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Commentary - Limitations of the National Comprehensive Cancer Network Guidelines for Prediction of Limited Life Expectancy in Men with Prostate Cancer - Beyond the Abstract

Precise assessment of life expectancy is very crucial in deciding the treatment used for men with prostate cancer1,2. Life expectancies are predicted due to treatment effectiveness generally decreasing with increasing comorbidity and age3,4. The National Comprehensive Cancer Network (NCCN) guidelines recommend: ≥20 years (surgery, radiation, or active surveillance), 10-20 years (active surveillance), and <10 years (observation)5. Although life expectancy guidelines are important in recommended treatment pathways, the methods for its calculations remain poorly defined and not uniformed, due to complex nature of comorbidity data and difficulties incorporating risk calculators into practice. Currently, the NCCN recommends calculating life expectancy by adding or subtracting 50% of expected life years if the patient is in the highest or lowest quartile of health. One issue with this approach is that guidelines do not give quartiles definitive’s. The purpose of this study was to assess the validity of the NCCN guidelines for prediction of survival in the lowest quartile of health, and hopefully improve practical application of the NCCN guidelines.

Using the California Cancer Registry (CRR), the study identified 1,915 men who were newly diagnosed with prostate cancer at the Greater Los Angeles and Long Beach Veterans Affairs Medical Centers between 1998-2004. The exclusion criteria were: men with no prostate cancer diagnosis, histology other than adenocarcinoma, incidental diagnosis at cystoprostatectomy, metastatic disease, and those with insufficient data to determine comorbidities or treatment. In total, 1,462 cases satisfied the inclusion criteria. To identify men in the lowest quartile, the researchers used Charlson Comorbidity scores, calculated their NCCN-predicated life expectancy, and compared with observed median survival in aggregate and across comorbidity subgroups. An alpha level of 0.05 was used to denote statistical significance for statistical analysis.

The results of the study showed that men with Charlson scores of 2+ (age <75) and 3+ (age ≥75) comprised of the lowest quartile of health. Among those <65, 65-69, 70-74, 75-79, and ≥80 years, observed survival vs NCCN-predicted life expectancy in years was similar: 10.4 vs. 16 11.1, 10.0 vs. 7.8, 6.2 vs. 6.4, 4.4 vs. 4.9, and 3.7 vs. 3.3, respectively. Although on average survival of those in lowest quartile of health was similar to NCCN-predicted survival, there was significant heterogeneity in survival among men differing Charlson scores. This demonstrates that NCCN guidelines misclassified 10-year life expectancy in 24% and 56% of men aged <65 and 65-69, and 5-year life expectancy in 18% of men age 70-74.

The heterogeneity in survival among those with different Charlson scores led to over- and underestimation of survival by the NCCN Method. In conclusion, the findings in this study argue that a more accurate determination of life expectancy assessment needed when deciding treatment for men with prostate cancer, one that integrate both Charlson comorbidities with the NCCN method.

Authors: Timothy J. Daskivich, MD, MSHPM, Laudren, MD, Douglas Skarecky, AB, Thomas Ahlering, MD, Stephen Freedland, MD

Affiliations: 1Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA 2Greater Los Angeles Veterans Affairs Medical Center, Los Angeles, Los Angeles, CA 3Department of Urology, University of California, Irvine, Irvine, California 4Long Beach Veterans Affairs Medical Center, Long Beach, California 5Durham Veterans Affairs Medical Center, Durham, North Carolina

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Reference:

Kent M, Vickers AJ. A systematic literature review of life expectancy prediction tools for patients with localized prostate cancer. J Urol. 2015;193(6):1938-1942.

Sammon JD, Abdollah F, D'Amico A, et al. Predicting Life Expectancy in Men Diagnosed with Prostate Cancer. Eur Urol. 2015;68(5):756-765.

Mohler JL, Armstrong AJ, Bahnson RR, et al. Prostate Cancer, Version 1.2016. J Natl Compr Canc Netw. 2016;14(1):19-30.

Daskivich TJ, Lai J, Dick AW, et al. Comparative effectiveness of aggressive versus nonaggressive treatment among men with early-stage prostate cancer and differing comorbid disease burdens at diagnosis. Cancer. 2014;120(16):2432-2439

Heidenreich A, Bellmunt J, Bolla M, et al. [EAU guidelines on prostate cancer. Part I: screening, diagnosis, and treatment of clinically localised disease]. Actas Urol Esp. 2011;35(9):501-514.