Research ArticleOriginal ResearchA

Patients’ Survival Expectations With and Without Their Chosen Treatment for Prostate Cancer

Jinping Xu, James Janisse, Julie J. Ruterbusch, Joel Ager, Joe Liu, Margaret Holmes-Rovner and Kendra L. Schwartz
The Annals of Family Medicine May 2016, 14 (3) 208-214; DOI: https://doi.org/10.1370/afm.1926

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  • Table 1

    Patient Demographics and Tumor Characteristics by Treatment Choice (N = 240)

    VariableSurgery n = 137Radiation n = 72WW/AS n = 31P value
    Age, mean (SD)59.4 (7.4)63.2 (7.2)64.3 (7.9)<.001
    Age group, No. (%).002
     ≤65102 (74.5)41 (56.9)14 (45.2)
     >6535 (25.5)31 (43.1)17 (54.8)
    Race, No. (%).81
     Black68 (49.6)36 (50.0)17 (54.8)
     White69 (50.4)36 (50.0)14 (45.2)
    Education, No. (%).70
     ≤High school46 (34.1)25 (35.2)11 (35.5)
     Some college37 (27.4)27 (38.0)10 (32.3)
     College graduate27 (20.0)11 (15.5)5 (16.1)
     Some postgraduate study25 (18.5)8 (11.3)5 (16.1)
    No. comorbidities, mean (SD)1.23 (1.0)1.75 (1.3)1.39 (1.0).01
    General health perception, mean (SD)2.71 (0.84)2.41 (0.89)2.26 (0.89).008
    Perceived cancer seriousness, mean (SD)3.8 (1.3)3.1 (1.3)2.9 (1.4)<.001
    Worry about prostate cancer, mean (SD)2.5 (1.0)2.1 (0.9)2.4 (1.0).004
    PSA level, No. (%).39
     ≤436 (26.9)22 (31.0)8 (28.6)
     5–980 (59.7)41 (57.7)15 (53.6)
     10–1915 (11.2)4 (5.6)5 (17.9)
     ≥203 (2.2)4 (5.6)0 (0.0)
    Gleason score, No. (%).03
     ≤648 (35.3)30 (46.2)15 (50.0)
     779 (58.1)25 (38.5)11 (36.7)
     8–109 (6.6)10 (15.4)4 (13.3)
    Stage, No. (%)<.001
     ≤T2a21 (15.4)51 (78.5)23 (76.7)
     T2b or T2NOS19 (14.0)8 (12.3)5 (16.7)
     ≥T2c96 (70.6)6 (9.2)2 (6.7)
    Risk level, No. (%)<.001
     Low risk8 (5.9)26 (40.0)9 (30.0)
     Intermediate risk29 (21.3)23 (35.4)15 (50.0)
     High risk99 (72.8)16 (24.6)6 (20.0)

    • PSA = prostate-specific antigen; WW/AS = watchful waiting or active surveillance.

    • Note: The general health perceptions scale ranged from 1 (Poor) to 5 (Excellent), the perceived cancer seriousness scale ranged from 1 (Not at all Serious) to 5 (Very Serious), and the worry about prostate cancer scale ranged from 1 (Not at all) to 4 (Very Much).

  • Table 2

    Comparisons of Perceived Life Expectancy Outcomes Between Treatment Groups in Unadjusted and Adjusted Analyses

    Treatment
    OutcomesSurgeryRadiationWW/AS
    Unadjusted, mean (SD), y
     Perceived LE without treatment8.01 (6.3)8.13 (5.4)9.97 (7.5)
     Perceived LE with treatment20.30 (6.7)b19.38 (6.6)c16.66 (7.1)
     Difference in perceived LE12.29 (7.7)b11.24 (7.3)b6.69 (7.9)
    Adjusted for covariates,a mean, y
     Perceived LE without treatment8.387.669.46
     Perceived LE with treatment20.03c19.5917.33
     Difference in perceived LE11.65b11.94b7.87

    • LE = life expectancy; WW/AS = watchful waiting or active surveillance.

    • ↵a Covariates include age, general health perception, perceived cancer seriousness, race, and risk level.

    • ↵b Significantly different from WW/AS; P ≤.05.

    • ↵c Nonsignificantly different from WW/AS; P ≤.10.

  • Table 3

    Multiple Linear Regression Results Predicting Perceived Difference in Life Expectancy with Treatment Choice (n = 235)

    Variableb (95% CI)SEβP value
    Age−0.18 (−0.31 to −0.04)0.07−0.18.01
    Race (Black = 0, White = 1)−1.32 (−3.24 to 0.61)0.98−0.09.18
    General health perception1.20 (0.08 to 2.33)0.570.14.04
    Perceived cancer seriousness0.97 (0.21 to 1.73)0.390.17.01
    Cancer risk levela−0.39 (−1.87 to 1.08)0.75−0.04.60
    Surgery vs WW/AS3.77 (0.50 to 7.04)1.670.25.02
    Radiation vs WW/AS4.06 (0.87 to 7.25)1.620.25.01

    • WW/AS = watchful waiting or active surveillance; b = Unstandardized regression coefficient; β = Standardized regression coefficient.

    • ↵a Prostate cancer risk level based on D’Amico criteria.

