“National guidelines recommend that men with low- and intermediate-risk prostate cancer who have life expectancies of fewer than 10 years should not be treated with radiation or surgery, since they are unlikely to live long enough to benefit from treatment. Yet a new study by UCLA researchers found that more than half of such men are receiving these aggressive treatments putting them at risk for potentially debilitating side effects.
“In the first study to rigorously address prostate cancer treatment trends by life expectancy in a large, nationally representative sample, UCLA researchers found that more than half of prostate cancer patients 66 years and older have life expectancies of fewer than10 years, but half of those still were over-treated for their prostate cancer with surgery, radiation or brachytherapy—the implantation of radioactive seeds in the prostate.
“Randomized controlled studies have suggested that significant differences in survival between watchful waiting—monitoring the cancer closely but not treating it—and aggressive therapies don’t develop until 10 years after treatment. Thus it makes sense not to treat men expected to die of something else within 10 years. But the UCLA researchers found that men were being treated aggressively anyway, with little regard for their quality of life, said study first author Dr. Timothy Daskivich, a UCLA Robert Wood Johnson fellow.
” ‘Life expectancy is poorly integrated into treatment decision-making for prostate cancer, yet it is one of the primary determinants of whether a patient will benefit from treatment with surgery or radiation,’ Daskivich said. ‘Because these treatments have side effects such as erectile dysfunction, urinary incontinence and bowel problems, it’s critical for men with limited life expectancies to avoid unnecessary treatment for low- and intermediate-risk prostate cancer.’ “
“A common prostate cancer therapy should not be used in men whose cancer has not spread beyond the prostate, according to a new study led by researchers at Henry Ford Hospital.
“The findings are particularly important for men with longer life expectancies because the therapy exposes them to more adverse side effects, and it is associated with increased risk of death and deprives men of the opportunity for a cure by other methods.
“The research study has been published online in European Urology.
“The focus of the new study is androgen deprivation therapy (ADT), in which an injectable or implanted medication is used to disrupt the body’s ability to make testosterone. ADT is known to have significant side effects such as heart disease, diabetes, increased weight gain and impotence; however a growing body of evidence suggests ADT may in fact lead to earlier death.
“Since the 1940s, the therapy has been a mainstay of treatment for prostate cancer that has metastasized, or spread beyond the prostate gland. Still other studies support the use of ADT when it is used as an adjuvant, or in addition to, radiation therapy for higher risk prostate cancer. No evidence exists to support the exclusive use of ADT for low risk or localized prostate cancer.”
Editor’s note: Patients with low- or intermediate-risk prostate cancer may sometimes choose to undergo less aggressive treatment so as to maintain quality of life. A recent study found that men with short life expectancies often undergo aggressive prostate cancer treatment. There are concerns that these men are unlikely to live long enough to benefit, and may experience unnecessary harmful side effects.
“Men with low- or intermediate-risk prostate cancer who had life expectancies of fewer than 10 years frequently underwent aggressive treatment with radiation therapy or less frequently with surgery, according to results of a SEER analysis.
“Timothy J. Daskivich, MD, MSHPM, of the department of urology at the University of California, Los Angeles, and colleagues used the SEER database to identify 96,032 men diagnosed with early-stage prostate cancer between 1991 and 2007. All men were aged at least 66 years and had a Gleason score of 7 or lower.
“Fifty-two percent of the study population (n=50,049) had a life expectancy that was shorter than 10 years.
“Results showed life expectancy decreased with older age and greater Charlson Comorbidity Index score. Life expectancy was less than 10 years among the following cohorts: men aged 66 to 69 years with a Charlson score ≥2; men aged 70 to 74 years with a Charlson score ≥1; and all men aged 75 to 79 years, as well as those aged at least 80 years, regardless of Charlson score.”
“New prognostic factors may be useful in predicting survival in patients with thin melanoma, according to research published online July 7 in the Journal of Clinical Oncology.
“Andrea Maurichi, M.D., of the Istituto Nazionale dei Tumori in Milan, and colleagues analyzed data for 2,243 patients with thin melanoma. The authors sought to explore new prognostic factors and construct a nomogram for predicting survival in individual patients.
“The researchers found that the worst prognosis for thin melanoma was associated with age older than 60 years, Breslow thickness greater than 0.75 mm, mitotic rate (MR) of 1 or higher, presence of ulceration, presence of lymphovascular invasion (LVI), and regression of 50 percent or greater. All of these factors, except age and regression, were significantly associated with sentinel node positivity. Independent predictors of survival, including age, MR, ulceration, LVI, regression, and sentinel node status, were used to construct a nomogram for predicting overall survival at 12 years.”
