The assessment of patient life-expectancy: how accurate are urologists and oncologists?

Lower urinary tract symptoms in elderly men: Considerations for prostate cancer testing

PURPOSE

Both lower urinary tract symptoms (LUTS) and prostate cancer (PCa) are common in elderly men. While LUTS are generally due to a benign etiology, they may provoke an evaluation with prostate-specific antigen (PSA), which can lead to a cascade of further testing and possible overdiagnosis in patients with competing risks. There is limited patient and provider understanding of the relationship between LUTS and PCa risk, and a lack of clarity in how to evaluate these men to balance appropriate diagnosis of aggressive PCa with avoidance of overdiagnosis.

METHODS

A literature review was performed using keywords to query the electronic database PubMed. All articles published before November 2023 were screened by title and abstract for articles relevant to our subject.

RESULTS

Epidemiological studies suggest that LUTS and PCa are largely independent in elderly men. The best available tools to assess PCa risk include PSA permutations, novel biomarkers, and imaging, but there are limitations in older men based on lack of validation in the elderly and unclear applicability of traditional definitions of "clinically significant" disease. We present a three-tiered approach to evaluating these patients.

CONCLUSION

Elderly men commonly have LUTS as well as a high likelihood of indolent PCa. A systematic and shared decision-making-based approach can help to balance objectives of appropriate detection of phenotypically dangerous disease and avoidance of over-testing and overdiagnosis.

Protocol of a randomised, controlled trial comparing immediate curative therapy with conservative treatment in men aged ≥75 years with non-metastatic high-risk prostate cancer (SPCG 19/GRand-P)

BACKGROUND

Older men (aged ≥75 years) with high risk, non-metastatic prostate cancer (PCa) are increasingly treated with curative therapy (surgery or radiotherapy). However, it is unclear if curative therapy prolongs life and improves health-related quality of life (HRQoL) in this age group compared to conservative therapy, which has evolved considerably during the last decade.

STUDY DESIGN

The Scandinavian Prostate Cancer Group (SPCG) 19/Norwegian Get-Randomized Research Group-Prostate (GRand-P) is a randomised, two-armed, controlled, multicentre, phase III trial carried out at study centres in Norway, Denmark, Finland, and Sweden.

ENDPOINTS

The primary endpoints are overall survival and HRQoL (burden of disease scale, European Organisation for the Research and Treatment of Cancer [EORTC] Elderly Cancer patients). Secondary endpoints are PCa-specific survival, metastasis-free survival, role-functioning scale (EORTC quality of life questionnaire 30-item core), urinary irritative/obstructive scale (26-item Expanded Prostate Cancer Index Composite [EPIC-26]), bowel scale (EPIC-26), intervention-free survival, PCa morbidity, use of secondary and tertiary systemic therapies, mean quality-adjusted life-years (QALYs), and mean total healthcare costs.

PATIENTS AND METHODS

A total of 980 men (aged ≥75 years) with non-metastatic, high-risk PCa will initially be screened with Geriatric 8 (G8) health status screening tool and Mini-COG© brief cognitive test. Participants identified by G8 as 'fit' or 'frail' will be randomised (ratio 1:1) to either immediate curative therapy (radiotherapy or prostatectomy) or conservative therapy (endocrine therapy or observation). Participants who are unable or unwilling to participate in randomisation will be enrolled in a separate observation group. Randomised patients will be followed for 10 years.

TRIAL REGISTRATION

Ethics approval has been granted in Norway (457593), Denmark (H-22051998), Finland (R23043) and Sweden (Dnr 2023-05296-01). The trial is registered on Clinicaltrials.org (NCT05448547).

Health care delivery system contributions to management of newly diagnosed prostate cancer

BACKGROUND

Despite clinical guidelines advocating for use of conservative management in specific clinical scenarios for men with prostate cancer, there continues to be tremendous variation in its uptake. This variation may be amplified among men with competing health risks, for whom treatment decisions are not straightforward. The degree to which characteristics of the health care delivery system explain this variation remains unclear.

METHODS

Using national Medicare data, men with newly diagnosed prostate cancer between 2014 and 2019 were identified. Hierarchical logistic regression models were used to assess the association between use of treatment and health care delivery system determinants operating at the practice level, which included measures of financial incentives (i.e., radiation vault ownership), practice organization (i.e., single specialty vs. multispecialty groups), and the health care market (i.e., competition). Variance was partitioned to estimate the relative influence of patient and practice characteristics on the variation in use of treatment within strata of noncancer mortality risk groups.

RESULTS

Among 62,507 men with newly diagnosed prostate cancer, the largest variation in the use of treatment between practices was observed for men with high and very high-risk of noncancer mortality (range of practice-level rates of treatment for high: 57%-71% and very high: 41%-61%). Addition of health care delivery system determinants measured at the practice level explained 13% and 15% of the variation in use of treatment among men with low and intermediate risk of noncancer mortality in 10 years, respectively. Conversely, these characteristics explained a larger share of the variation in use of treatment among men with high and very high-risk of noncancer mortality (26% and 40%, respectively).

CONCLUSIONS

Variation among urology practices in use of treatment was highest for men with high and very high-risk noncancer mortality. Practice characteristics explained a large share of this variation.

Using Competing Risk of Mortality to Inform the Transition from Prostate Cancer Active Surveillance to Watchful Waiting

BACKGROUND

For men on active surveillance (AS) for prostate cancer (PCa), disease progression and age-related changes in health may influence decisions about pursuing curative treatment.

OBJECTIVE

To evaluate the predicted PCa and non-PCa mortality at the time of reclassification among men on AS, to identify clinical criteria for considering a transition from AS to watchful waiting (WW).

DESIGN, SETTING, AND PARTICIPANTS

Patients enrolled in a large AS program who experienced biopsy grade reclassification (Gleason grade increase) were retrospectively examined. All patients who had complete documentation of medical comorbidities at reclassification were included.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

A validated model was used to assess 10- and 15-yr untreated PCa and non-PCa mortalities based on patient comorbidities and PCa clinical characteristics. We compared the ratio of predicted PCa mortality with predicted non-PCa mortality ("predicted mortality ratio") and divided patients into four risk tiers based on this ratio: (1) tier 1 (ratio: >0.33), (2) tier 2 (ratio 0.33-0.20), (3) tier 3 (ratio 0.20-0.10), and (4) tier 4 (ratio <0.10).

RESULTS AND LIMITATIONS

Of the 344 men who were reclassified, 98 (28%) were in risk tier 1, 85 (25%) in tier 2, 93 (27%) in tier 3, and 68 (20%) in tier 4 for 10-yr mortality. Fifteen-year risk tiers were distributed similarly. The 23 (6.7%) men who met the "transition triad" (age >75 yr, Charlson Comorbidity Index >3, and grade group ≤2) had a 14-fold higher non-PCa mortality risk and a lower predicted mortality ratio than those who did not (0.07 vs 0.23, p < 0.001). The primary limitations of our study included its retrospective nature and the use of predicted mortalities.

