A Nomogram Predicting 10-Year Life Expectancy In Candidates For Radical Prostatectomy Or Radiotherapy For Prostate Cancer

Main Category: Prostate / Prostate Cancer
Also Included In: Urology / Nephrology
Article Date: 31 Mar 2008 - 0:00 PDT

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UroToday.com - Family Physicians Could Help in Predicting Life Expectancy without Prostate Cancer.

In the online version of the Journal of Clinical Oncology, Dr. Ravinder Mohan, Department of Family and Community Medicine, Eastern Virginia Medical School has published an interesting correspondence regarding the role for primary care physicians in determining care for patients diagnosed with prostate cancer (CaP).

Dr. Mohan corresponds regarding an article by Walz et al. (J Clin Oncol 2007;25:3576-81) who published a 10-year life expectancy nomogram in candidates undergoing radical prostatectomy or radiotherapy for CaP. That article was followed by an editorial by Ross and Kantoff who question "How many nomograms do we need?" (J Clin Oncol 2007;25:3563-64). Dr. Mohan writes that patients are diagnosed with CaP by the urologist, who has performed the biopsy. They then get counseled by the urologist and possibly a radiation oncologist regarding therapy. In perhaps one visit, the large array of implications of treatment and side effects along with an assessment of the patient's comorbidities is undertaken. Most commonly, the decision about whether to treat, along with the type of treatment, is finalized before the patient ever returns to the primary care physician. Dr. Mohan agrees that the urologist is best versed in the outcome predictors that should guide treatment options. However, he points out that 40 published nomograms indicate that urologists are not able to better predict optimal treatment. This is because the statistical differences in outcomes are marginal. He cites the fact that the treatment choice may add 3 years or less of quality-adjusted life.

What are needed according to Dr. Mohan are nomograms that better estimate the patient's health-adjusted life expectancy (HALE). Then, as a second step CaP outcomes nomograms could more accurately predict how CaP or treatment could influence survival. While the American Cancer Society and American Urological Association already require an estimate of the patient's HALE as a first step, an empiric HALE performed by urologists or medical oncologists is poor, as described by Walz. While Walz points out the need for HALE assessment, their nomogram compares only the risk of CaP mortality to non-cancer factors. Mohan points out that the calculation of HALE is cumbersome, as it requires the scoring of comorbidities followed by a calculation of the effect of comorbidity on life expectancy. Walz has already published that life-tables alone are inaccurate predictors of life expectancy in these patients.

In a study of community patients 70 years or older, two-thirds did not think their primary care physician could predict their life expectancy accurately. However, the majority of these patients desired a discussion about life expectancy. A dedicated visit to the primary care physician, argues Dr. Mohan, could focus on a patient's health records, habits, comorbidities and quality of life to predict 10-year survival. This could also provide an opportunity for the primary physician who knows the patient best to engage in the decision and determine that the patient is competent, well informed and free from decision bias or coercion. These approaches would benefit patient decision making and are extremely valid suggestions for urologists to implement.

Walz J, Gallina A, Saad F, Montorsi F, Perrotte P, Shariat SF, Jeldres C, Graefen M, Bénard F, McCormack M, Valiquette L, Karakiewicz PI.

J Clin Oncol. 2007 Aug 20;25(24):3576-81
doi: 10.1200/JCO.2006.10.3820

Reported by UroToday.com Contributing Editor Christopher P. Evans, MD, FACS

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