**Patients' Survival Expectations Before Localized Prostate Cancer Treatment by Treatment Status**

Ravinder Mohan, Hind Beydoun, Myra L. Barnes-Ely, LaShonda Lee, John W. Davis, Raymond Lance and Paul Schellhammer *Department of Family and Community Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA* 

#### **1. Introduction**

266 Topics in Cancer Survivorship

Wyser, C., Stulz, P., Solèr, M., Tamm, M., Müller-Brand, J., Habicht, J., et al. (1999).

Zeiher, B.G., Gross, T.J., Kern, J.A,, Lanza, L.A., Peterson, M.W. (1995). Predicting

history. *Eur Respir J,* Vol.34, No.2, pp. 380-386

Vol.108, No.1, pp. 68-72

Prospective evaluation of an algorithm for the functional assessment of lung resection candidates. *Am J Respir Crit Care Med,* Vol.159, No.5 Pt 1, pp. 1450-1456 Young, R.P., Hopkins, R.J., Christmas, T., Black, P.N., Metcalf, P., Gamble, G.D. (2009).

COPD prevalence is increased in lung cancer, independent of age, sex and smoking

postoperative pulmonary function in patients undergoing lung resection. *Chest,*

Although around 80% of men aged 80 years and older and 15% to 30% of men aged 50 years and older have microscopic undiagnosed prostate cancer found at autopsy, only 3% men die because of prostate cancer.**1** Increasing prostate-specific antigen (PSA) screening at younger ages has increased overdiagnosis2 and overtreatment3 of localized prostate cancer (LPC). More than 90% of US patients currently diagnosed with prostate cancer have LPC and approximately 94% of patients with LPC choose treatment.4 Based on data from leading studies, a model had recently projected only a 0% to 2% 15-year mortality from low-grade (Gleason score <7) screen-detected LPC in men aged 55 to 74 years if they chose observation instead oftreatment.5 By consensus, urologists and radiation oncologists recommend treatment for LPC if a patient has a further 10-year life expectancy 6 (the10-year rule7) regardless of cancer grade, even though no randomized trials have shown that treatment can improve survival in patients in whom the cancer was screen-detected. National guidelines by the American Cancer Society and the National Comprehensive Cancer Network (NCCN) also recommend treatment for most patients.8 However, in the review by Zeliadt et al,9 different studies had found that patients rate the sexual, urinary, and bowel side effects of treatment to be just as important as the potential benefit in survival; that if risks and benefits of treatment were explained with-out bias, 75% of patients chose a lower radiation dose despite a lower predicted survival; that 90% of physicians but fewer than 20% of patients ranked the effect of treatment on survival as one of their top 4 concerns; and that patients who chose treatment believed that treatment was guaranteed to improve survival. At a median of 6 years after treatment, health-related quality of life (HRQOL) of treated patients was worse than that of controlpatients.10 Many patients regretted that they chosetreatment.11

To our knowledge, no studies of patient-physician communication have examined patients' anticipated survival benefit of treatment. Without data from randomized trials in screendetected patients, it is difficult to counsel patients regarding their survival with and without treatment. Even with the use of multi-factorial models, accuracy of predicted survival is 75% or lower.12 Physicians are also poor at estimating baseline co-morbidity adjusted life expectancy (CALE), which is critical in making an informed decision.13 Thus, patients may

Patients' Survival Expectations Before Localized Prostate Cancer Treatment by Treatment Status 269

with LPC in a Prostate Cancer Outcomes Study15 had a disease score of 1 or 2, and almost half (55.5%) of our patients had a disease score of 1 or 2. Both studies used the same version and scoring of the CCI. Patients were placed in 4 CALE categories: <5 years, 5 to 10 years, 10

Patients were asked the following 2 questions: "How long do you expect you will live *without*  any treatment for prostate cancer?" (Q1) and "How long do you expect you will live after treatment for prostate cancer?" (Q2). The possible responses to both questions were grouped into 4 categories (similar to the CALE categories): <5 years, 5 to 10 years, 10 to 20 years, and >20 years. These 4 categories were also scored from 1 to 4, respectively. Based on Q1, Q2, and CALE scores, we calculated the patient's PDLO (which is CALE category score minus Q1 category score) and the patient's PILT (which is Q2 category score minus Q1 category score). A PDLO of 10 or more years is at least a 2-category difference between the CALE category and the Q1 category; this is only possible if the CALE was >20 years and the Q1 response was 5 to 10 years or if the CALE was 10 to 20 years and the Q1 response was <5 years. Similarly, a PILT of 10 or more years indicates that the response to Q2 was 10 years or more than the response to Q1. We conducted ordinal logistic regression analyses to identify the main socio-demographic, health, and cancer characteristics that could predict PDLO and PILT of 10 or more years. The following validated self-administered scales were used. (1) The Short-Form 36 (SF-36, version 2) measures generic HRQOL; we calculated physical component summary and mental component summary scores from SF-36 data.18 (2) The Prostate Cancer Index measures urinary, sexual, and bowel symptoms and how much they bother the patient.19 (3) The Duke Activity Status Index20 measures functional capacity in metabolic equivalents; this scale asks patients whether they could perform 12 activities which have different levels of exertion. (4) The Hospital Anxiety and Depression Scale measures the presence and severity of anxiety and depression.21 (5) The Fear of Cancer Recurrence Scale measures the fear of possible cancer recurrence.22 (6) The Medical Outcomes Study Social Support Survey measures social support in an overall score that includes multidimensional sub-scores. 23 (7) The Delighted-Terrible Seven Faces Scale24 was used to measure patient satisfaction with life, health, and with education given by physicians about treatment options for LPC. (8) The Rapid Estimation of Health Literacy in Medicine scale, discussed earlier, measures

to 20 years, and 20 years. These 4 categories were scored, respectively, from 1 to 4.

health literacy; this was the only scale administered by telephone.14

Frequencies and relative frequencies were used to describe categorical variables. Continuous variables were described using the mean, median, and SD. Chi-square tests, Fisher's exact test, and independent sample *t* tests were used to examine bivariate associations. Unadjusted and adjusted odds ratios (ORs) and their 95% CIs were estimated using ordinal logistic regression analysis. Socio-demographic and health factors that were found to be associated with PDLO and PILT in the bivariate analysis at an alpha level of 0.20 were kept in the multivariate models. All analyses were performed using SAS software

Surveys were mailed to 430 patients newly diagnosed with LPC, but 69 patients had already started treatment by the time the patients received the surveys, 3 patients never received the

**4. Statistical analyses** 

**5. Results** 

(version 9.1, SAS Institute, Inc., Cary, NC).

accept a treatment recommendation not knowing what their baseline CALE is, how much the newly diagnosed cancer could reduce it, or how effectively treatment could minimize that reduction. Current over-treatment of LPC might be because patients do not understand the pros and cons of treatment.

In this study we surveyed newly diagnosed patients about their anticipation of survival with and without treatment. By estimating their baseline CALE without considering the newly diagnosed cancer, we calculated their perceived decrease in longevity with observation (PDLO), and their perceived increase in longevity with treatment (PILT) for the cancer.
