title: Undertreatment of Men in Their Seventies with High-risk Nonmetastatic Prostate Cancer.
abstract: BACKGROUND
  Many elderly men with high-risk nonmetastatic prostate cancer (HRnMPCa) do not receive radical treatment, despite the high mortality associated with conservative management.
  
  
  OBJECTIVE
  To investigate how age and comorbidity affect treatment of men with HRnMPCa.
  
  
  METHODS
  This was an observational nationwide register study during 2001-2012. We identified 19 190 men of <80 yr of age diagnosed with HRnMPCa in the National Prostate Cancer Register of Sweden and 95 948 age-matched men without prostate cancer in the register of the total population.
  
  
  METHODS
  The outcome was the proportion of men with HRnMPCa receiving radical treatment (radical prostatectomy or radiotherapy). Vital status and the Charlson comorbidity index (CCI) were obtained from nationwide registers. The 10-yr survival of men without prostate cancer, stratified by age and CCI, was used as a measure of the life expectancy of the men with prostate cancer.
  
  
  CONCLUSIONS
  The proportions receiving radical treatment varied with life expectancy among men younger than 70 yr, whereas use of these treatments did not match the long life expectancy of men in their seventies with CCI 0-1. Only 10% of men aged 75-80 yr with CCI 0 received radical treatment despite 52% probability of 10-yr life expectancy, compared with approximately half of the men younger than 70 yr with a similar life expectancy. The use of radical treatment for HRnMPCa increased with time in all Swedish counties, but a threefold difference between counties remained in 2009-2012 for patients aged 70-80 yr with CCI 0-1. Uncertain external validity is a study limitation, and the impact of physician versus patient preferences on treatment selection could not be assessed.
  
  
  CONCLUSIONS
  Otherwise healthy men in their seventies with HRnMPCa were less likely to receive radical treatment than younger men with a similar life expectancy, although increasing use of radical treatment was observed during the study period. Our findings highlight the need for improved methods for clinical decision-making, including improved assessment of life expectancy.
  
  
  RESULTS
  We performed a nationwide register study that showed that many healthy men in their seventies live for at least another 10 yr. Despite this long life expectancy, men in their seventies with high-risk nonmetastatic prostate cancer were often not treated with radical prostatectomy or radiotherapy, possibly because their life expectancy was underestimated. Our study highlights the need for improved clinical decision-making, which should incorporate an assessment of the patient's life expectancy.
authors: Department of Urology, Helsingborg Hospital, Lund University, Helsingborg, Sweden; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK. Electronic address: ola.bratt@med.lu.se.
authors: Ola
authors: O
authors: Bratt
authors: Regional Cancer Centre, Uppsala/Örebro, Uppsala University Hospital, Uppsala, Sweden.
authors: Yasin
authors: Y
authors: Folkvaljon
authors: Department of Oncology, Karolinska Institute, Stockholm, Sweden.
authors: Marie
authors: M
authors: Hjälm Eriksson
authors: Department of Urology, Karolinska Institute, Stockholm, Sweden.
authors: Olof
authors: O
authors: Akre
authors: Department of Urology, Karolinska Institute, Stockholm, Sweden.
authors: Stefan
authors: S
authors: Carlsson
authors: Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.
authors: Linda
authors: L
authors: Drevin
authors: Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden.
authors: Ingela
authors: I
authors: Franck Lissbrant
authors: Departments of Urology and Population Health, New York University and Manhattan Veterans Affairs Medical Center, New York Harbor Health Care System, New York, NY, USA.
authors: Danil
authors: D
authors: Makarov
authors: Departments of Urology and Population Health, New York University and Manhattan Veterans Affairs Medical Center, New York Harbor Health Care System, New York, NY, USA.
authors: Stacy
authors: S
authors: Loeb
authors: Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden.
authors: Pär
authors: P
authors: Stattin
mesh_terms: D000367:Age Factors; D000368:Aged; D000066491:Clinical Decision-Making; D015897:Comorbidity; D006801:Humans; D008017:Life Expectancy; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011468:Prostatectomy / Q000706:statistics & numerical data*; D011471:Prostatic Neoplasms / Q000473:pathology / Q000628:therapy*; D011787:Quality of Health Care; D011878:Radiotherapy / Q000706:statistics & numerical data*; D012042:Registries; D012306:Risk; D013548:Sweden
keywords: Age; Comorbidity; Epidemiology; Prostatic neoplasms; Treatment