CONCLUSIONS

At reclassification, nearly half of patients had a more than five-fold and one in five patients had a more than ten-fold higher risk of non-PCa death than patients having a risk of untreated PCa death. Despite a more significant cancer diagnosis, a transition to WW for older men with multiple comorbidities and grade group <3 PCa should be considered.

PATIENT SUMMARY

Men with favorable-risk prostate cancer and life expectancy of >10 yr are often enrolled in active surveillance, which entails delay of curative treatment until there is evidence of more aggressive disease. We examined a group of men on active surveillance who developed more aggressive disease, and found, nevertheless, that the majority of these men continued to have a dramatically higher risk of death from non-prostate cancer causes than from prostate cancer based on a risk prediction tool. For men older than 75 yr, who have multiple medical conditions and who do not have higher-grade cancer, it may be reasonable to reconsider the need for curative treatment given the low risk of death from prostate cancer compared with the risk of death from other causes.

A Clinical Decision Aid to Support Personalized Treatment Selection for Patients with Clinical T1 Renal Masses: Results from a Multi-institutional Competing-risks Analysis

BACKGROUND

Personalized treatment for clinical T1 renal cortical masses (RCMs) should take into account competing risks related to tumor and patient characteristics.

OBJECTIVE

To develop treatment-specific prediction models for cancer-specific mortality (CSM), other-cause mortality (OCM), and 90-d Clavien grade ≥3 complications across radical nephrectomy (RN), partial nephrectomy (PN), thermal ablation (TA), and active surveillance (AS).

DESIGN, SETTING, AND PARTICIPANTS

Pretreatment clinical and radiological features were collected for consecutive adult patients treated with initial RN, PN, TA, or AS for RCMs at four high-volume referral centers (2000-2019).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Prediction models used competing-risks regression for CSM and OCM and logistic regression for 90-d Clavien grade ≥3 complications. Performance was assessed using bootstrap validation.

RESULTS AND LIMITATIONS

The cohort comprised 5300 patients treated with RN (n = 1277), PN (n = 2967), TA (n = 476), or AS (n = 580). Over median follow-up of 5.2 yr (interquartile range 2.5-8.7), there were 117 CSM, 607 OCM, and 198 complication events. The C index for the predictive models was 0.80 for CSM, 0.77 for OCM, and 0.64 for complications. Predictions from the fitted models are provided in an online calculator (https://small-renal-mass-risk-calculator.fredhutch.org). To illustrate, a hypothetical 74-yr-old male with a 4.5-cm RCM, body mass index of 32 kg/m², estimated glomerular filtration rate of 50 ml/min, Eastern Cooperative Oncology Group performance status of 3, and Charlson comorbidity index of 3 has predicted 5-yr CSM of 2.9-5.6% across treatments, but 5-yr OCM of 29% and risk of 90-d Clavien grade 3-5 complications of 1.9% for RN, 5.8% for PN, and 3.6% for TA. Limitations include selection bias, heterogeneity in practice across treatment sites and the study time period, and lack of control for surgeon/hospital volume.

CONCLUSIONS

We present a risk calculator incorporating pretreatment features to estimate treatment-specific competing risks of mortality and complications for use during shared decision-making and personalized treatment selection for RCMs.

PATIENT SUMMARY

We present a risk calculator that generates personalized estimates of the risks of death from cancer or other causes and of complications for surgical, ablation, and surveillance treatment options for patients with stage 1 kidney tumors.

Estimating patient health in prostate cancer treatment counseling

BACKGROUND

We assessed the concordance among urologists' judgment of health quartiles for patients with localized prostate cancer, and compared the life expectancy (LE) and ensuing treatment recommendations when following National Comprehensive Cancer Network (NCCN) guidelines based on actuarial life tables versus the Kent model, a validated LE prediction model.

METHODS

NCCN suggests using actuarial life tables and relying on surgeon assessment of patient health to increase (for the best quartile) or decrease (for the worst quartile) LE by 50%. Eleven urologic surgeons allocated quartile of health and recommended treatments for ten patient vignettes. The 10-year survival probability was calculated using the Kent model and compared to the life-table estimate based on health quartile by surgeon consensus.

RESULTS

Surgeon assessment agreed with the presumed true quartile of health based on a validated model in 41% of cases. For no case did three-quarters of surgeons assign health quartile correctly; in half of cases, <50% of surgeons assigned the correct quartile. The NCCN comorbidity-adjusted LE estimates underestimated risk of death in the best health quartile and overestimated risk of death in the worst health quartile, compared to the Kent model. Patients with LE > 10 years on NCCN estimation were recommended more frequently for surgery (81%) and those with ≤10 years estimated LE were more commonly recommended for radiation (57%) or observation (29%).

CONCLUSIONS

A method based on physician-assessed health quartiles for LE estimation, as suggested by the NCCN guidelines, appears too crude to be used in the treatment counseling of men with localized prostate cancer, as compared to a validated prediction model, such as the Kent model.

Impact of frailty on surgery for glioblastoma: a critical evaluation of patient outcomes and caregivers' perceptions in a developing country

OBJECTIVE

The authors aimed to evaluate the impact of age and frailty on the surgical outcomes of patients with glioblastoma (GBM) and to assess caregivers' perceptions regarding postdischarge care and challenges faced in the developing country of India.

METHODS

This was a retrospective study of patients with histopathologically proven GBM from 2009 to 2018. Data regarding the clinical and radiological characteristics as well as surgical outcomes were collected from the institute's electronic database. Taking Indian demographics into account, the authors used the cutoff age of 60 years to define patients as elderly. Frailty was estimated using the 11-point modified frailty index (mFI-11). Patients were divided into three groups: robust, with an mFI score of 0; moderately frail, with an mFI score of 1 or 2; and severely frail, with an mFI score ≥ 3. A questionnaire-based survey was done to assess caregivers' perceptions about postdischarge care.

RESULTS

Of the 276 patients, there were 93 (33.7%) elderly patients and 183 (66.3%) young or middle-aged patients. The proportion of severely frail patients was significantly more in the elderly group (38.7%) than in the young or middle-aged group (28.4%) (p < 0.001). The authors performed univariate and multivariate analysis of associations of different short-term outcomes with age, sex, frailty, and Charlson Comorbidity Index. On the multivariate analysis, only frailty was found to be a significant predictor for in-hospital mortality, postoperative complications, and length of hospital and ICU stay (p < 0.001). On Cox regression analysis, the severely frail group was found to have a significantly lower overall survival rate compared with the moderately frail (p = 0.001) and robust groups (p < 0.001). With the increase in frailty, there was a concomitant increase in the requirement for readmissions (p = 0.003), postdischarge specialist care (p = 0.001), and help from extrafamilial sources (p < 0.001). Greater dissatisfaction with psychosocial and financial support among the caregivers of severely frail patients was seen as they found themselves ill-equipped to provide postdischarge care at home (p < 0.001).

