Life expectancy ≤ 10 years and the risks associated with treatment

According to Reuters, a new article, forthcoming on line in the Annals of Internal Medicine, tells us (not too surprisingly) that, “Older men with other illnesses may not live long enough to benefit from aggressive prostate cancer treatments, such as prostate removal or radiation, and they’d have to live with their side effects.”

Apparently, in an editorial that accompanies the main article, Lazzaro et al. write that, “The challenge for the physician is to accurately evaluate the life expectancy of a patient in order to balance the risk for prostate cancer mortality with that of other-cause mortality.”

Again, this is hardly a surprise to anyone with even a limited understanding of the natural history of prostate cancer in older patients … and prostate cancer is most common in men > 60 years of age.

The article in Reuters was supposedly to be published on line earlier this week, and we had been hoping to be able to see at least the abstract of the paper in the Annals of Internal Medicine, but as of this morning that abstract is still not available on line. That article is based on additional data from the Prostate Cancer Outcomes Study (PCOS) that we also referred to yesterday.

“If you’re going to die of a heart attack in 5 years, what’s the point of going through radiation?” Dr. David Penson, the study’s senior author is quoted as asking by Reuters. “The key point is that when men are choosing therapy for prostate cancer, they need to consider their tumor characteristics, their age and other characteristics,” he continues.

According to Reuters, in the study data reported in the Annals of Internal Medicine, and based on the PCOS data set (which included men between 39 and 89 years of age diagnosed between October 1994 and October 1995), Penson et al. report that, after tracking these men for some 15 years from diagnosis:

  • The risk of dying from high-risk prostate cancer was 18 percent.
  • The risk of dying from low-risk prostate cancer was 3 percent.
  • Older men were more likely to die from something other than prostate cancer during the 10 years following diagnosis if they had other ailments.
  • For men with three or more co-morbid conditions
    • About 40 percent of men of 61 to 74 years of age died of something else within 10 years of their prostate cancer diagnosis.
    • About 71 percent of men of 75 years and older died of something else within 10 years of their prostate cancer diagnosis.

We are not yet able to use the data from this study to individualize decision making about the management of prostate cancer or the appropriateness of active surveillance over invasive therapies. However, what this study does tell us very clearly is that, even among men being diagnosed nearly 20 years ago, the risk of death from prostate cancer within 10 years of diagnosis among men diagnosed with low-risk disease is small, and it is particularly small for men with one or more co-morbidities. Thus the potential benefits of treatment for men with a life expectancy of 10 years or less are limited by comparison with the risks to quality of life from the treatment itself. By comparison, active surveillance and other forms of careful monitoring look like excellent potential options.

7 Responses

  1. When I was diagnosed at 64 years old, one urologist had the gall to tell me, in the first 10 minutes, how long I was going to live. He had absolutely no clue with whom he was speaking. So I only have 4,745 days left by his compromised bedside manner. I have no prostate cancer now, and with a cholesterol level of 165 and participation in several sports he might have been a tiny bit wrong. Some doctors sure love playing that “God card” though.

  2. Does that above statistic — “risk of dying from high-risk prostate cancer was 18 per cent” — apply to men who have not had treatment for their high-risk prostate cancer?

  3. Dear Chris:

    No. That was regardless of types of treatment over time. If one had no treatment for high-risk prostate cancer at all, I have to assume that the risk of prostate cancer-specific mortality would be higher.

  4. High risk/low risk. How is this defined. After being diagnosed with prostate cancer, when would it become apparent that it was either high or low risk? Is there a test?

  5. Dear Nancy:

    There are three basic, clinical risk categories for men with localized prostate cancer. (Anyone who has non-localized prostate cancer at diagnosis is de facto “high risk”.)

    The three clinical risk categories for men diagnosed with localized disease are as follows (as originally defined by a set of researchers led by Dr. Anthony D’Amico and therefore known as the D’Amico risk categories):

    Low risk are those men with all of these three characteristics — a clinical stage of T2a or lower; a PSA level of less than 10 ng/ml; and a Gleason score of 6 or lower.

    Intermediate risk are those men with any one or more of these characteristics — a clinical stage of T2b or T2c (depending on the staging system being used); a PSA level of 10-20 ng/ml; and a Gleason score of 7.

    High risk are those men with any one or more of these characteristics — a clinical stage of T3 or T4; a PSA level of 20 ng/ml or higher; and a Gleason score of 8, 9 or 10.

    Any man can be assigned to one of these clinical risk categories as soon as he has the results of his biopsy (because by then he should already have been told his PSA level and his clinical stage as well as his Gleason score).

    There are minor variations in how different organizations assign risk, but the D’Amico system is the basis on which all such risk assignments are constructed.

    Hope that helps. There is no additional test required to assign men to one of these three risk categories.

  6. Dear Sir:

    I have already had eight cycles of chemotherapy, and my PSA came down from 11.03 to 5.03 ng/ml. I am experiencing some side effects, and a new treatment is under way.

    I am soon going to have a choline-11 PET scan, and I would like to be able to find out how long it takes for the Taxol to be removed from my body. After that we will take further decisions.

    Fco. Benzo

  7. Dear Francisco:

    It is not clear to me what your clinical stage is. Did you have chemotherapy for an aggressive, early-stage or a recurrent form of prostate cancer? Have you already had treatment with either surgery or radiation therapy or both (before the chemotherapy)?

    Taxanes like docetaxel (Taxotere) and paclitaxel (Taxol) are cleared from the body relatively quickly, with more than 85% of docetaxel being excreted from the body within 86 hours after infusion according to studies using radioactively labeled forms of this drug.

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