COMMENTARY

Reframing Prostate Cancer as 'Chronic Disease'

Timothy Daskivich, MD; Matthew J. Resnick, MD

Disclosures

May 22, 2013

In This Article

Which Patients Should Be Treated With Aggressive Therapy?

Dr. Daskivich: But it begged the question: Who should be treated with aggressive therapy in the first place? Because prostate cancer is an indolent disease, the benefits of aggressive treatment are not realized for about 8-10 years after treatment. For men who don't survive that long, there is really no benefit of aggressive treatment, and, in fact, you incur side effects that significantly affect quality of life during that time. You're just making these men worse off in the short term if they don't live longer than 10 years.

At UCLA, we've done a number of studies looking at how to better inform men of their likelihood of living long enough to benefit from aggressive treatment. We found a couple of variables that are strong predictors to help better inform these men of their likelihood of living long enough to benefit. One is comorbidity. What I saw in your study was that 27% of men who were treated aggressively had more than 2 comorbidities at the time of diagnosis. When we looked at our Veterans Affairs database, it showed that men who had similar comorbidity burdens were dying of other causes more than half of the time at 10 years. If they had more than 3 on the Charleston score, they died of other causes more than three quarters of the time at 10 years. More than half to three quarters of these men are not benefiting from aggressive treatment. What we would like to do is better inform these men of their likelihood of benefit in the long term. When we talk to them up front, we can say, "Here is your likelihood of incurring these side effects and here is your likelihood of benefiting from treatment." Then they can make an informed treatment decision.

Dr. Resnick: I think the work that you're doing is fantastic. There is a real opportunity to begin to understand the value or preference our patients place on survival and to reduce the anxiety that is associated with a prostate cancer diagnosis compared with the risk for harm from treatment, which is considerable.

Using some of the work that you're doing in comorbidity and some of the work that we're doing in quality of life, and merging those 2 fields to optimize the benefit-to-harm ratio for men individually, is how we should move forward.

I think that you and I both agree that we need to be a little more thoughtful about how we use aggressive treatment -- meaning surgery, radiation, or other novel therapies -- in men with newly diagnosed low-risk disease.

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