CONCLUSIONS

Frailty is a better predictor of poorer surgical outcomes than chronological age in terms of duration of hospital and ICU stay, postoperative complications, and in-hospital mortality. It also adds to the psychosocial and financial burdens of the caregivers, making postdischarge care challenging.

Clinical Frailty Scale in Predicting Postoperative Outcomes in Older Patients Undergoing Curative Surgery for Urologic Malignancies: A Prospective Observational Cohort Study

OBJECTIVE

To examine the utility of the Clinical Frailty Scale (CFS) in predicting outcomes in older adults with urologic malignancies undergoing curative surgeries.

METHODS

This prospective observational cohort study was conducted in a university-based tertiary medical center. Patients aged 75 years or older who were scheduled to undergo curative surgery for a urologic malignancy from January 2017 to December 2017 were recruited. Patients were grouped according to the CFS scores. The primary postoperative outcome measures were a major complication within 30 days and a decline in the activities of daily living (ADL) within 30 days and 90 days. Multivariable analyses and the area under the receiver operating characteristic curve were performed to investigate the association between the CFS and postoperative outcomes.

RESULTS

A total of 82 patients, 50% women, were enrolled with mean age 81.6 years. The CFS was significantly associated with postoperative outcomes in a dose-response relationship. When compared with those with a CFS <5, patients with CFS scores ≥5 had a 10.3-times higher risk for a major complication, 8.5-times and 21.4-times higher risk for a decline in ADL within 30 days and 90 days. The area under the receiver operating characteristic curves for the CFS to predict a major complication, the 30-day decline in ADL and the 90-day decline in ADL were 0.60, 0.73, and 0.79.

CONCLUSION

A higher CFS score predicted a higher risk of poor outcomes in this population. It is recommended that patients with higher CFS scores, especially above 5, are needed to receive further multidisciplinary perioperative care.

Life expectancy estimates for patients diagnosed with prostate cancer in the Veterans Health Administration

PURPOSE

Accurate life expectancy estimates are required to inform prostate cancer treatment decisions. However, few models are specific to the population served or easily implemented in a clinical setting. We sought to create life expectancy estimates specific to Veterans diagnosed with prostate cancer.

MATERIALS AND METHODS

Using national Veterans Health Administration electronic health records, we identified Veterans diagnosed with prostate cancer between 2000 and 2015. We abstracted demographics, comorbidities, oncologic staging, and treatment information. We fit Cox Proportional Hazards models to determine the impact of age, comorbidity, cancer risk, and race on survival. We stratified life expectancy estimates by age, comorbidity and cancer stage.

RESULTS

Our analytic cohort included 145,678 patients. Survival modeling demonstrated the importance of age and comorbidity across all cancer risk categories. Life expectancy estimates generated from age and comorbidity data were predictive of overall survival (C-index 0.676, 95% CI 0.674-0.679) and visualized using Kaplan-Meier plots and heatmaps stratified by age and comorbidity. Separate life expectancy estimates were generated for patients with localized or advanced disease. These life expectancy estimates calibrate well across prostate cancer risk categories.

CONCLUSIONS

Life expectancy estimates are essential to providing patient-centered prostate cancer care. We developed accessible life expectancy estimation tools for Veterans diagnosed with prostate cancer that can be used in routine clinical practice to inform medical-decision making.

Understanding of prognosis in non-metastatic prostate cancer: a randomised comparative study of clinician estimates measured against the PREDICT prostate prognostic model

PREDICT Prostate is an individualised prognostic model that provides long-term survival estimates for men diagnosed with non-metastatic prostate cancer ( www.prostate.predict.nhs.uk ). In this study clinician estimates of survival were compared against model predictions and its potential value as a clinical tool was assessed. Prostate cancer (PCa) specialists were invited to participate in the study. 190 clinicians (63% urologists, 17% oncologists, 20% other) were randomised into two groups and shown 12 clinical vignettes through an online portal. Each group viewed opposing vignettes with clinical information alone, or alongside PREDICT Prostate estimates. 15-year clinician survival estimates were compared against model predictions and reported treatment recommendations with and without seeing PREDICT estimates were compared. 155 respondents (81.6%) reported counselling new PCa patients at least weekly. Clinician estimates of PCa-specific mortality exceeded PREDICT estimates in 10/12 vignettes. Their estimates for treatment survival benefit at 15 years were over-optimistic in every vignette, with mean clinician estimates more than 5-fold higher than PREDICT Prostate estimates. Concomitantly seeing PREDICT Prostate estimates led to significantly lower reported likelihoods of recommending radical treatment in 7/12 (58%) vignettes, particularly in older patients. These data suggest clinicians overestimate cancer-related mortality and radical treatment benefit. Using an individualised prognostic tool may help reduce overtreatment.

Patient Characteristics and General Practitioners' Advice to Stop Statins in Oldest-Old Patients: a Survey Study Across 30 Countries

BACKGROUND

Statins are widely used to prevent cardiovascular disease (CVD). With advancing age, the risks of statins might outweigh the potential benefits. It is unclear which factors influence general practitioners' (GPs) advice to stop statins in oldest-old patients.

OBJECTIVE

To investigate the influence of a history of CVD, statin-related side effects, frailty and short life expectancy, on GPs' advice to stop statins in oldest-old patients.

DESIGN

We invited GPs to participate in this case-based survey. GPs were presented with 8 case vignettes describing patients > 80 years using a statin, and asked whether they would advise stopping statin treatment.

MAIN MEASURES

Cases varied in history of CVD, statin-related side effects and frailty, with and without shortened life expectancy (< 1 year) in the context of metastatic, non-curable cancer. Odds ratios adjusted for GP characteristics (ORadj) were calculated for GPs' advice to stop.

KEY RESULTS

Two thousand two hundred fifty GPs from 30 countries participated (median response rate 36%). Overall, GPs advised stopping statin treatment in 46% (95%CI 45-47) of the case vignettes; with shortened life expectancy, this proportion increased to 90% (95CI% 89-90). Advice to stop was more frequent in case vignettes without CVD compared to those with CVD (ORadj 13.8, 95%CI 12.6-15.1), with side effects compared to without ORadj 1.62 (95%CI 1.5-1.7) and with frailty (ORadj 4.1, 95%CI 3.8-4.4) compared to without. Shortened life expectancy increased advice to stop (ORadj 50.7, 95%CI 45.5-56.4) and was the strongest predictor for GP advice to stop, ranging across countries from 30% (95%CI 19-42) to 98% (95% CI 96-99).

CONCLUSIONS

The absence of CVD, the presence of statin-related side effects, and frailty were all independently associated with GPs' advice to stop statins in patients aged > 80 years. Overall, and within all countries, cancer-related short life expectancy was the strongest independent predictor of GPs' advice to stop statins.

Defining low-value PSA testing in a large retrospective cohort: Finding common ground between discordant guidelines

BACKGROUND

Reports of low-value prostate-specific antigen (PSA) testing (testing in which the harms outweigh the benefits) generally employ population level data sources. While such results may be generalizable, they often lack the detail necessary to understand provider clinical decision making and guideline concordance. Using a retrospective study of PSA testing at our institution we intend to characterize the frequency and patterns associated with low-value PSA testing.

