Quality of life (QoL) analyses in the context of therapeutic trials and standard-of-care therapies are now commonplace, deepening our understanding of current therapeutic strategies and the disease overall. However, follow-up duration of QoL analyses rarely extends beyond a period of 5 to 10 years. Studies characterizing the experience of people living beyond a decade after a prostate cancer diagnosis are rare, and thus our understanding of the long-term survivor population is nearly nonexistent. To address this, in a study published in this issue, Meissner et al¹ present patient-reported outcomes (PROs) data from nearly 3,000 prostate cancer survivors who had undergone prior prostatectomy, including data integrating QoL, frailty, and emotional well-being collected an average of 17.4 years after surgery. This is the first study to characterize these PROs after such a prolonged period. As advances in treatment are increasing the number of people surviving after a prostate cancer diagnosis, understanding impacts of QoL, frailty, and emotional well-being on the survivor experience is a critical first step in enhancing the quality of survival for these individuals.

Worldwide, the number of annual diagnoses of prostate cancer is expected to double in the next 15 years, from approximately 1.4 to 2.9 million.² With a median age at diagnosis of 67 years in the United States, many of those diagnosed will be older adults with comorbid illnesses or age-related factors that inherently increase the risk of frailty, underscoring the need for clinicians to measure and take frailty into account over time. The International Society of Geriatric Oncology recommends screening older patients with prostate cancer with a G8 geriatric screening tool that risk-stratifies individuals into fit, vulnerable, or frail categories.³ This approach enables clinicians to engage those individuals who are vulnerable or frail with interventions that may enhance their well-being, perhaps reversing aspects of the frailty phenotype, and potentially enabling them to undergo treatments with a greater likelihood of conferring long-term benefit. If frailty is associated with poorer QoL and emotional well-being, as suggested by Meissner et al,¹ an assessment of this type would be useful not only at the initial diagnosis and treatment decision but also in the follow-up period. An annual assessment, for example, could address and preempt reversible causes of frailty, such as referrals to physical therapy, engagement with pharmacy team members to reduce polypharmacy, or connecting with dieticians for nutritional support. Such low-cost and low-intensity interventions promise to reduce the risk of mortality and improve emotional health and the overall survivorship experience. Indeed, advocacy and guidelines organizations, including ASCO, similarly recommend risk stratification approaches for any individual older than 65 years with a cancer diagnosis, suggesting widespread support for such an approach across the cancer care spectrum.⁴ Extending this approach to the survivor population would be a reasonable use of resources, enabling a standardized safety net assessment for an aging population at high risk. Efforts to implement these kinds of assessments in our oncology and cancer survivorship clinics should be considered.

Numerous approaches could be taken to improve QoL and mood in prostate cancer survivors. Some of the most enticing approaches are those focused on diet, exercise, and lifestyle changes. Epidemiologic studies suggest that death from prostate cancer is affected by both diet and exercise following diagnosis and treatment.⁵ We have known for more than 20 years through interventional studies of resistance and aerobic exercise that overall QoL and fatigue are improved with these interventions. Greater clinician awareness of these data, and their implementation into comprehensive survivorship programs, offers an opportunity to reduce the risks induced by frailty.⁶

Meissner et al¹ were successful in analyzing data from nearly 3,000 prostate cancer survivors included in their study. The duration of time since treatment (average 17.4 years) and the median age of participants (79.4 years) also speak to the dedication of the patient group. These individuals are committed to sharing their experiences, even almost 2 decades after treatment. As investigators and clinicians, we have more commonly engaged populations that are closer to localized or systemic treatments, and we have been more limited in broader survey research such as this. Despite our lack of engaging them, prostate cancer survivors appear eager to be heard. A separate analysis included 15,824 prostate cancer survivors at various stages of the cancer journey who completed an online survey of approximately 80 questions to share their experiences with diagnosis and treatment, including QoL assessments.⁷ The survey study was open to enrollment for a mere 60 days before reaching and exceeding its enrollment goal, clearly demonstrating the interest of the prostate cancer survivor population in sharing perspectives on their experience if investigators wish to engage.

As we consider prostate cancer survivorship and the way that our patients are living longer, it is incumbent upon us to think more broadly about how the oncology community can enhance their lives beyond surgery, radiation, or other definitive treatments. Multivariate analyses performed by Meissner et al¹ suggest that frailty is more common in patients who experience disease relapse and require subsequent therapy. That said, it remains to be determined what proportion of frailty risk can be directly attributed to specific prostate cancer treatments. Their work further shows that, even after a cure, frailty is a risk. Strategies to identify and reverse frailty and support mental health are needed across the lifetime of these individuals, and the oncology community must remember this over the years of long-term follow-up to ensure that we are a consistently positive force for the health of the prostate cancer survivor community over time. Perhaps these efforts will remain in some of our practices, and certainly we will need to engage colleagues in internal medicine and primary care to understand and support this group of survivors, especially as this study demonstrates the extent of life ahead of them. Regardless, we must expand our reach and curiosity and consider long-term follow-up beyond the 10-year mark as we strive to positively affect our patients’ quality of survival for as long as possible.