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Authors Daskivich TJ, Chamie K, Kwan L, et al.
Review Date Dec 2010
Citation Cancer 2010: DOI: 10.1002/cncr.25751; published 29 November 2010
Clinical guidelines recommend that men with low-risk prostate cancer and significant comorbidity should not be treated aggressively because they are more likely to die of other causes before they die from their prostate cancer and aggressive treatments have risks of side effects that adversely affect quality of life. However, these men are still susceptible to overtreatment. Given that aggressive treatment for low risk prostate cancer is also not recommended in older men with a life expectancy of less than 10 years, the authors sought to compare the impact of comorbidity and age on treatment choice in men with low-risk disease.
To compare the impact of comorbidity and age on treatment choice in men with low-risk disease.
509 men with low-risk prostate cancer diagnosed at the Greater Los Angeles and Long Beach Veterans Affairs Medical Centers between 1997 and 2004 were included in the study. Rates of aggressive treatment (radical prostatectomy, radiation therapy, brachytherapy) were determined among men of different ages and with different Charlson comorbidity scores.
Multivariate modelling was used to determine the influence of both variables in predicting nonaggressive treatment, and Cox proportional hazards analysis was used to compare the risk of other-cause mortality among groups according to Charlson score and age.
Men with Charlson scores ≥3 were treated aggressively in 54% of cases (30 of 56 men), while men aged >75 years at diagnosis were treated aggressively in 16% of cases (7 of 44 men).
In multivariate analysis, age >75 years was a much stronger predictor of nonaggressive treatment (relative risk, 12.0; 95% confidence interval [CI], 5.4-28.3) than a Charlson score ≥3 (relative risk, 2.0; 95% CI, 1.3-2.9). In survival analysis, men with Charlson scores ≥3 had an 8-fold increased risk (hazard ratio, 8.4; 95% CI, 4.2-16.6) and 70% probability of other-cause mortality at 10 years, whereas age >75 years was associated with a 5-fold increased risk (hazard ratio, 4.9; 95%CI, 1.7-13.8) and a 24% probability of other-cause mortality.
Men with significant comorbidity often were overtreated for low-risk prostate cancer. Like advanced age, significant comorbidity should be a strong relative contraindication to aggressive treatment in men with low-risk disease.
Points to Note
- Clinical guidelines suggest that a man’s life expectancy should be taken into account in treatment decisions for low-risk prostate cancer. Life expectancy is affected by a man’s age as well as general health status and comorbid conditions. Comorbidities cal also impact on the likelihood of adverse effects of aggressive treatments.
- This American study has shown that age >75 years was significantly more likely to lead to non-aggressive treatment than was a high score on a comorbidity index, even though each factor impacts on life expectancy.
- The study showed that the men with a high comorbidity index and low-risk prostate cancer had a high risk of dying from causes other than prostate cancer 10 years following treatment and a very low risk of dying from prostate cancer.
- The authors suggest that given these 10 year risks. the fact that over half of the men with severe comorbidities had aggressive treatments represents significant over-treatment. They recommend that comorbidities should play a greater part in treatment decisions for low-risk prostate cancer, in fact high levels of comorbidity should be considered a contraindication.
- There are some limitations to the study: all patients were from 2 specific treatment centres perhaps affecting generalisability of the findings; data collection was retrospective and based on medical records; low to follow-up through not being able to locate adequate records for some men.