Older, sicker men with prostate cancer may bypass aggressive treatment

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As men with localized prostate cancer weigh the multitude of treatment options, they may want to consider the interplay between comorbid conditions, age and tumor features with other-cause mortality and disease-specific mortality. Older men with several comorbid conditions face a higher risk of other-cause mortality within 10 years of diagnosis, according to a study published May 20 in Annals of Internal Medicine.

Appropriate treatment for prostate cancer hinges on an accurate estimation of life expectancy, partially because survival benefits of aggressive treatment for low- and intermediate-risk disease are delayed eight to 10 years, according to Timothy J. Daskivich, MD, from University of California, Los Angeles, and colleagues. However, few data have examined the association between comorbidities and mortality risks.  

Daskivich and colleagues sought to evaluate the link between comorbid conditions, age and tumor features with other-cause and disease-specific mortality over the long term.

The prospective cohort study focused on 3,183 men with nonmetastatic prostate cancer. Patients were assessed for 12 comorbid conditions at the time of diagnosis: diabetes, bleeding gastrointestinal ulcer, chronic lung disease, congestive heart failure, stroke, myocardial infarction, angina or chest pain, cirrhosis or liver disease, arthritis, inflammatory bowel disease, hypertension and depression. Tumors were classified as low, intermediate or high risk.

The cohort was stratified by the number of comorbid conditions, which revealed 10-year other-cause mortality rates of 26 percent, 40 percent and 71 percent among men younger than 60 years, aged 61-74 years and older than 75 years at time of diagnosis with three or more comorbid conditions, respectively.  

Other-cause mortality risk increased with the number of comorbid conditions and disease-specific mortality increased with greater tumor risk.

“A competing-risks model analyzing the subhazard of prostate cancer mortality associated with nonaggressive treatment among comorbidity groups suggested that there may be a benefit to aggressive therapy in men with little or no comorbid disease. However, these treatments may not be as valuable in men with more comorbid conditions.”

Daskivich et al affirmed the prognostic value of the 12 comorbid conditions in predicting other-cause mortality. They also reviewed their findings in light of the U.S. Preventive Services Task Force recommendation that men with a life expectancy less than 10 years gain little or no benefit from aggressive treatment.

A similar cutoff applied to comorbidity and age suggests men ages 60 years or older with three or more comorbid conditions may want to weigh the risk for other-cause mortality with any potential survival benefit from aggressive treatment.

The researchers recommended men with a new diagnosis of prostate cancer understand the likely benefit and potential harm of aggressive treatment and that physicians share the higher risk of other-cause death before realization of a survival benefit from surgery or radiation therapy with patients who have multiple comorbidities.