Accuracy of life tables in predicting overall survival in patients after radical prostatectomy

Influence of Baseline Cardiovascular Comorbidities on Mortality after Androgen Deprivation Therapy for Metastatic Prostate Cancer

Few studies have assessed the benefits of androgen deprivation therapy (ADT) in men with metastatic prostate cancer (PC; mPC) at an old age or with major cardiovascular conditions. A retrospective cohort consisted of 3835 men with newly diagnosed mPC from the Taiwan Cancer Registry of 2008–2014. Among them, 2692 patients received only ADT in the first year after the cancer diagnosis, and 1143 patients were on watchful waiting. The inverse probability of treatment-weighted Cox model was used to estimate the effects of ADT on all-cause mortality and PC-specific mortality according to age, and the status of congestive heart failure (CHF), coronary arterial diseases (CADs), and stroke at the baseline. After a median follow-up of 2.65 years, 1650 men had died. ADT was associated with a 17–22% risk reduction in all-cause and PC-specific mortality in men without stroke, CAD, or CHF in the 65–79-year group. The survival benefit diminished in men with any of these preexisting conditions. In contrast, ADT was not found to be associated with any survival benefit in the ≥80-year group, even though they did not present with any major cardiovascular disease at the baseline. Patients who had CHF, CAD, or stroke at the baseline did not show a survival benefit following ADT in any of the age groups. Men who have preexisting major cardiovascular diseases or are ≥80 years do not demonstrate a survival benefit from ADT for mPC. The risk–benefit ratio should be considered when using ADT for mPC in older men especially those with major cardiovascular comorbidities.

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.

Clinical and Demographic Factors Associated With Receipt of Non Guideline-concordant Initial Therapy for Nonmetastatic Prostate Cancer

OBJECTIVES

To determine the extent to which initial therapy for nonmetastatic prostate cancer was concordant with nationally recognized guidelines using supplemented cancer registry data and what factors were associated with receipt of nonguideline-concordant care.

METHODS

Initial therapy for 8229 nonmetastatic prostate cancer cases diagnosed in 2004 from cancer registries in 7 states was abstracted as part of the Centers for Disease Control's Patterns of Care Breast and Prostate Cancer study conducted during 2007 to 2009. The National Comprehensive Cancer Network clinical practice guidelines version 1.2002 was used as the standard of care based on recurrence risk group and life expectancy (LE). A multivariable model was used to determine risk factors associated with receipt of nonguideline-concordant care.

RESULTS

Nearly 80% with nonmetastatic prostate cancer received guideline-concordant care for initial therapy. Receipt of nonguideline-concordant care (including receiving either less aggressive therapy or more aggressive therapy than indicated) was related to older age, African American race/ethnicity, being unmarried, rural residence, and especially to being in the high recurrence risk group where receiving less aggressive therapy than indicated occurred more often than receiving more aggressive therapy (adjusted OR=4.2; 95% CL, 3.5-5.2 vs. low-risk group). Compared with life table estimates adjusted for comorbidity, physicians tended to underestimate LE.

CONCLUSIONS

Receipt of less aggressive therapy than indicated among high-risk group men with >5-year LE based on life table estimates adjusted for comorbidity was a concern. Physicians may tend to underestimate 5-year survival among this group and should be alerted to the importance of recommending aggressive therapy when warranted. However, based on more recent guidelines, among those with low-risk disease, the proportion considered to be receiving less aggressive therapy than indicated may now be lower because active surveillance is now considered appropriate.

Prediction of long-term other-cause mortality in men with early-stage prostate cancer: results from the Prostate Cancer Outcomes Study

OBJECTIVE

To provide population-based estimates of other-cause mortality by age and comorbidity in men with prostate cancer for use at the point of care in shared decision making.

MATERIALS AND METHODS

We sampled 3183 men with nonmetastatic prostate cancer from the Prostate Cancer Outcomes Study, a US population-based prospective cohort. Survival analysis accounting for competing risks was used to provide predictions of other-cause and cancer-specific mortality by age, comorbidity, and tumor risk through 14 years of follow-up.

RESULTS

Older men had a higher absolute risk of other-cause mortality associated with comorbidity. For men with comorbidity counts of 0, 1, 2, and 3+, cumulative incidence of other-cause mortality at 14 years was 9%, 18%, 30%, and 35% for those younger than 60 years; 26%, 26%, and 48%, and 52% for those aged 60-70 years; and 49%, 57%, 66%, and 74% for those older than 70 years. Prostate cancer mortality at 14 years was 5%, 8%, and 23% for men with low-, intermediate-, and high-risk disease. Competing risk pictograms for each age/comorbidity/tumor-risk pair provide visual characterization of these risks over time.

