Longer life or quality of life? What do newly diagnosed patients really want?

A third, and interesting, late-breaking poster to be presented at the upcoming annual meeting of the American Urological Association looked into patient perspectives on quality of life as opposed to quantity of life in prostate cancer treatment decision making.

Moses et al. (Late-Breaking Science & Technology Posters; abstract no. LB-S&T-33) used data from a cohort of 1,555 men in the so-called “Live Well Live Long Study” — a prospective, multi-site study of men diagnosed with clinically localized prostate cancer between 2010 and 2014.  Prior to their treatment, all participants were asked a series of trade-off questions like these:

  • “Which is the worst for you to live with long term, unable to have erections, rectal bleeding, no sex drive, pain, cancer spreading, urgency of urination, or leakage of urine?”
  • “How long do you expect you will live if being treated with” radical prostatectomy, radiation therapy, or active surveillance?”

The answers to these questions were then used to build models that could be used to predict the likelihood that a particular patient would receive radical prostatectomy, radiation therapy, or active surveillance by using independent predictor variables such as D’Amico classification, age, race/ethnicity, education, employment, expected quantity of life, and attitudes towards treatment side-effects.

The researchers found that:

  • In all models tested
    • D’Amico classification  was a positive predictor of treatment received.
    • Patient age was a positive predictor of treatment received.
    • Side effects of treatment was not a significant predictor of treatment received.
  • In the trade-off between the two treatment outcomes based on the two questions given above,
    • 87.4 percent of patients reported that cancer spreading/progressing was the worst outcome for them to accept long-term.
    • The odds ratios (ORs) among men with a post-treatment life expectancy of 10 to 20 years were
      • OR = 10.5 for radical prostatectomy (p = 0.01)
      • OR = 148.9 for radiation therapy (p < 0.001)
      • OR = 111.6 for active surveillance (p < 0.001)
    • The ORs among men with a post-treatment life expectancy of > 20 years were
      • OR = 88.8 for radical prostatectomy (p < 0.001)
      • OR = 655 for radiation therapy (p < 0.001)
      • OR = 542.2 for active surveillance (p < 0.001)

The authors conclude that:

When making their [prostate cancer] treatment decision, attitudes towards [prostate cancer] treatment side-effects are likely important; however, the findings of this study suggest that men care more about the quantity of life a particular treatment modality will provide than quality of life after treatment.

What The “New” Prostate Cancer InfoLink finds interesting is that a group of researchers was at least willing to explore this issue.

We suspect, however, that there are significant methodological issues related to how this study was carried out, and we have to wonder what the patients had been told about the risks and complications associated with invasive treatment for prostate cancer and their likelihoods of being alive at 10 and 20 years after initial management on active surveillance when this study was started back in 2010. The results seem to have a strong aroma of a self-fulfilling prophecy.

4 Responses

  1. Agree re your conclusion re this study.

  2. I’ve found that there are two major (interrelated) influences in how questions like this are answered: (1) how soon after diagnosis was the question asked, and (2) how many specialists the patient has seen. Because the first meeting is always with a urologist and the news is shocking, the first reaction is invariably “just cut it out.” With time, information gathering on sites like this, and meeting with a variety of specialists, those reactions often change. This study proves the importance of encouraging patients to take their time and gather information before deciding.

  3. “Longer life or quality of life?”

    It should be well known that this is a false dichotomy since no-one has yet proven that the various screening strategies yield an increase in overall survival. Urology surgeons and their associates are the worst offenders in promoting this false dichotomy.

  4. Dear David:

    “Longer life vs. quality of life” is by no means a “false dichotomy” at all. There are extensive data on a range of therapies that may or may not extend survival under very specific circumstances. This is utterly separate from the issue of whether screening is a good idea or not. Try putting yourself in the shoes of a 67-year-old man who is failing all known forms of androgen deprivation (inclusive of abiraterone and enzalutamide). The survival benefit of any other known therapy at that point in time is distinctly small. But there are a lot of things that can be done to maintain your quality of life without trying to extend it.

    Conversely, we know that some men with Gleason 8-10 high-risk tumnors can actually be cured if they are treated early. So in a case like that there is very definitely a quality of life vs quantity of life equation to be solved by each patient because no one can guarantee to an individual patient up front that invasive therapy of a specific type will cure him. It may or it may not. One only finds out afterwards!

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