Patients with clinically localized prostate cancer face a wide array of management options. Treatment may include definitive local therapy. Although prostate cancer is the second leading cause of cancer mortality, with approximately 3% of all men dying of the disease,1 its natural history is heterogeneous and most prostate cancers are clinically insignificant. In one autopsy study, as many as 1 in 3 men older than 50 years had histologic evidence of prostate cancer.2 Estimates show that 8 men will be diagnosed with prostate cancer for every 1 who dies of the disease.3
Any active treatment leads to a decrease in quality of life.4 Ideally, treatment would be reserved for patients most likely to die of their disease. Currently, no accurate test exists to identify these patients. Various prognostic models have been described to stratify prostate cancers. Commonly used prognostic models include the Partin tables,5 the Kattan nomograms,6 and the CAPRA (Cancer of the Prostate Risk Assessment) score.7 Population-based cohort studies have defined the natural history of prostate cancer diagnosed in the pre–prostate-specific antigen (PSA) era and managed without curative treatment. Albertsen et al.8 defined the risk for prostate cancer mortality stratified by age and Gleason score. Johansson et al.9 reported 15-year survival rates stratified by stage and grade.9 Recently, Kattan et al.10 developed a nomogram incorporating PSA to predict 10-year disease-specific survival in men treated without curative therapy.
Elderly patients diagnosed with prostate cancer are at risk for non-prostate cancer mortality. Therefore, an estimate of life expectancy is essential for informed decision-making. Life expectancy is commonly estimated using the Social Security Administration (SSA) life tables, which provides life expectancies in years of life. However, most research studies report survival rates associated with prostate cancer. Therefore, during a patient counseling session, the risk posed by the prostate cancer may be difficult to convey when life expectancy is presented in years and prostate cancer survival is presented as a survival rate or chance at an arbitrary interval.
A better way to convey the risk for prostate cancer is to tailor the survival rate for patients by estimating their life-time risk for dying from prostate cancer, which can be done using standard actuarial methods. The authors used previously published mortality rates for prostate cancer to create life tables that estimate a patient's life expectancy and lifetime risk for dying from prostate cancer managed without curative therapy. The authors also illustrate how the calculations can be modified to account for lead-time bias from PSA screening and clinician assessment of overall health.
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Kattan MW, Eastham JA, Stapleton AM et al.. A preoperative nomogram for disease recurrence following radical prostatectomy for prostate cancer. J Natl Cancer Inst 1998;90:766–771.
Cooperberg MR, Pasta DJ, Elkin EP et al.. The University of California, San Francisco Cancer of the Prostate Risk Assessment score: a straightforward and reliable preoperative predictor of disease recurrence after radical prostatectomy. J Urol 2005;173:1938–1942.
Albertsen PC, Hanley JA, Fine J. 20-year outcomes following conservative management of clinically localized prostate cancer. JAMA 2005;293:2095–2101.
Kattan MW, Cuzick J, Fisher G et al.. Nomogram incorporating PSA level to predict cancer-specific survival for men with clinically localized prostate cancer managed without curative intent. Cancer 2008;112:69–74.
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