METHODS

We leveraged the electronic health record to determine guideline-defined low-value testing in our health system from 07/01/2012 to 06/30/2017. Secondarily, we measured the between-testing interval for repeat tests and the rates of prostate cancer risk factors and comorbidities among men receiving screening.

RESULTS

Overall, 21,145 PSA tests were performed on 12,303 men. The rate of low-value testing ranged from 23.4 to 56.8%, depending upon the specific guideline. For repeat tests, the median between-testing interval was 12.6 months. Risk factors for prostate cancer were uncommon, but more frequent in men age <55 years compared to men age 55-69 years (17.6% vs. 13.5%, p < 0.001). Screened older men (age >70 years) were more likely to have a Charlson Comorbidity Index ≥ 3, compared to the 55-69 reference group (31.4% vs. 17.3%, p < 0.001).

CONCLUSION

Low-value prostate cancer testing is prevalent. Between-testing intervals were often times shorter than recommended. Screening among younger men was frequent despite low rates of risk factors. High rates of comorbidity may limit life expectancy among older men receiving screening. These findings highlight the need for improved guidance with prostate cancer screening.

An audit of urological MDT decision making in the South West of England

Objective:

The formation of multidisciplinary teams (MDTs) was formalised for urological cancer services by the National Institute for Health and Care Excellence (NICE) in the 2002 Improving Outcomes in Urological Cancer guidance. This project aimed to assess the variability of MDT recommendations when presented with the same patient. It covered the type and grade of tumour, recorded stage, treatment recommendations and whether clinical trials were considered.

Materials and methods:

Anonymised details of 10 patients were sent to South West Trust MDTs in two tranches. Details included age, clinical history, haematology and biochemistry results, digital radiology, and pathology text. A panel of representative urologists and urological oncologists from the region decided on optimal treatment and key points of management decisions.

Results:

The MDTs were not consistent in decision making. This agrees with a previous survey of urologists which also showed inconsistent decision making, and under-use of clinical cues. Some decisions contradicted NICE guidelines in force at the time.

Conclusions:

MDTs are now an instrumental, integrated part of cancer management. It is vital for assurance of best patient care and best outcomes that the MDT considering and planning treatment is fully functional and well informed on the evidence base, with effective communications. This audit suggests that this is not the case. The Oxford Centre for Evidence-based Medicine – Levels of Evidence is not applicable to this study.

Cancer cachexia: Diagnosis, assessment, and treatment

Cancer cachexia is a multi-factorial syndrome, which negatively affects quality of life, responsiveness to chemotherapy, and survival in advanced cancer patients. Our understanding of cachexia has grown greatly in recent years and the roles of many tumor-derived and host-derived compounds have been elucidated as mediators of cancer cachexia. However, cancer cachexia remains an unmet medical need and attempts towards a standard treatment guideline have been unsuccessful. This review covers the diagnosis, assessment, and treatment of cancer cachexia; the elements impeding the formulation of a standard management guideline; and future directions of research for the improvement and standardization of current treatment procedures.

Life expectancy calculation in urology: Are we equitably treating older patients?

Introduction

The aim of our study was to determine the contemporary practice in the utilization of life expectancy (LE) calculations among urological clinicians.

Material and methods

Members of the Irish Society of Urology (ISU) and the British Association of Urological Surgeons (BAUS) completed a questionnaire on LE utilization in urological practice.

Results

The survey was delivered to 1251 clinicians and the response rate was 17% (n = 208/1251). The majority (61%, n = 127) of urologists were aware of methods available for estimated LE calculation.Seventy-one percent (n = 148) had never utilized LE analysis in clinical practice and 81% (n = 170) routinely used 'eyeballing' (empiric prediction) for estimating LE. Life expectancy tables were utilized infrequently (12%, n = 25) in making the decision for treatment in the setting of multi-disciplinary meetings.

Conclusions

LE is poorly integrated into treatment decision-making; not only for the management of urological patients but also in the multidisciplinary setting. Further education and awareness regarding the importance of LE is vital.

Early Stage Cancer in Older Adults: Prostate-Avoiding Overtreatment and Undertreatment

The diagnosis of prostate cancer in elderly men is likely to increase over the next several decades, owing to changing demographics and a rising population of men older than 65 years. Given the heterogeneity and well-documented challenges in screening, diagnosing, and managing indolent versus aggressive prostate cancer, the geriatric patient population is particularly vulnerable to prostate cancer treatment nuances. Clinicians must become familiar with geriatric assessment tools to better answer life-expectancy questions prior to counseling patients on treatment options. The preferences and values of patients and their families must always be considered when making screening and treatment decisions. Careful selection of patients following a holistic evaluation will not only minimize overtreatment and undertreatment of prostate cancer, but may also allow for the early identification of unique geriatric vulnerabilities and permit quicker interventions to improve the quality of life of these men during their elderly years.

Comorbidity assessment in localized prostate cancer: a systematic review protocol

The objective of this study is to review and summarize the methods and tools used to measure comorbidity in localized prostate cancer (PCa) and in particular to assess whether these tools are adequately validated and reliable for determining the impact of comorbidity on survival and treatment decisions for this disease.Specifically, the review questions are.

What rates of glaucoma progression are clinically significant?

Clinically important rates of glaucoma progression (worsening) are ones that put a patient at risk of future functional impairment or reduction of vision-related quality of life. Rates of progression can be evaluated through measuring structural or functional changes of the optic nerve. Most treated eyes do not progress at rates that will lead to future visual impairment, but there are a significant proportion (3-17%) of eyes, that are at risk of impairment even under clinical care. While very fast rates of progression (e.g. MD progression of -1.5 dB/year) are generally problematic, much slower rates also may be deleterious for young patients, particularly those diagnosed with late disease. As a result, it is important to consider life expectancy, disease severity and vision-related quality of life based treatment targets to estimate future prognosis when evaluating whether a rate of glaucoma progression can be clinically relevant.

Benefits of Minimal Access Surgery in Elderly Patients with Pelvic Cancer

An increasing proportion of patients requiring treatment for malignancy are elderly, which has created new challenges for oncologic surgeons. Aging is associated with an increasing prevalence of frailty and comorbidities that may affect the outcome of surgical procedures. By decreasing complications and shortening length of hospital stay without affecting oncologic safety, surgery performed using the robot, rather than traditional laparotomy, improves the chances of a better outcome in our growing elderly populations. In addition to age, surgeons should take into account factors, such as frailty and comorbidities that correlate with outcome.

Predicting Life Expectancy in Men Diagnosed with Prostate Cancer

CONTEXT

The widespread use of prostate-specific antigen (PSA) screening has led to the detection of more indolent prostate cancer (PCa) in healthy men. PCa treatment and screening must therefore balance the potential for life gained against the potential for harm. Fundamental to this balance is physician awareness of a patient's estimated life expectancy (LE).

OBJECTIVE

To review the evidence on LE differences between men diagnosed with PCa and the general population. To examine clinician- and model-predicted LE and publicly available LE calculators.

