Karim Chaime, M.D.
Mark Litwin, M.D., M.P.H.
It’s an ongoing debate: Should men over a certain age be treated for prostate cancer? And should these patients be submitted to treatments that may result in significant side effects if they may not live very much longer?
Now, a study by researchers at UCLA’s Jonsson Comprehensive Cancer Center has shown that men over 75 are being undertreated, while patients with a single comorbid condition such as peripheral vascular disease or those in wheelchairs are being over-treated and doing much more poorly than expected.
“This study suggests that men with certain medical conditions are being treated just as aggressively for their prostate cancer as men who are healthy, even though they are more likely to die of non-prostate cancer causes. Conversely, men over 75 are not being aggressively treated when they may, in fact, fare better than younger men with complicating health issues,” said Dr. Karim Chamie, a postdoctoral fellow in urologic oncology and health services research and first author of the study. “There are individual medical problems that impact survival much more so than simply being 75 years of age.”
The retrospective study, which looked at the records for 1,031 men diagnosed with localized prostate cancer between 1997 and 2004, appeared Sept. 26 in the early online edition of the Journal of General Internal Medicine.
The patients studied were being treated at the Greater Los Angeles and Long Beach Veteran’s Affairs Medical Center, where care is subsidized through a federal program. So there was no financial incentive to treat patients in the study, removing physician reimbursement from the equation.
“Because these are VA patients, it eliminates any speculation or concern that treatment decisions were being made with reimbursement or the bottom line in mind,” Chamie said. “This really speaks to the underlying psychology of physicians and how they manage patients with prostate cancer.”
In this study, Chamie and his team sought to determine the probability of prostate cancer treatment and survival among men with a single comorbid condition. They measured the risk of undergoing treatment for men with a host of medical problems, such as chronic obstructive pulmonary disease (COPD), diabetes with and without organ damage, congestive heart failure, stroke, heart attack, liver disease, peripheral vascular disease and other comorbid conditions.
Even though prostate cancer patients with the comorbid conditions had lower survival rates than those without, they were being treated just as aggressively. Approximately two-thirds of men with or without comorbidities underwent aggressive treatment for their prostate cancer.
The study found that only 16 percent of men with prostate cancer who had no comorbid conditions died of other causes at the 10-year mark. Conversely, in diabetics with no associated organ damage, 35 percent were dead of causes other than their cancer after 10 years. In men with peripheral vascular disease treated for their cancer, 49 percent were dead at 10 years. In diabetics with organ damage, such as kidney or eye problems, 50 percent were dead at 10 years out. And in men with moderate to severe COPD, 65 percent were dead at the 10-year mark.
The study also examined the age of patients and found that only about a quarter of men aged 75 were being treated for their prostate cancer, even though their chances of living another 10 years were 58 percent.
“I think some physicians may think that a man with only one comorbid condition is healthier than he may in fact be,” Chamie said. “Some patients, even those with just a single comorbid condition, might benefit from surveillance, as they may die as a result of other causes before their prostate cancer, as well as avoid being exposed to some of the debilitating side effects of treatments.”
“This study suggests that while physicians use patient age of 75 as a very strong cue to avoid over-treatment of men with prostate cancer, they are less likely to integrate certain comorbidities into prostate cancer decision making," said Dr. Mark S. Litwin, professor and chairman of the urology department, senior author of the study and a researcher at UCLA’s Jonsson Comprehensive Cancer Center. “There are some medical conditions that portend a poor prognosis and should therefore be taken into consideration in the decision-making process.”
The study was funded by the American Cancer Society, the Ruth L. Kirschstein National Research Service Award, a Jonsson Comprehensive Cancer Center Seed Grant and the National Institute of Diabetes and Digestive and Kidney Diseases.
UCLA's Jonsson Comprehensive Cancer Center has more than 240 researchers and clinicians engaged in disease research, prevention, detection, control, treatment and education. One of the nation's largest comprehensive cancer centers, the Jonsson center is dedicated to promoting research and translating basic science into leading-edge clinical studies. In July 2011, the Jonsson Cancer Center was named among the top 10 cancer centers nationwide by U.S. News & World Report, a ranking it has held for 11 of the last 12 years. For more information on the Jonsson Cancer Center, visit our website at http://www.cancer.ucla.edu.