CONCLUSION

Our survival tables may be used at the point of care as part of shared decision making. Men aged >60 years with multiple comorbidities have substantial risk of other-cause mortality within 15 years of diagnosis and should consider conservative management for low-risk disease, given its low incidence of cancer-specific mortality. Men with high-risk disease, regardless of age or comorbidity, are at greater risk for cancer mortality and may still be appropriate candidates for aggressive treatment.

Weighted versus unweighted Charlson score to predict long-term other-cause mortality in men with early-stage prostate cancer

BACKGROUND

Clinicians need a simple yet accurate method to predict other-cause mortality to inform medical decision making for men with prostate cancer (PCa).

OBJECTIVE

To compare weighted and unweighted Charlson Comorbidity Index scores in predicting long-term, other-cause mortality in men with early-stage PCa.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study of 1482 men with early-stage PCa diagnosed in 1998-2004 at two Southern California Veterans Affairs medical centers.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Subhazard ratios and cumulative incidence of other-cause mortality associated with weighted and unweighted Charlson scores, calculated by competing-risks regression accounting for cancer mortality, along with Harrell concordance index (C-index) values.

RESULTS AND LIMITATIONS

Weighted and unweighted Charlson scores were identical in 88.6% of subjects (1313 of 1482 men) across all scores and in 91.7% of subjects (1359 of 1482 men) across scores of 0, 1, 2, and ≥3. In competing-risks analysis, hazards of other-cause mortality were similar when comparing weighted and unweighted scores. Men with weighted scores of 1, 2, and ≥3 (vs. 0) had subhazard ratios of 2.3 (95% confidence interval [CI], 1.6-3.2), 4.1 (95% CI, 2.9-5.8), and 8.3 (95% CI, 5.9-11.5), respectively. Men with unweighted scores of 1, 2, and ≥3 (vs. 0) had subhazard ratios of 2.5 (95% CI, 1.8-3.5), 4.5 (95% CI, 3.2-6.3), and 10.3 (95% CI, 7.2-14.7), respectively. The C-indexes for prediction of other-cause mortality were nearly identical for weighted scores (0.759 [95% CI, 0.715-0.780]) and unweighted scores (0.756 [95% CI, 0.717-0.780]). The difference in C-index between the two methods was -0.003 (95% CI, -0.01 to 0.004).

CONCLUSIONS

An unweighted Charlson score yields similar strength of association and variance in predicting long-term, other-cause mortality compared with a weighted Charlson score.

PATIENT SUMMARY

A simple count of major comorbidities provides similar accuracy to a weighted index in predicting death from other causes in men with early-stage prostate cancer.

Challenges of managing elderly men with prostate cancer

The incidence of prostate cancer increases with age. Current evidence suggests that prostate cancer is under treated in patients aged ≥70 years, despite evidence of efficacy and acceptable toxicity. Radical cystectomy and definitive radiotherapy are often denied owing to fears of post-operative complications and radiotherapy-associated gastrointestinal and genitourinary toxicity. However, modern radical prostatectomy techniques provide excellent clinical outcomes with low perioperative morbidity. Moreover, volume-restricted intensity-modulated radiation therapy is a significant improvement over previous 2D conformal radiotherapy with similar efficacy and lower toxicity. Androgen-deprivation therapy is also under-prescribed among the elderly, owing to concerns of increases in cardiac deaths and osteoporosis acceleration. However, prospective trials have not identified any increase in cardiovascular mortality among elderly men receiving androgen-deprivation therapy compared to age-matched controls. Most patients on androgen deprivation eventually progress to a castration-resistant state. At this stage, the disease still responds to newer agents that target the androgen pathway and to chemotherapy. Among the elderly, chemotherapy is under-prescribed even though it has been demonstrated to be palliative and improve survival. We describe the trends in prostate cancer management in the elderly and the importance of assessing comorbidity status, tumour characteristics, and health status, including a complete geriatric evaluation, before making treatment recommendations.

Life tables adjusted for comorbidity more accurately estimate noncancer survival for recently diagnosed cancer patients

OBJECTIVES

To provide cancer patients and clinicians with more accurate estimates of a patient's life expectancy with respect to noncancer mortality, we estimated comorbidity-adjusted life tables and health-adjusted age.