EVIDENCE ACQUISITION

A comprehensive search of the PubMed database between 1990 and September 2014 was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Free text protocols of the following search terms were used "life expectancy prostate cancer", "life expectancy non-cancer", "non-cancer mortality prostate", and "comorbidity-adjusted life expectancy". Two internet search engines were queried daily for 1 mo for the search term "life expectancy calculator", and the top 20 results were examined.

EVIDENCE SYNTHESIS

Of 992 articles and 32 websites screened, 17 articles and nine websites were selected for inclusion. Men with non-screening-detected PCa and distant disease at diagnosis were found to have shorter LE than age-matched peers, whereas men with localized PCa had prolonged LE. In general, clinician-predicted 10-yr LE was pessimistic and of limited accuracy; however, model-predicted LE provided only modest improvements in accuracy (c-index of models 0.65-0.84). Online LE calculators provide consistent LE estimates, but government life tables provide LE estimates near the mean for all calculators examined.

CONCLUSIONS

The accuracy of clinician-predicted survival is limited, and while available statistical models offer improvement in discrimination, it is unclear whether they provide advantages over freely available government life tables.

PATIENT SUMMARY

We examined differences in life expectancy between men diagnosed with prostate cancer and the general population, and ways of predicting life expectancy to help guide treatment decisions. We found that current models for predicting life expectancy specific to prostate cancer might not be any better than government life tables or simple rules of thumb.

Evaluation and Management of the Geriatric Urologic Oncology Patient

The geriatric population presents a unique set of challenges in urologic oncology. In addition to the known natural history of disease, providers must also consider patient factors such as functional and nutritional status, comorbidities and social support when determining the treatment plan. The development of frailty measures and biomarkers to estimate surgical risk shows promise, with several assessment tools predictive of surgical complications. Decreased dependence on chronologic age is important when assessing surgical fitness, as age cutoffs prevent appropriate treatment of many elderly patients who would benefit from surgery. Within bladder, kidney and prostate cancers, continued refinement of surgical techniques offers a broader array of options for the geriatric patient than previously available.

Report of a Simplified Frailty Score Predictive of Short-Term Postoperative Morbidity and Mortality

BACKGROUND

Frailty is an objective method of quantifying a patient's fitness for surgery. Its clinical use is limited by the time needed to complete, as well as a lack of evidence-based interventions to improve outcomes in identified frail patients. The purpose of this study was to critically analyze the components of the Fried Frailty Criteria, among other preoperative variables, to create a simplified risk assessment amenable to a busy clinical setting, while maintaining prognostic ability for surgical outcomes.

STUDY DESIGN

We performed a prospective evaluation of patients that included the 5-component Fried Frailty Criteria, traditional surgical risk assessments, biochemical laboratory values, and clinical and demographic data. Thirty-day postoperative outcomes were the outcomes of interest.

RESULTS

There were 351 consecutive patients undergoing major intra-abdominal operations enrolled. Analysis demonstrated that shrinking and grip strength alone hold the same prognostic information as the full 5-component Fried Frailty Criteria for 30-day morbidity and mortality. The addition of American Society of Anesthesia (ASA) score and serum hemoglobin creates a composite risk score, which facilitates easy classification of patients into discrete low (ref), intermediate (odds ratio [OR] 1.974, 95% CI 1.006 to 3.877, p = 0.048), and high (OR 4.889, 95% CI 2.220 to 10.769, p < 0.001) risk categories, with a corresponding stepwise increase in risk for 30-day postoperative complications. Internal validation by bootstrapping confirmed the results.

CONCLUSIONS

This study demonstrated that 2 components of the Fried Frailty Criteria, shrinking and grip strength, hold the same predictive value as the full frailty assessment. When combined with American Society of Anesthesiologists score and serum hemoglobin, they form a straightforward, simple risk classification system with robust prognostic information.

Charlson comorbidity index is an important prognostic factor for long-term survival outcomes in Korean men with prostate cancer after radical prostatectomy

PURPOSE

To analyze overall survival (OS), prostate cancer (PCa)-specific survival (PCaSS), and non-PCaSS according to the Charlson Comorbidity Index (CCI) after radical prostatectomy (RP) for PCa.

MATERIALS AND METHODS

Data from 336 patients who had RP for PCa between 1992 and 2005 were analyzed. Data included age, preoperative prostate-specific antigen (PSA), prostate volume, clinical stage, and pathologic stage. Pre-existing comorbidities were evaluated by the CCI, and patients were classified into two CCI score categories (0, ≥1).

RESULTS

The mean age of patients was 64.31±6.12 years. The median PSA value (interquartile range, IQR) was 11.30 (7.35 and 21.02) ng/mL with a median follow-up period (IQR) of 96.0 (85.0 and 121.0) months. The mean CCI was 0.28 (0-4). Five-year OS, PCaSS, and non-PCaSS were 91.7%, 96.3%, and 95.2%, respectively. Ten-year OS, PCaSS, and non-PCaSS were 81.9%, 92.1%, and 88.9%, respectively. The CCI had a significant influence on OS (p=0.022) and non-PCaSS (p=0.008), but not on PCaSS (p=0.681), by log-rank test. In multivariate Cox regression analysis, OS was independently associated with the CCI [hazard ratio (HR)=1.907, p=0.025] and Gleason score (HR=2.656, p<0.001). PCaSS was independently associated with pathologic N stage (HR=2.857, p=0.031), pathologic T stage (HR=3.775, p=0.041), and Gleason score (HR=4.308, p=0.001). Non-PCaSS had a significant association only with the CCI (HR=2.540, p=0.009).

CONCLUSION

The CCI was independently associated with both OS and non-PCaSS after RP, but the CCI had no impact on PCaSS. The comorbidities of a patient should be considered before selecting RP as a curative modality for PCa.

A prospective study examining the association between preoperative frailty and postoperative complications in patients undergoing minimally invasive surgery

BACKGROUND AND PURPOSE

Current surgical decision-making is overly subjective and often misjudges a patient's physiologic state. The concept of frailty has gained recent recognition and potentially represents a measureable phenotype, which can quantify a patient's physiologic reserve and risk of an adverse surgical outcome. We sought to investigate the relationship between preoperative markers of frailty and postoperative complications in patients undergoing minimally invasive surgery (MIS).

METHODS

Frailty, using the methodology described by Fried and coworkers, was prospectively measured in patients who presented to urology, general surgery, and surgical oncology clinics where major MIS (endoscopic, laparoscopic, or robotic) was planned. The relationship between preoperative markers of frailty and 30-day postoperative complications was our primary outcome measure.

RESULTS

Our cohort includes 80 patients. Mean age and body mass index were 60.0 (range 19-87) years and 29.2 (range 18.4-53.1) kg/m(2), respectively. The majority of patients were male (57.5%) and Caucasian (65.0%). Thirteen patients were deemed "intermediately frail" or "frail," and the remaining 67 were classified as "not frail." Thirteen (16.25%) patients experienced any postoperative complication. Five (38.5%) of the intermediately frail and frail patients experienced a complication, compared with eight (11.9%) of the not frail patients (odds ratio=5.914; 95% confidence interval=1.25-27.96; P=0.025).

