Questioning the Ten-Year Life Expectancy Rule for High-Grade Prostate Cancer: Comparative Effectiveness of Aggressive Vs. Non-Aggressive Treatment of High-Grade Disease in Older Men with Differing Comorbid Disease Burdens

To determine if the ten-year rule should apply to men with high-grade, clincially localized prostate cancer, we characterized the survival benefits of aggressive (surgery, radiation, brachytherapy) over non-aggressive treatment (watchful waiting, active surveillance) among older men with differing comorbidity at diagnosis.

We sampled 44,521 men older than 65 with cT1-2, poorly differentiated prostate cancer diagnosed in 1991-2007 from the SEER-Medicare database. We used propensity-adjusted, competing-risks regression to calculate 5- and 10-year cancer mortality among those treated aggressively and nonaggressively across comorbidity subgroups. We determined 5- and 10-year absolute risk reduction in cancer mortality and numbers needed to treat to prevent one cancer death at ten years.

In propensity-adjusted, competing-risks-regression analysis, aggressive treatment was associated with significantly lower risk of cancer mortality for those with Charlson scores of 0 (SHR0.43, 95%CI 0.39-0.47), 1 (SHR0.48, 95%CI 0.40-0.58), and 2 (SHR0.46, 95%CI 0.34-0.62) but not 3+ (SHR0.68, 95%CI 0.44-1.07). Absolute reductions in cancer mortality between those treated aggressively and non-aggressively were 7%, 5.5%, 6.9%, and 2.5% at 5 years and 11.3%, 7.9%, 8.6%, and 2.8% at 10 years for men with Charlson scores of 0, 1, 2, and 3+, respectively; numbers needed to treat to prevent one cancer death at ten years were 9, 13, 12, and 36 men.

The ten-year rule may not apply to men with high-grade, clinically localized disease. Older men with Charlson scores ≤2 should consider aggressive treatment of such disease due to its substantial short-term cancer survival benefits.

Urology. 2016 Apr 11 [Epub ahead of print]

Timothy J Daskivich, Julie Lai, Andrew W Dick, Claude M Setodji, Janet M Hanley, Mark S Litwin, Christopher Saigal, Urologic Disease in America Project

Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA. Electronic address: ., RAND Corporation, Santa Monica, CA., RAND Corporation, Santa Monica, CA., RAND Corporation, Santa Monica, CA., RAND Corporation, Santa Monica, CA., Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA; Department of Health Policy & Management, Fielding School of Public Health, University of California, Los Angeles, CA., RAND Corporation, Santa Monica, CA; Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA; Department of Health Policy & Management, Fielding School of Public Health, University of California, Los Angeles, CA.

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