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Journal of Clinical Oncology, Vol 26, No 4 (February 1), 2008: pp. 690-691 © 2008 American Society of Clinical Oncology. DOI: 10.1200/JCO.2007.14.7108
Family Physicians Could Help in Predicting Life Expectancy Without Prostate CancerDepartment of Family and Community Medicine, Eastern Virginia Medical School, Norfolk, VA To the Editor: Walz et al report on development of yet another nomogram to predict 10-year life expectancy (LE) in patients with localized prostate cancer.1 In the accompanying editorial, Ross et al ask, "How many more nomograms do we need?"2 As family physicians, in the current climate of disorganized care, we find that treatment decisions for prostate cancer are made between the urologist who did the biopsy and the patient. Typically, a date for prostatectomy, or a referral for the radiation oncologist, is determined when the patient visits his urologist after a positive biopsy. The diagnosis of cancer, the bewildering array of treatment choices and their benefits—not to mention their complications, the patient's list of comorbidities, and his preferences are all addressed in that one visit. Unless the patient insists he is in doubt, the decision to treat or not treat, and the modality of treatment, is more or less finalized before the patient returns to see the referring primary care physician. This is likely because the treating urologist is in the best position to assess a range of outcome predictors such as tumor grade and stage and predict which treatment should be recommended. However, it is not easy for urologists, as is evidenced by the development of more than 40 different nomograms, to better predict optimal treatment. Probably the main difficulty lies in the fact that on weighing the pros and cons of different treatments and nontreatment, statistically the differences in outcomes are marginal. On average, it seems a judicious choice would add fewer than 2 to 3 years of quality-adjusted life.3 In this context, we do need more nomograms, but not ones based on urologic criteria of cancer stage and grade; several of those already exist. Outcomes research has likely defined accurately the effect of these tumor criteria on LE; the variations in predictions by different nomograms might lie in the effect of age and comorbidities on LE. What we need more of is better estimation of the patient's LE without prostate cancer—that is, the patient's health-adjusted LE (HALE). As a second step, nomograms could more accurately predict how the cancer or its treatment could influence survival. Guidelines by both the American Cancer Society4 and the American Urological Association5 already require, as a first step, an estimate of the patient's HALE before cancer characteristics can be factored in to find the best treatment. Walz et al cite evidence that empiric HALE prediction by urologists and oncologists is poor, and in their introduction, emphasize the need of a priori HALE assessment, but their nomogram compares only the risk of mortality from cancer and noncancer factors. Calculation of HALE based on use of comorbidity indices is also too cumbersome for clinical practice, because it requires the scoring of comorbidity followed by a calculation of the effect of comorbidity on LE.6 Walz et al have also reported recently that life-tables alone are inaccurate predictors of LE in these patients.7 Research in physician-predicted LE in primary care or hospitalized patients is almost exclusively limited to end-of-life situations. In one study of community-dwelling patients 70 years or older, 66% of patients did not think their primary physician could predict LE accurately.8 However, just as many patients in this study did want their "main" physician to talk to them about their LE. Family physicians are usually not called on to calculate HALE and would only rarely consult life-tables to estimate a patient's LE at a given age. However, this could be done in a visit targeted for this purpose. The patient would have to be referred back to the referring physician. In this visit, instead of relying on only a comorbidity score, the patient's health record, current health habits, and health-related quality of life could be reviewed with the patient to predict if a survival longer than 10 years could be expected. Most patients may have not even checked a life-table to know what their LE would be at their age if they were in average health. This will also be an opportunity for the patient's primary physician, who has presumably known the patient for a longer time than the urologist, to share the preferences of the patient and his family and make sure that the patient is competent, well informed, and free of coercion.9 Considering how small the relative benefit is of one treatment versus the other, and how profoundly each choice could affect the patient's remaining life, our patients should get such an evaluation. AUTHOR'S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest. REFERENCES
1. Walz J, Gallina A, Saad F, et al: A nomogram predicting 10-year life expectancy in candidates for radical prostatectomy or radiotherapy for prostate cancer. J Clin Oncol 25:3576-3581, 2007 2. Ross RW, Kantoff PW: Predicting outcomes in prostate cancer: How many more nomograms do we need? J Clin Oncol 25:3563-3564, 2007 3. Alibhai SM, Naglie G, Nam R, et al: Do older men benefit from curative therapy of localized prostate cancer? J Clin Oncol 21:3318-3327, 2003 4. Scherr D, Swindle PW, Scardino PT: National Comprehensive Cancer Network Guidelines for the Management of Prostate Cancer. Urology 61:14-24, 2003 (suppl 2A)[CrossRef][Medline] 5. Thompson I, Thrasher JB, Aus G, et al: Guideline for the management of clinically localized prostate cancer: 2007 update. J Urol 177:2106-2131, 2007[CrossRef][Medline] 6. Albertsen PC, Fryback DG, Storer BE, et al: The impact of comorbidity on life expectancy among men with localized prostate cancer. J Urol 156:127-132, 1996[CrossRef][Medline] 7. Walz J, Gallina A, Hutterer, G, et al: Accuracy of life tables in predicting overall survival in candidates for radiotherapy for prostate cancer. Int J Rad Onc Bio Phy 69:88-94, 2007 8. Kistler CE, Lewis CL, Amick HR, et al: Older adults’ beliefs about physician-estimated life expectancy: A cross-sectional survey. BMC Family Practice 7:9, 2006[CrossRef][Medline] 9. Mold JW: Facilitating shared decision making with patients. Am Fam Physician 74:1209-1212, 2006[Medline]
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Copyright © 2008 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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