CONCLUSION

The advent of MIS has potentially lured surgeons into thinking older and patients with comorbidities may more easily tolerate this surgical approach compared with traditional open techniques. Our data suggest, however, that intermediately frail or frail patients are at increased risk of experiencing postoperative complications compared with not frail patients.

Impact of Charlson comorbidity index varies by age in patients with prostate cancer treated by radical prostatectomy: a competing risk regression analysis

PURPOSE

To investigate the prognostic impact of the Charlson comorbidity index (CCI) on either cancer-specific mortality (CSM) or other-cause mortality (OCM) according to age in patients with prostate cancer (PC) who underwent radical prostatectomy (RP).

METHODS

Data from 336 patients who underwent RP for PC between 1992 and 2005 were analyzed. Variables, including the preoperative prostate-specific antigen (PSA), prostate volume, clinical stage, and pathologic stage, were compared across age groups (<65 or ≥65 years old). Preexisting comorbidities were evaluated by the CCI, and patients were classified into two CCI score categories (0 or ≥1).

RESULTS

The median (interquartile range) follow-up period was 96 (85-121) months. Subjects were divided into two subgroups according to age: <65 years (n = 151) or ≥65 years (n = 185). There was no significant difference in PSA, biopsy Gleason sum, body mass index, pathologic stage, or CCI between the two age groups. OCM was significantly associated with the CCI score (P = 0.011). Cumulative incidence estimates obtained from competing risk regression analysis indicated that CCI was not associated with CSM (P = 0.795) or OCM (P = 0.123) in the ≥65-year group. However, in men <65 years, cumulative incidence estimates for OCM were significantly associated with CCI (P = 0.036).

CONCLUSIONS

CCI was independently associated with OCM after RP, but only in men <65 years old. CCI was not associated with CSM in either age group. Accordingly, a thorough evaluation of patient's comorbidities is mandatory when considering aggressive surgical treatment, especially in relatively young patients.

Challenging the 10-year rule: The accuracy of patient life expectancy predictions by physicians in relation to prostate cancer management

INTRODUCTION

: We assess physicians' ability to accurately predict life expectancies. In prostate cancer this prediction is especially important as it affects screening decisions. No previous studies have examined accuracy in the context of real cases and concrete end points.

METHODS

: Seven clinical scenarios were summarized from charts of deceased patients. We recruited 100 medical professionals to review these scenarios and estimate each patient's life expectancy. Responses were analyzed with respect to the patients' actual survival end points, then stratified based on the demographic information provided.

RESULTS

: Respondent factors, such as sex, level of training, location of work or specialty, made no significant difference on prediction accuracy. Furthermore, respondents were typically pessimistic in their estimations with a negative linear trend between estimated life expectancy and actual survival. Overall, respondents were within 1 year of actual life expectancy only 15.9% of the time; on average, respondents were 67.4% inaccurate in relation to actual survival. If framed in terms of correctly identifying which patients would live more than or less than 10 years (dichotomous accuracy), physicians were correct 68.3% of the time.

CONCLUSIONS

: Physicians do poorly at predicting life expectancy and tend to underestimate how long patients have left to live. This overall inaccuracy raises the question of whether physicians should refine screening and treatment criteria, find a better proxy or dispose of the criteria altogether.

Competing risks of death in patients with localized renal cell carcinoma: a comorbidity based model

PURPOSE

Multiple risks compete with cancer as the primary cause of death. These factors must be considered against the benefits of treatment. We constructed a model of competing causes of death to help contextualize treatment trade-off analyses in patients with localized renal cell carcinoma.

MATERIALS AND METHODS

We identified 6,655 individuals 66 years old or older with localized renal cell carcinoma in the linked SEER (Surveillance, Epidemiology and End Results)-Medicare data set for 1995 to 2005. We used Fine and Gray competing risks proportional hazards regression to predict probabilities of competing mortality outcomes. Prognostic markers included race, gender, tumor size, age and the Charlson comorbidity index score.

RESULTS

At a median followup of 43 months, age and comorbidity score strongly correlated with patient mortality and were most predictive of nonkidney cancer death, as measured by concordance statistics. Patients with localized, node negative kidney cancer had a low 3 (4.7%), 5 (7.5%) and 10-year (11.9%) probability of cancer specific death but a significantly higher overall risk of death from competing causes within 3 (10.9%), 5 (20.1%) and 10 years (44.4%) of renal cell carcinoma diagnosis, depending on comorbidity score.

CONCLUSIONS

Informed treatment decisions regarding patients with solid tumors must integrate not only cancer related variables but also factors that predict noncancer death. We established a comorbidity based predictive model that may assist in patient counseling by allowing quantification and comparison of competing risks of death in patients 66 years old or older with localized renal cell carcinoma who elect to proceed with surgery.

Remaining Life Expectancy Measurement and PSA Screening of Older Men

BACKGROUND: Guidelines recommend informed decision-making regarding prostate specific antigen (PSA) screening for men with at least 10 years of remaining life expectancy (RLE). Comorbidity measures have been used to judge RLE in previous studies, but assessments based on other common RLE measures are unknown. We assessed whether screening rates varied based on four clinically relevant RLE measures, including comorbidities, in a nationally-representative, community-based sample. METHODS: Using the National Social Life, Health and Aging Project (NSHAP), we selected men over 65 without prostate cancer (n=709). They were stratified into three RLE categories (0-7 years, 8-12 years, and 13+ years) based on validated measures of comorbidities, self-rated health status, functional status, and physical performance. The independent relationship of each RLE measure and a combined measure to screening was determined using multivariable logistic regressions. RESULTS: Self-rated health (OR = 6.82; p < 0.01) most closely correlated with RLE-based screening, while the comorbidity index correlated the least (OR = 1.50; p = 0.09). The relationship of RLE to PSA screening significantly strengthened when controlling for the number of doctor visits, particularly for comorbidities (OR= 43.6; p < 0.001). Men who had consistent estimates of less than 7 years RLE by all four measures had an adjusted PSA screening rate of 43.3%. CONCLUSIONS: Regardless of the RLE measure used, men who were estimated to have limited RLE had significant PSA screening rates. However, different RLE measures have different correlations with PSA screening. Specific estimates of over-screening should therefore carefully consider the RLE measure used.

Can self-reported disability assessment behaviour of insurance physicians be explained? Applying the ASE model

Background

Very little is known about the attitudes and views that might underlie and explain the variation in occupational disability assessment behaviour between insurance physicians. In an earlier study we presented an adjusted ASE model (Attitude, Social norm, Self-efficacy) to identify the determinants of the disability assessment behaviour among insurance physicians. The research question of this study is how Attitude, Social norm, Self-efficacy and Intention shape the behaviour that insurance physicians themselves report with regard to the process (Behaviour: process) and content of the assessment (Behaviour: assessment) while taking account of Knowledge and Barriers.