The gist: Some women who have been diagnosed with breast cancer in one breast decide to have both breasts surgically removed out of concern that cancer might arise in the other breast, too. However, recent research shows that such a procedure—known as contralateral prophylactic mastectomy (CPM)—might have very little benefit in terms of long-term survival; the percentage of patients who undergo CPM and who are still disease-free 20 years later is no more than 1% higher than the percentage of patients who do NOT undergo CPM and are still disease-free after 20 years. But, the authors said, “Survival is only one potential benefit of a cancer risk-reduction strategy; effects on cancer-related anxiety, cosmesis, and self-image are also important in decision-making processes.”
“The choice of contralateral prophylactic mastectomy (CPM) by women with breast cancer (BC) diagnosed in one breast has recently increased in the US but may confer only a marginal life expectancy benefit depending on the type and stage of cancer, according to a study published July 16 in the JNCI: Journal of the National Cancer Institute.
“To assess the survival benefit of CPM, Pamela R. Portschy, of the Department of Surgery, University of Minnesota, Minneapolis, and colleagues, developed a model simulating survival outcomes of CPM or no CPM for women with newly diagnosed stage I or II breast cancer, using data from the Surveillance, Epidemiology, and End Results (SEER) registry and large meta-analyses. Survival benefit projections were made for women by age (40, 50, or 60 years), breast cancer stage (I or II), and estrogen receptor (ER) status (positive or negative). Women with BRCA mutations were excluded from the analysis because they have a much higher risk of developing contralateral breast cancer.
“The average gain in life expectancy from CPM ranged from 0.13 to 0.59 years for women with stage I BC and from 0.08 to 0.29 years for those with stage II BC. The procedure was more beneficial for younger women and for those with stage I and ER-negative BC. The 20-year disease-free survival benefit ranged from 4.25% to 7.20% for women with stage I BC and from 2.73% to 4.62% for women with stage II BC, depending on age and ER status. However, the 20-year overall survival difference between CPM and no CPM did not exceed 1% for any group.”
“Lung, liver, and other visceral metastases are associated with the poorest survival in advanced hormone-refractory prostate cancer, according to results from a meta-analysis that sets the benchmark for prognosis.
“Lung metastases were associated with 30% higher adjusted odds of death compared with bone metastases (median survival 17 versus 20 months, P<0.002), Susan Halabi, PhD, of Duke University, and colleagues found.
“Liver metastases were even worse, with 40% higher adjusted odds of death compared with lung metastases after adjustment for performance status, prostate specific antigen (PSA), and age (median 12 months, P<0.001), the group reported here at the American Society of Clinical Oncology meeting.”
The gains made in the fight against cancer may be greater than is immediately obvious from the statistics. While deaths from cancer in the U.S. decreased 12% between 1970 and 2008, deaths due to other illnesses have decreased much more steeply. For example, deaths from heart disease fell by 62% in the same time period. However, the latter trend may explain the former—sharp declines in deaths from many illnesses, as well as from accidents, have led to an increase in life expectancy. More people are avoiding death from other causes and living long enough to eventually develop cancer; cancer risk rises steadily with advancing age. This trend may partially counterbalance the significant progress made in decreasing cancer death rates.
Men with advanced, incurable prostate cancer who are treated with the latest drugs have nearly three times the life expectancy of men treated a decade ago, according to data from the Royal Marsden Hospital in the UK. Men who were treated in trials or under drug access schemes at the hospital survived 41 months on average, compared with between 13 and 16 months, 10 years ago. All had prostate cancer, which had spread and no longer responded to standard hormone treatments. Just over three-quarters of the patients received a chemotherapy drug called docetaxel, which was approved for National Health Service (NHS) use in 2005.
“More than half of radiation oncologists and urologists in the United States use prostate cancer nomograms, but only about one-quarter use quality-of-life and life-expectancy prediction instruments, according to a study published in the June issue of The Journal of Urology. Simon P. Kim, M.D., M.P.H., from the Mayo Clinic in Rochester, Minn., and colleagues used a nationally representative mail survey of prostate cancerspecialists (313 radiation oncologists and 328 urologists) to assess clinical implementation of quality-of-life instruments, prostate cancer nomograms, and life-expectancy prediction tools in late 2011.”