Over-treatment of older men with life expectancies < 10 years

According to a paper newly published in Cancer, “Men aged < 80 years at diagnosis who have life expectancies < 10 years often receive aggressive treatment for low-risk and intermediate-risk prostate cancer, mostly with radiation therapy.” Unless you look at the details of this paper, you could easily get the impression that this conclusion refers to men being diagnosed and treated today. In fact, the data supporting this conclusion apply only to men diagnosed between 1991 and 2007. (See also this report on the ScienceDaily web site.)

Now it is certainly true that men who are diagnosed with early-stage, low- and intermediate-risk prostate cancer today, and who also have major comorbidities and a life expectancy of < 10 years, are still at risk for over-treatment of their cancer (for a number of reasons, including uncertainty about their life expectancy). However, it is important to see the new paper by Daskivich et al. as a reference against which to be able to assess whether such risk for over-treatment declines over time in the future. It does not tell us what the actual risk for over-treatment is today, in 2014.

Daskivich et al. actually report the following:

  • They sampled data from 96,032 men aged ≥ 66 years and diagnosed with early-stage prostate cancer and Gleason scores ≤ 7 between 1991 to 2007 (using data from the Surveillance, Epidemiology, and End Results-Medicare database).
  • Overall, life expectancy (i.e., the 10-year other-cause mortality rate) was < 10 years for 50,049/96,032 of these men (52 percent).
  • Life expectancy varied based on age and comorbidity score and was < 10 years for
    • Men aged 66 to 69 years with Charlson scores ≥ 2
    • Men aged 70 to 74 years with Charlson scores ≥ 1
    • All men aged 75 to 79 years
    • All men aged ≥ 80 years
  • For the men with a life expectancy < 10 years, treatment was aggressive (surgery, radiation, or brachytherapy) for
    • 68 percent of men aged 66 to 69 years
    • 69 percent of men aged 70 to 74 years
    • 57 percent of men aged 75 to 79 years
    • 24 percent of men aged ≥ 80 years
  • For the same set of men with a life expectancy of < 10 years, aggressive treatment was
    • Radiation therapy for
      • 50 percent of men aged 66 to 69 years
      • 53 percent of men aged 70 to 74 years
      • 63 percent of men aged 75 to 79 years
      • 69 percent of men aged ≥ 80 years
    • Surgery for
      • 30 percent of men aged 66 to 69 years
      • 25 percent of men aged 70 to 74 years
      • 13 percent of men aged 75 to 79 years
      • 9 percent of men aged ≥ 80 years

It is profoundly to be hoped that, when we are able to look at comparable data for the period from 2008 to 2014, we will see a far greater percentage of these men with limited life expectancies being managed on active surveillance and/or watchful waiting so that therapy can be deferred for as long as possible, and the patients can maintain the highest possible quality of life until it is clear that aggressive or palliative therapy is really necessary.

The “New” Prostate Cancer InfoLink understands that some older men with limited life expectancies will simply not be willing to accept “living with” a known diagnosis of cancer — even low-risk prostate cancer that is highly unlikely to even metastasize. However, all these men have the right to, and should be given, a thorough and careful explanation of the risks and benefits of aggressive treatment as compared to expectant management.

5 Responses

  1. To assess appropriateness of aggressive treatment, isn’t it important to know the PSA score at diagnosis, and the PSA doubling rate?

  2. Dear Grover:

    The authors of this paper state that their analysis was limited to men diagnosed with either low-risk or intermediate-risk prostate cancer.
    Low-risk men must have a clinical stage of T2a or less, a PSA level of 10 ng/ml or less, and a Gleason score of 6 or less; intermediate-risk men can have a clinical stage no higher than T2c, a Gleason score of no higher than 7 and a PSA level no higher than 20 ng/ml. The PSA doubling time is not a factor in assignment of risk level.

    I have not seen the entire text of this paper — only the abstract. Obviously, any man who had high-risk disease (i.e., a clinical stage of T3 or higher, a PSA level of 20 of higher, or a Gleason score of 8 or higher) would not have been eligible for inclusion in this analysis. Dr. Daskivich and his colleagues are not stating that no man over 65 with a life expectancy of < 10 years needs treatment. All they are saying is that there are an awful lot of such men getting aggressive treatment who are highly unlikely to gain any benefit from such treatment in terms of their life expectancy, and so those men are at great risk for the side effects and complications of treatment but unlikely to receive any other significant benefit. I am confident that if you got hold of the full text of the paper, it would address some of these issues in a god deal more detail.

  3. I totally agree with your last two paragraphs. Patient preference must get considered, particularly if the patient is not beset by other health issues.

  4. What is the Charlson score based on? Reference if possible please.

  5. The Charlson score or Charlson co-morbidity index is a number based on a combination of a patient’s age and the presence or absence of a number of common health conditions. It can be used to project the probability of death within 10 years for an individual patient. The higher the patient’s score, the lower the probability of his or her long-term survival. Thus it is a useful way to classify people into groups based on their general, overall health. There are several variations on the Charlson score that can be used that have slightly different levels of accuracy under specific circumstances. The link in this response gives you access to a detailed overview for one of the basic versions.

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