Methods

This study was based on 231 questionnaires filled in by insurance physicians, resulting into 48 scales and dimension scores. The number of variables was reduced by a separate estimation of each of the theoretical ASE constructs as a latent variable in a measurement model. The saved factor scores of these latent variables were treated as observed variables when we estimated a path model with Lisrel to confirm the ASE model. We estimated latent ASE constructs for most of the assigned scales and dimensions. All could be described and interpreted. We used these constructs to build a path model that showed a good fit.

Results

Contrary to our initial expectations, we did not find direct effects for Attitude on Intention and for Intention on self reported assessment behaviour in the model. This may well have been due to the operationalization of the concept of 'Intention'. We did, however, find that Attitude had a positive direct effect on Behaviour: process and Behaviour: Assessment and that Intention had a negative direct effect on Behaviour: process.

Conclusion

A path model pointed to the existence of relationships between Attitude on the one hand and self-reported behaviour by insurance physicians with regard to process and content of occupational disability assessments on the other hand. In addition, Intention was only related to the self reported behaviour with regard to the process of occupational disability assessments. These findings provide some evidence of the relevance of the ASE model in this setting. Further research is needed to determine whether the ASE variables measured for insurance physicians are related to the real practice outcomes of occupational disability assessments.

Impact of comorbidity on survival among men with localized prostate cancer

PURPOSE

To provide patients and clinicians more accurate estimates of comorbidity-specific survival stratified by patient age, tumor stage, and tumor grade.

PATIENTS AND METHODS

We conducted a 10-year competing risk analysis of 19,639 men 66 years of age and older identified by the Surveillance, Epidemiology, and End Results (SEER) program linked to Medicare program files. All men were diagnosed with localized prostate cancer and received no surgery or radiation within 180 days of diagnosis. The analysis was stratified by tumor grade and stage and by age and comorbidity at diagnosis classified using the Charlson comorbidity index. Underlying causes of death were obtained from SEER.

RESULTS

During the first 10 years after diagnosis, men with moderately and poorly differentiated prostate cancer were more likely to die from causes other than their disease. Depending on patient age, Gleason score, and number of comorbidities present at diagnosis, 5-year overall mortality rates for men with stage T1c disease ranged from 11.7% (95% CI, 10.2% to 13.1%) to 65.7% (95% CI, 55.9% to 70.1%), and prostate cancer-specific mortality rates ranged from 1.1% (95% CI, 0.0% to 2.7%) to 16.3% (95% CI, 13.8% to 19.4%). Ten-year overall mortality rates ranged from 28.8% (95% CI, 25.3% to 32.6%) to 94.3% (95% CI, 87.4% to 100%), and prostate cancer-specific mortality rates ranged from 2.0% (95% CI, 0.0% to 5.3%) to 27.5% (95% CI, 21.5% to 36.5%).

CONCLUSION

Patients and clinicians should consider using comorbidity-specific data to estimate the threat posed by newly diagnosed localized prostate cancer and the threat posed by competing medical hazards.

The impact of preoperative erectile dysfunction on survival after radical prostatectomy

PURPOSE

Erectile dysfunction (ED) and cardiovascular disease (CVD) share etiology and pathophysiology. The underlying pathology for preoperative ED may adversely affect survival following radical prostatectomy (RP). We examined the association between preoperative ED and survival following RP.

MATERIALS AND METHODS

Between 1983 and 2000, a single surgeon performed RP on 2511 men, with preoperative ED (ED group, n= 231, 9.2%) or without ED (No ED group, n= 2280, 90.8%). We retrospectively analysed their CVD-specific survival (CVDSS), prostate cancer-specific survival (PCSS), non-PCSS (NPCSS) and overall survival (OS) from time of surgery.

RESULTS

With median follow-up of 13 years after RP, 449 men (18%) died (140 from prostate cancer, 309 from other causes). Kaplan-Meier analyses demonstrated significant differences in CVDSS (P < 0.001), NPCSS (P < 0.001) and OS (P < 0.001), but not in PCSS (P= 0.12), between the ED group vs No ED group. In univariate proportional hazards analyses, preoperative ED was associated with a significant decrease in OS, hazard ratio (HR), 1.71 (95% CI, 1.34-2.23), P < 0.001. However, in multivariable analyses, the association of ED with survival became non-significant (HR, 1.25 (95% CI, 0.97-1.66), P= 0.111) after adjusting for other prognostic factors, such as age, preoperative prostate-specific antigen (PSA) level, Gleason score, pathologic stage, body mass index and Charlson Comorbidity Index.

CONCLUSIONS

Preoperative ED is associated with decreased overall survival and survival from causes other than prostate cancer following RP. However, preoperative ED was not an independent predictor of overall survival after adjusting for other predictors of survival. Urologists should carefully assess pretreatment ED status to enhance appropriate treatment recommendation for men with prostate cancer.

The development of instruments to measure the work disability assessment behaviour of insurance physicians

Background

Variation in assessments is a universal given, and work disability assessments by insurance physicians are no exception. Little is known about the considerations and views of insurance physicians that may partly explain such variation. On the basis of the Attitude - Social norm - self Efficacy (ASE) model, we have developed measurement instruments for assessment behaviour and its determinants.

Methods

Based on theory and interviews with insurance physicians the questionnaire included blocks of items concerning background variables, intentions, attitudes, social norms, self-efficacy, knowledge, barriers and behaviour of the insurance physicians in relation to work disability assessment issues. The responses of 231 insurance physicians were suitable for further analysis. Factor analysis and reliability analysis were used to form scale variables and homogeneity analysis was used to form dimension variables. Thus, we included 169 of the 177 original items.

Results

Factor analysis and reliability analysis yielded 29 scales with sufficient reliability. Homogeneity analysis yielded 19 dimensions. Scales and dimensions fitted with the concepts of the ASE model. We slightly modified the ASE model by dividing behaviour into two blocks: behaviour that reflects the assessment process and behaviour that reflects assessment behaviour.

The picture that emerged from the descriptive results was of a group of physicians who were motivated in their job and positive about the Dutch social security system in general. However, only half of them had a positive opinion about the Dutch Work and Income (Capacity for Work) Act (WIA). They also reported serious barriers, the most common of which was work pressure. Finally, 73% of the insurance physicians described the majority of their cases as 'difficult'.

Conclusions

The scales and dimensions developed appear to be valid and offer a promising basis for future research. The results suggest that the underlying ASE model, in modified form, is suitable for describing the assessment behaviour of insurance physicians and the determinants of this behaviour. The next step in this line of research should be to validate the model using structural equation modelling. Finally, the predictive value should be tested in relation to outcome measurements of work disability assessments.