STUDY DESIGN AND SETTING

Using data from the Surveillance Epidemiology and End Results-Medicare database, we estimated comorbidity scores that reflect the health status of people who are 66 years of age and older in the year before cancer diagnosis. Noncancer survival by comorbidity score was estimated for each age, race, and sex. Health-adjusted age was estimated by systematically comparing the noncancer survival models with US life tables.

RESULTS

Comorbidity, cancer status, sex, and race are all important predictors of noncancer survival; however, their relative impact on noncancer survival decreases as age increases. Survival models by comorbidity better predicted noncancer survival than the US life tables. The health-adjusted age and national life tables can be consulted to provide an approximate estimate of a person's life expectancy, for example, the health-adjusted age of a black man aged 75 years with no comorbidities is 67 years, giving him a life expectancy of 13 years.

CONCLUSION

The health-adjusted age and the life tables adjusted by age, race, sex, and comorbidity can provide important information to facilitate decision making about treatment for cancer and other conditions.

Effect of age, tumor risk, and comorbidity on competing risks for survival in a U.S. population-based cohort of men with prostate cancer

BACKGROUND

Accurate estimation of life expectancy is essential to offering appropriate care to men with early-stage prostate cancer, but mortality risks associated with comorbidity are poorly defined.

OBJECTIVE

To determine the effect of age, comorbidity, and tumor risk on other-cause and prostate cancer-specific mortality in men with early-stage disease.

DESIGN

Prospective cohort study.

SETTING

A nationally representative, population-based cohort.

PATIENTS

3183 men with nonmetastatic prostate cancer at diagnosis.

MEASUREMENTS

Baseline self-reported comorbidity (scored as a count of 12 major comorbid conditions), tumor characteristics, initial treatment, and overall and disease-specific mortality through 14 years of follow-up. Survival analyses that accounted for competing risks were performed.

RESULTS

Fourteen-year cumulative other-cause mortality rates were 24%, 33%, 46%, and 57% for men with 0, 1, 2, and 3 or more comorbid conditions, respectively. For men diagnosed at age 65 years, subhazard ratios for other-cause mortality among those with 1, 2, or 3 or more comorbid conditions (vs. none) were 1.2 (95% CI, 1.0 to 1.4), 1.7 (CI, 1.4 to 2.0), and 2.4 (CI, 2.0 to 2.8), respectively. Among men with 3 or more comorbid conditions, 10-year other-cause mortality rates were 26%, 40%, and 71% for those aged 60 years or younger, 61 to 74 years, and 75 years or older at diagnosis, respectively. Prostate cancer-specific mortality was minimal in patients with low-risk (3%) and intermediate-risk (7%) disease but appreciable in those with high-risk disease (18%) and did not vary by number of comorbid conditions (10% to 11% in all groups).

LIMITATION

Comorbid conditions were self-reported.

CONCLUSION

Older men with multiple major comorbid conditions are at high risk for other-cause mortality within 10 years of diagnosis and should consider this information when deciding between conservative management and aggressive treatment for low- or intermediate-risk prostate cancer.

PRIMARY FUNDING SOURCE

National Cancer Institute.

Consideration of comorbidity in risk stratification prior to prostate biopsy

BACKGROUND

Previously, the patient-reported Total Illness Burden Index for Prostate Cancer (TIBI-CaP) questionnaire and/or the physician-reported Charlson Comorbidity Index (CCI) have provided assessments of competing comorbidity during treatment decisions for patients with prostate cancer. In the current study, the authors used these assessments to determine comorbidity and prognosis before prostate biopsy and the subsequent diagnosis of prostate cancer to identify those patients least likely to benefit from treatment.

METHODS

A prospective observational cohort study was performed of 104 participants aged 64.0 years ± 6.5 years from 3 institutions representing different health care delivery systems. Patients were identified before undergoing transrectal ultrasound-guided prostate biopsy and followed for a median of 28 months. Associations between the comorbidity scores and nonelective hospital admissions were investigated using logistic regression and Cox proportional hazards models.

RESULTS

Among the 104 patients who underwent prostate biopsy, 2 died during the follow-up period. The overall hospital admission rate was 20% (21 of 104 patients). Higher scores on both the TIBI-CaP (≥ 9) and CCI (≥ 3) were found to be significantly associated with an increased odds for hospital admission (odds ratio, 11.3 [95% confidence interval (95% CI), 2.4-53.6] and OR, 5.7 [95% CI, 1.4-22.4]) and hazards ratios (HRs) for time to hospital admission (HR, 3.8 [95% CI, 1.3-11.2] and HR, 3.2 [95% CI, 1.1-9.1]), respectively.

