Life expectancy and lifetime risk of prostate cancer mortality

The recently revised National Comprehensive Cancer Network guidelines for the management of prostate cancer emphasize the importance of life expectancy in estimating individual patient risk of prostate cancer mortality — particularly for those patients with low- and very low-risk disease.

Kim et al. have now published a methodology that  should allow physicians, when counseling newly diagnosed patients, to more effectively communicate the risk for death from prostate cancer as compared to the risk of death from competing causes through an estimate of the patients’ lifetime risks of prostate cancer-specific mortality.

The process uses a special form of actuarial life table (“double decrement” life tables) to calculate age-specific mortality rates using data from the Social Security Administration life tables and Gleason score-specific mortality rates reported from a pre-PSA cohort study. The new life tables provide life expectancy and risk for prostate cancer death based on age at diagnosis, Gleason score, and other factors.

The authors offer the following example: A 60-year-old prostate cancer patient with a Gleason score of 7 has an overall life expectancy 10.2 years based on the pre-PSA cohort data. His risk for prostate cancer-specific death during these 10.2 expected years of life is 49 percent. However, if it is assumed that early detection as a consequence of PSA testing introduces a 10-year “lead-time bias,” the patient’s risk for death from prostate cancer decreases to 26 percent. Furthermore, if the patient was in the bottom (poorest) quartile for overall health and his disease was detected by prostate examination, the risk for death from prostate cancer was 32 percent.

The authors have developed a Web-based tool that allows online performance of these computions. Unfortunately, however, this tool is not as user-friendly as we believe it needs to be, and most patients would find it difficult to apply in its present form. We hope that this online tool can be improved because it offers a potentially very useful way to estimate lifetime risk of prostate cancer mortality — particularly for those with low- and very low-risk disease who are considering active surveillance as an appropriate form of management for their disease.

Editorial addition: Since posting the above material early this morning, we have been advised by Roswell Park Cancer Center that they are very conscious of the need to improve the above-mentioned Web page and are working hard to be able to offer a significantly more user-friendly version of their lifetime risk estimator as soon as possible. We will keep readers informed of relevant developments.

10 Responses

  1. If the model is based on Albertson’s paper, which is pre-PSA, it would be very unwise to try to extrapolate the information to men diagnosed by PSA even knowing there is a 10-year lead time. The result is highly likely to be incorrect. The only group for whom it may be appropriate is men who are diagnosed by an abnormal digital rectal exam.

  2. Dr. Chodak: My assumption is that this model needs to be appropriately tested. I don’t believe that the authors are suggesting it is “accurate.” My impression is that they are saying it is a means of making an “estimate” that ought to be better than just guessing.

  3. A 105 year old can use the tool but a 49-year-old can’t. Another missed opportunity.

  4. Tony:

    This tool isn’t that accurate. If I was a 49-year-old (or even a 47-year-old) I would just enter my age as 50. It will still give you a rough estimate, which is all that this tool can really do anyway.

  5. What is the life expectancy of a 65 year old with a Gleason of 7 with removal of the prostate as opposed to no treatment?

  6. Tony:

    You can use the Kattan pre-treatment nomogram to project your probability of prostate cancer-specific survival at 15 years and your probability of biochemical-free recurrence at 10 years post surgery. However, in addition to your age and your Gleason score you will need to know your PSA level, your clinical stage, and the number of positive and negative biopsy cores taken by your urologist at the time of biopsy.

  7. What is the life expectancy of a 72-year-old with and without removal of prostate — with a Gleason of 6, clinical stage T1c, PSA 23.4, with 2 biopsy cores positive and 14 negative?

  8. Dear Andy:

    It is impossible to answer this question accurately for an individual. However, there is a lot of evidence now to suggest that — on average — the life expectancy of individuals with a tumor of the type you describe would not be changed by radical surgery.

  9. Gleason score 10; PSA “well over 100” per the physicians; pelvic bones and pelvic lymph — what is typical life expectancy?

  10. Dear Ellen:

    There is no real way to tell you a “typical” life expectancy for the sort of patient you describe, because so much will depend on how that patient responds to treatment. If you were to join our social network, where we can ask you some more questions about the specific patient, then we might be able give you some better feedback.

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