Self-rated health as a tool for estimating health-adjusted life expectancy among patients newly diagnosed with localized prostate cancer: a preliminary study

PURPOSE

Localized prostate cancer (LPC) patients are faced with numerous treatment options, including observation or watchful waiting. The choice of treatment largely depends on their baseline health-adjusted life expectancy (HALE). By consensus, physicians recommend treatment if the patient's HALE is ten or more years. However, the estimation of HALE is difficult. Although subjective by nature, self-rated health (SRH) is a robust predictor of mortality. We studied the usefulness of SRH in estimating HALE in patients who are considering treatment for LPC.

METHODS

A total of 144 LPC patients from a large urology private practice in Norfolk, Virginia, were surveyed before they had chosen a treatment option.

RESULTS

HALE determined by SRH correlated well with objective health measures and was higher than age-based life expectancy by an average of 2 years. The observed difference in life expectancy due to SRH adjustment was higher among patients with a better socioeconomic and health profile.

CONCLUSIONS

SRH is an easy-to-use indicator of HALE in LPC patients. A table for HALE estimation by age and SRH is provided for men aged 70-80 years. Additional research with larger samples and prospective study designs are needed before the SRH method can be used in primary care and urology settings.

Prediction of mortality after radical prostatectomy by Charlson comorbidity index

OBJECTIVES

Prostate cancer treatment should depend on the characteristics of a patient's prostate cancer as well as overall health status. A possible adverse consequence of poor patient selection is a lack of benefit because of premature death from another cause. We evaluated the association between perioperative comorbidity and risk of death from causes other than prostate cancer in men who underwent radical prostatectomy (RP).

METHODS

We conducted a retrospective cohort study of 14,052 men who underwent RP from 1983 to 2006. The Charlson Comorbidity Index (CCI) score was calculated using the discharge records for the prostatectomy hospitalization. Mortality status and cause of death were obtained via chart review and searches of national databases. Cox proportional hazards regression was used to estimate the hazard ratio (HR) of death from causes other than prostate cancer after RP by CCI score (0, 1, 2+).

RESULTS

The median age at RP was 58.1 years. The median follow-up was 7.6 years (interquartile range 4.3-11.5). Of 849 deaths, 599 (70.6%) resulted from causes other than prostate cancer. On multivariable analysis, men with a CCI ≥2 had a statistically significantly higher risk of death from causes other than prostate cancer compared with those with lower CCI scores (HR 2.18, 95% CI 1.30-3.64, P = .0003).

CONCLUSIONS

Greater perioperative comorbidity was associated with a higher risk of death from causes other than prostate cancer in men who underwent RP. Physicians should consider using a standardized tool to assess perioperative comorbidities to enhance appropriate recommendation for surgical treatment.

Incorporating mortality risk into estimates of 5-year glaucoma risk

PURPOSE

To incorporate mortality risk, a potentially important factor to consider when deciding whether to initiate therapy for ocular hypertensives, into estimates of 5-year glaucoma risk.

DESIGN

Comparison study of estimates of glaucoma risk that do and do not account for mortality risk.

METHODS

We computed 5-year risk of glaucoma for a set of hypothetical glaucoma suspects. We then determined their 5-year risk of death using the Charlson index, which is based on age and comorbidity, and computed mortality-adjusted 5-year risk that the individual will develop glaucoma before death.

RESULTS

Accounting for mortality risk reduces the risk of developing glaucoma in one's lifetime. For example, a 75-year-old patient with an unadjusted 5-year glaucoma risk of 51.0% can have mortality-adjusted 5-year glaucoma risks of 41.8% (18% relative risk reduction) or 20.2% (60% relative risk reduction) assuming the patient has a Charlson comorbidity score of 1 or 3, respectively.

CONCLUSIONS

Shortened life expectancy reduces 5-year risk of developing glaucoma. Thus, mortality risk is another factor clinicians should consider when deciding whether to initiate treatment of glaucoma suspects.

How accurate are doctors, nurses and medical students at predicting life expectancy?

BACKGROUND

Predicted patient life expectancy, based on a patient's medical history, is an important component of medical decision making. This study therefore aimed to determine the consistency, accuracy and precision with which doctors, nurses and medical students predict life expectancy (LE).

METHODS

20 doctors, 20 nurses and 20 medical students (4th and 5th year) independently examined 70 hypothetical patient case scenarios containing age, sex and comorbidity; this included 13 duplicate scenarios. Accuracy and consistency of prediction was assessed by comparison with statistical LE estimates generated using evidence-based actuarial and life insurance industry methods in collaboration with a team of professional actuaries.

RESULTS

Doctors, nurses and medical students underestimated LE by a mean (95% confidence interval) of -1.46 (-0.31 to -2.61), -1.79 (-0.52 to -3.06) and -2.24 (-1.16 to -3.32) years with an equivalent root mean squared error (RMSE) of 4.74, 5.49 and 5.08 years respectively. LE predictions were equal to actuarial LE in less than 10% of cases and accurate to within 25% of actuarial LE in less than 45% of cases. Intra-observer reliability was 91%, 85% and 87% for doctors, nurses and medical students respectively. Inter-observer reliability was 66%, 57% and 57% for the three groups.

CONCLUSION

Doctors, nurses and medical students were inconsistent, inaccurate and imprecise in their prediction of LE with a tendency toward underestimation. This may lead to patients being managed inappropriately. There is a need for improved training and objective outcome prediction models.

For which glaucoma suspects is it appropriate to initiate treatment?

OBJECTIVE

Because uncertainty exists about which glaucoma suspects should be treated, this study sought to identify the glaucoma suspects who an expert panel could agree would be appropriate or inappropriate to treat.

DESIGN

The RAND/UCLA appropriateness method, a well-established procedure to synthesize the scientific literature with expert opinion to resolve uncertainty on a health topic.

PARTICIPANTS

Eleven-member panel composed of recognized international leaders in the field of glaucoma.

METHODS

Based on a systematic review of the literature on potentially important factors to consider when deciding to initiate treatment, more than 1000 scenarios of glaucoma suspects initially were created. The panel formally rated the appropriateness of initiating treatment for glaucoma suspects through a 2-round modified Delphi method, a technique that preserves the confidentiality of individual panelists'ratings but allows panelists to compare their own ratings with those of the entire panel.

MAIN OUTCOME MEASURES

Final ratings for scenarios were categorized as appropriate, uncertain, or inappropriate to treat according to typical prespecified statistical criteria previously used in projects using the RAND/UCLA appropriateness method. Tools were developed to help clinicians to approximate the panel ratings of glaucoma suspects.

RESULTS

The panel chose age, life expectancy, intraocular pressure (IOP), central corneal thickness, cup-to-disc ratio, disc size, and family history as the variables to consider when deciding whether to treat glaucoma suspects. Permutations of these variables created 1800 unique scenarios. The panel rated 587 (33%) scenarios as appropriate, 585 (33%) as uncertain, and 628 (35%) as inappropriate for treatment initiation. Analysis of variance determined that IOP had greater impact than any other variable on panel ratings. A point system was created with 96% sensitivity and 93% specificity for predicting panel ratings of appropriateness for a glaucoma suspect.

CONCLUSIONS

An expert panel can reach agreement on the appropriateness and inappropriateness of treatment for glaucoma suspects.