Squibb, Bayer, Dendreon, Ferring, Fergene, Janssen, Merck, Myovant, Nymox, Pfizer, Sanofi, Tolmar, Boston Scientific, and MDx Health. OS has received personal fees from AAA, Astellas, AstraZeneca, Bayer, Blue Earth diagnostics, Bravarin Nordic, Bristol-Myers Squibb, Clovis, Constellation, Dendreon, EMD Serono, Endocyte, Pfizer, Progenics, Sanofi, Merck, Myriad, Noria Therapeutics, Noxopaharm, Point Biopharma, Tenebio, Theragnostics, Telix, Clarity Pharmaceuticals, Novartis, and Janssen, and has received grants from AAA, AstraZeneca, Bayer, Endocyte, Progenics, Sanofi, Innocrin, Invitae, Merck, Novartis, Sotio and Janssen. KO reports consulting for Exelixis. DR declares no conflict of interest.
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Spratt, D.E., Shore, N., Sartor, O. et al. Treating the patient and not just the cancer: therapeutic burden in prostate cancer. Prostate Cancer Prostatic Dis (2021). https://doi.org/10.1038/s41391-021-00328-1