CONCLUSIONS

TIBI-CaP and CCI scores were found to successfully predict which patients were at high risk for nonelective hospital admission. These patients are likely to have poorer health and a potentially shortened lifespan. Therefore, comorbidity analysis using these tools may help to identify those patients who are least likely to benefit from prostate cancer therapy and should avoid prostate biopsy.

Comorbidity and competing risks for mortality in men with prostate cancer

BACKGROUND

Accurate estimation of life expectancy is essential for men deciding between aggressive and conservative treatment of prostate cancer. The authors sought to assess the competing risks of nonprostate cancer and prostate cancer mortality among men with differing Charlson comorbidity index scores and tumor risks.

METHODS

The authors conducted a retrospective study of 1482 men with nonmetastatic prostate cancer diagnosed from 1997 to 2004 at the Greater Los Angeles and Long Beach Veterans Affairs Medical Centers. They performed Kaplan-Meier and competing risks regression analyses to assess survival outcomes.

RESULTS

After a mean follow-up of 6.0 years, 370 (25%) men died from other causes, whereas 44 (3%) died of prostate cancer. At 10 years after diagnosis, men with Charlson scores 0, 1, 2, and 3+ had nonprostate cancer mortality rates of 17%, 34%, 52%, and 74%, respectively. In competing risks regression analysis, each point increase in Charlson score was associated with a 2-fold increase in hazard of nonprostate mortality. Men with Charlson 3+ had 8.5× the hazard of death from other causes, compared with men with the lowest scores (subhazard ratio, 8.5; 95% confidence interval, 6.2-11.7). After stratification by tumor risk, nonprostate mortality rates remained markedly elevated among men with higher Charlson scores, whereas prostate cancer mortality was rare, especially among low-risk and intermediate-risk groups (0.4%, 3%, and 8% for low, intermediate, and high risk, respectively).

CONCLUSIONS

Men with the highest Charlson scores should consider conservative management of low-risk and intermediate-risk tumors, given their exceedingly high risk of death from other causes and low risk of prostate cancer mortality.

Impact of age at diagnosis on prostate cancer treatment and survival

PURPOSE

Older men are more likely to be diagnosed with high-risk prostate cancer and to have lower overall survival. As a result, age often plays a role in treatment choice. However, the relationships among age, disease risk, and prostate cancer-specific survival have not been well established.

PATIENTS AND METHODS

We studied men in the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) database with complete risk, treatment, and follow-up information. High-risk patients were identified by using the validated Cancer of the Prostate Risk Assessment (CAPRA) score. Competing risks regression was used to identify the independent impact of age on cancer-specific survival. We also analyzed the effect of local treatment on survival among older men with high-risk disease.

RESULTS

In all, 26% of men age ≥ 75 years presented with high-risk disease (CAPRA score 6 to 10). Treatment varied markedly with age across risk strata; older men were more likely to receive androgen deprivation monotherapy. Controlling for treatment modality alone, or for treatment and risk, age did not independently predict cancer-specific survival. Furthermore, controlling for age, comorbidity, and risk, older men with high-risk tumors receiving local therapy had a 46% reduction in mortality compared with those treated conservatively.

CONCLUSION

Older patients are more likely to have high-risk prostate cancer at diagnosis and less likely to receive local therapy. Indeed, underuse of potentially curative local therapy among older men with high-risk disease may in part explain observed differences in cancer-specific survival across age strata. These findings support making decisions regarding treatment on the basis of disease risk and life expectancy rather than on chronologic age.

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.

Prostate cancer in the elderly

Prostate cancer is the most frequent malignancy in men and predominantly in elderly men. The issue of prostate cancer is likely to assume greater importance with progressive aging of the population. With frequent use of PSA testing most patients were diagnosed with localized cancer even in senior adults. Cancer-specific mortality is low in elderly men with prostate cancer and is dependent on the aggressiveness of the tumor. Currently, no established guidelines for the management of prostate cancer in the elderly exist, and treatment of senior adults with localized cancer is not optimal. While elderly men with indolent disease will not benefit from curative treatment, some patients with aggressive cancers will progress if not adequately treated. Comorbidity is the main predictor of life expectancy in the elderly. In everyday clinical practice, treatment decisions are much more influenced by age than by comorbidity. Curative treatment is an effective treatment option for selected elderly with localized prostate cancer. Conversely, most elderly men with prostate cancer received hormonal therapy, although the benefit of hormonal therapy in localized cancer is not clear and is associated with severe toxicities in some patients. In conclusion, there is a need for more risk stratified approaches for the management of prostate cancer in the elderly to avoid unnecessary intervention in men who unlikely benefit from such intervention, and allow treatment in those who might benefit from it.

