A Decision Analysis for Treatment of Clinically Localized Prostate Cancer

Abstract

OBJECTIVE:To determine the preferred treatment of clinically localized prostate cancer. DESIGN:Cancer grade, patient age, and comorbidities are considered in a Markov model with Monte Carlo sensitivity analyses. Large and recent pooled analyses and patient-derived utilities are included. RESULTS:Principal findings suggest benefit for radical prostatectomy relative to watchful waiting for men under 70 years of age with low to moderate comorbidity. Men older than 70 with high comorbidity and disease of low to moderate grade do better with watchful waiting. CONCLUSIONS:Cohort-level sensitivity analyses suggest a quality-adjusted treatment benefit for radical prostatectomy for younger men and treatment harm for older men. Tailored patient and clinician decisions remain necessary, especially for men older than 70 in good health but with aggressive cancers. radical prostatectomy (RP) would help resolve the debate. The results of such a trial, however, are at least a decade away. In the meantime, we must rely on rational comparisons of the risks and benefits with either choice.The purpose of this study is to compare WW and RP in a decision analysis in which the risks of adverse events and patients' feelings about those events are quantified. Our perspective is that of society; we analyzed the data to determine the preferred treatment for a hypothetical cohort of men with localized prostate cancer. Although costeffectiveness is important, it is not included in this report. Our outcomes of interest are life expectancy, with and without adjustments for quality of life, for WW and RP patients who are between the ages of 60 and 75.Two large pooled analyses of metastasis-free survival have recently been conducted: one on WW patients, 4 and one on RP patients. 5,6 In addition, a recent analysis by Albertsen et al. has illustrated the increased risk of death due to noncancerous chronic illnesses in the prostate cancer population. 7 Recent studies have also examined treatment and complication impacts on quality of life 8,9 and patient utilities. 10 Our analysis incorporates all of these recent developments in an attempt to provide a comprehensive and current evaluation of the choice between RP and WW for localized prostate cancer. METHODS Decision Analysis ModelWe build on a model of prostate cancer previously published by the Prostate Patient Outcomes Research Team (PORT). 11 We analyzed this model previously, 12 and we found it reasonably approximated the natural history of prostate cancers. In our Markov model (depicted in Fig. 1), all patients begin with localized prostate cancer with no evidence of metastases and are treated by WW or RP. Each 6 months, a fraction of the patients progress to hormonally controlled metastatic disease. In subsequent 6-month periods, a fraction of these patients progress to hormone-refractory metastatic disease and eventual death from prostate cancer. At every 6-month period, a fraction of the patients die from causes other than prostate cancer. The arrows in Figure 1 illustrate the permissibl...

Association between comorbidity and clinical characteristics of MS

“…Our findings suggest that the findings of clinical trials excluding patients with comorbidities should be generalized cautiously to patients with comorbidities. Precedents exist for comorbidity‐based differences in disease management in other conditions, including hypertension, community‐acquired pneumonia, and prostate cancer (29–31).…”

Patient preference and decision-making for initiating metastatic colorectal cancer medical treatment

“…While several methods are available that directly elicit preference, standard gamble is associated with the highest test-retest reliability within the cancer population, 28;36 and has theoretical advantages. 36;37 Because standard gamble involves uncertainty, it is the only preference measure that captures patients' risk attitudes: risk-averse, risk-neutral, or risk-seeking.…”

“…While several methods are available that directly elicit preference, standard gamble is associated with the highest test-retest reliability within the cancer population, 28;36 and has theoretical advantages. 36;37 Because standard gamble involves uncertainty, it is the only preference measure that captures patients' risk attitudes: risk-averse, risk-neutral, or risk-seeking. 27;38 Additionally, using a patient-specific measure is preferable for our study to using group-level measures such as EQ-5D or Health Utility Index, which reflects societal preferences rather than individual preferences and values.…”

Responsiveness of disease-specific and generic utility instruments in prostate cancer patients

“…In contrast to many other clinical or policy decisions, the best thing to do with respect to screening for prostate cancer or treatment for localized prostate cancer almost always turns on patientsÕ preferences for the outcomes of treatment [1,3,[49][50][51]. This is because sexual, urinary, and bowel problems after treatment are common and long-lasting, whereas the mortality benefits of treatment are modest.…”