Additional Files

  • The Article in Brief

    Patients' Survival Expectations With and Without Their Chosen Treatment for Prostate Cancer

    Jinping Xu , and colleagues

    Background To make informed treatment decisions, patients with localized prostate cancer (LPC) need a realistic understanding of the likely benefits and harms of each treatment option. This study examines survival expectations of patients who choose one of three main types of treatment options (surgery, radiation, or observation).

    What This Study Found Most men with localized prostate cancer underestimate their life expectancy without treatment and overestimate the gain in life expectancy with surgery or radiation ? misperceptions that may lead to overtreatment, decisional regret and decreased post-treatment quality of life. A survey of 260 men aged 75 or older with newly diagnosed LPC showed that without any treatment, 33 percent of patients expected to live less than 5 years, 41 percent five to 10 years, 21 percent 10 to 20 years, and 5 percent more than 20 years. With their chosen treatment (surgery, radiation or watchful waiting/active surveillance), 3 percent of patients expected to live less than five years, 9 percent five to 10 years, 33 percent 10 to 20 years and 55 percent more than 20 years. While only 25 percent of all patients in the study expected to live more than 10 years, the authors note that a recent update of the largest and longest-followed active surveillance cohort of men diagnosed with LPC showed 98 percent and 94 percent prostate cancer-specific survival rates at 10- and 15-year follow-up respectively. Moreover, while the patients who chose surgery in this study expected to gain 12 years of life from active treatment, recently published data showed surgery does not significantly improve prostate cancer specific survival compared with observation after 10 years follow-up. These unrealistic expectations, the authors write, are of particular concern because men who choose active treatment have survival almost identical to that of those who choose observation, yet active treatment is associated with high rates of impotence and incontinence.

    Implications

    • The authors conclude there is an urgent need for interdisciplinary and cross-specialty communication with patients who have prostate cancer. In collaboration with oncology specialists, primary care physicians, they note, are often best positioned to help patients develop realistic life expectancy estimates and associated treatment goals.

  • Annals Journal Club

    May/Jun 2016: Prostate Cancer Patients' Survival Expectations With and Without Their Chosen Treatment


    The Annals of Family Medicine encourages readers to develop a learning community of those seeking to improve health care and health through enhanced primary care. You can participate by conducting a RADICAL journal club and sharing the results of your discussions in the Annals online discussion for the featured articles. RADICAL is an acronym for Read, Ask, Discuss, Inquire, Collaborate, Act, and Learn. The word radical also indicates the need to engage diverse participants in thinking critically about important issues affecting primary care and then acting on those discussions.1

    HOW IT WORKS

    In each issue, the Annals selects an article or articles and provides discussion tips and questions. We encourage you to take a RADICAL approach to these materials and to post a summary of your conversation in our online discussion. (Open the article online and click on "TRACK Discussion: Submit a comment.") You can find discussion questions and more information online at: http://www.AnnFamMed.org/site/AJC/.

    CURRENT SELECTION

    Article for Discussion

    Xu J, Janisse J, Ruterbusch JJ, et al. Patients' survival expectations with and without their chosen treatment for prostate cancer. Ann Fam Med 2016;14(3):208-214.

    Discussion Tips

    Rarely do scientific publications selected for jounal club provide insight from a patient's perspective of disease. That perspective influences decision making and the perception of life expectancy. This study investigates the expectations of patients with localized prostate cancer for survival with and without their chosen treatment.

    Discussion Questions

    • What question is asked by this study and why does it matter to a family physician?
    • Discuss strengths/weaknesses of the study design.
    • To what degree can the findings be accounted for by:
      1. How patients were selected, excluded, or lost to follow-up?
      2. How were the main variables measured and what others could alter a patient's perception of disease severity or decision-making (eg, marital status)?
      3. Could the results have been influenced by a nonresponse bias given the response rate of 68%?
      4. Confounding (false attribution of causality because 2 variables discovered to be associated actually are associated with a 3rd factor)? How might physician-patient dynamics influence patient perception of life expectancy?
      5. Chance?
    • What are the main study findings?
    • How comparable is the study sample to similar patients in your practice?
    • What contextual factors are important for interpreting the findings?2-3
    • Will this study change your practice? Is it applicable to other disease states and treatment decisions? 4
    • What tools can help educate patients and facilitate discussions on realistic life expectancy?5
    • How might primary care clinicians engage in important treatment decisions such as localized prostate cancer that are frequently made external to their clinics?
    • Reflect on factors in your life that may affect your perception of disease severity and how these factors might influence your treatment decisions?

    References

    1. Stange KC, Miller WL, McLellan LA, et al. Annals Journal Club: It's time to get RADICAL. Ann Fam Med. 2006;4(3):196-197 http://annfammed.org/content/4/3/196.full.
    2. American Cancer Society. Watchful waiting vs active surveillance for prostate cancer. http://www.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-treating-watchful-waiting. Accessed Mar 15, 2016.
    3. Sommers BD, Beard CJ, D'Amico AV, Kaplan I, Richie JP, Zeckhauser RJ. Predictors of patient preferences and treatment choices for localized prostate cancer. Cancer. 2008;113(8):2058-2067.
    4. Kureshi F, Jones PG, Buchanan DM, Abdallah MS, Spertus JA. Variation in patients' perceptions of elective percutaneous coronary intervention in stable coronary artery disease: cross sectional study. BMJ. 2014;349:g5309.
    5. Lee SJ, Boscardin WJ, Kirby KA, Covinsky KE. Individualizing life expectancy estimates for older adults using the Gompertz Law of Human Mortality. PLoS One. 2014;9(9):e108540.

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