Development and external validation of a highly accurate nomogram for the prediction of perioperative mortality after transurethral resection of the prostate for benign prostatic hyperplasia

PURPOSE

Benign prostatic hyperplasia affects 60% of men at the age of 60 years. Transurethral resection of the prostate is the gold standard of therapy. We assessed the 30-day mortality rate after transurethral resection of the prostate for benign prostatic hyperplasia, identified risk factors related to 30-day mortality and developed a model that discriminates among individual 30-day mortality risk levels.

MATERIALS AND METHODS

We performed development (7,362) and external validation (7,362) of a multivariable logistic regression model predicting the individual probability of 30-day mortality after transurethral resection of the prostate based on an administrative data set (Quebec Health Plan) of 14,724 patients 43 to 99 years old treated between January 1, 1989 and December 31, 2000.

RESULTS

Overall 30-day mortality occurred in 58 patients (0.4%) undergoing transurethral resection of the prostate. On univariable analyses increasing age (p <0.001) and increasing Charlson comorbidity index (p <0.001) were statistically significant predictors of 30-day mortality after transurethral resection of the prostate. Conversely annual surgical volume was not. On multivariable analyses age (p <0.001) and Charlson comorbidity index (p <0.001) reached independent predictor status. The accuracy of the age and Charlson comorbidity index based nomogram that predicts the individual probability of 30-day mortality after transurethral resection of the prostate was 83% in the external validation cohort.

CONCLUSIONS

Age and Charlson comorbidity index are important determinants of 30-day mortality after transurethral resection of the prostate. The combination of these parameters allows an 83% accurate prediction of individual 30-day mortality risk after transurethral resection of the prostate. Despite limitations such as the need for additional external validations and possibly the need for inclusion of clinical parameters, the use of the current model is warranted for the purpose of informed consent before transurethral resection of the prostate and/or for patient counseling.

Thirty-day mortality after nephrectomy: clinical implications for informed consent

BACKGROUND

The existing literature suggests that the surgical mortality (SM) observed with nephrectomy for localised disease varies from 0.6% to 3.6%.

OBJECTIVE

To examine age- and stage-specific 30-d mortality (TDM) rates after partial or radical nephrectomy.

DESIGN, SETTING, AND PARTICIPANTS

We relied on 24535 assessable patients from the National Cancer Institute (NCI) Surveillance, Epidemiology, and End Results (SEER) database.

MEASUREMENTS

In 12283 patients, logistic regression models were used to develop a tool for pretreatment prediction of the probability of TDM according to individual patient and tumour characteristics. External validation was performed on 12252 patients.

RESULTS AND LIMITATIONS

In the entire cohort of 24535 patients, 219 deaths occurred during the initial 30 d after nephrectomy (0.9% TDM rate). TDM increased with age (≤49 yr: 0.5% vs 50-59 yr: 0.7% vs 60-69 yr: 0.9% vs 70-79 yr: 1.2% vs ≥80 yr: 2.0%; χ(2) trend p<0.001) and stage (0.3% for T1-2N0M0 vs 1.3% for T3-4N0-2M0 vs 4.2% for T1-4N0-2M1; χ2 trend p=<0.001). TDM decreased in more recent years (1988-1993: 1.3% vs 1994-1998: 0.9% vs 1999-2002: 0.7% vs 2003-2004: 0.6%; χ2 trend p<0.001) and was lower after partial versus radical nephrectomy (RN) (0.4% vs 0.9%; p=0.008). Only age (p<0.001) and stage (p<0.001) achieved independent predictor status. The look-up table that relied on the regression coefficients of age and stage reached 79.4% accuracy in the external validation cohort.

CONCLUSIONS

Age and stage are the foremost determinants of TDM after nephrectomy. Our model provides individual probabilities of TDM after nephrectomy, and its use should be highly encouraged during informed consent prior to planned nephrectomy.