Originally published 4/4/2017
At the time of a prostate cancer (PCa) diagnosis, many patients have co-existing health conditions. Naming them equates to a litany of ill health: previous heart attack, congestive heart failure, vascular disease, dementia, chronic obstructive pulmonary disease (COPD), rheumatological conditions, diabetes, liver disease, kidney disease, previous cancer, some degree of paralysis, obesity, high blood pressure, etc.
The Charlson Comorbidity Index, which also includes factors such as age, AIDS and other things, offers a way to score total comorbidities at the time of diagnosis in order to predict life expectancy, i.e., the higher the score, the shorter life expectancy. This affects a PCa patient’s treatment plan.
For example, if the patient has at least 10 years of life expectancy, he may be a candidate for an aggressive treatment like radical prostatectomy. However, if his life expectancy is, say, three years, his PCa might be managed with Active Surveillance, androgen deprivation therapy, etc.
Thus, a 2019 paper showed how accurate assessment of a patient’s life expectancy can improve his treatment plan.[i]
Now there is a specific scoring system for PCa patients, called the Prostate Cancer Comorbidity Index (PCCI). Similar to Charlson, as a score increases from zero to ten+, the life expectancy drops.
The 2019 study found all-cause mortality rates for 181,009 PCa patients to be as follows:
| PCCI score | 10-year all-cause mortality rate |
| 0 | 15% |
| 1-2 | 26% |
| 3-4 | 36% |
| 5-6 | 41% |
| 7-9 | 52% |
| 10+ | 69% |
As our earlier blog below points out, focal therapy is an outpatient middle ground between whole-gland treatment vs. conservative management using surveillance or hormone treatment.
PCa patients whose high comorbidity scores disqualify them for prostatectomy or radiation can contact Sperling Prostate Center to learn if they are candidates for a minimally invasive tumor destruction procedure that does not require general anesthesia.
If you have prostate cancer (PCa) but you also have a coexisting condition like high blood pressure, cardiovascular disease or diabetes, are you a good candidate for a radical (meaning total gland) treatment? It could turn out to be a rougher journey than you bargained on. A January, 2017 publication reports on the relationship between comorbidities (presence of a chronic condition in addition to PCa) and rates of overall survival after radical treatment. For unhealthy men, it’s a big CAUTION sign.
In the study by Hjälm-Eriksson et al.[ii], 611 patients were put on total androgen blockade to reduce prostate size followed by external beam radiation therapy (EBRT) and high dose rate (HDR) brachytherapy boosts. Note: While the patients had radiation, not prostatectomy, the authors use the term radical treatment, suggesting that what they found with radiation would also apply to surgery.
The patients were treated between 1998-2004, and were followed for a minimum of 10 years. At the time of diagnosis, 51% (312) of them had some degree of comorbidity. Based on PCa clinical factors he patient cohort was divided into three groups: low-risk (8.2%), intermediate risk (64%) and high risk (27.8%). Comorbidities were rated according to the Charlson scale, which predicts the likelihood of one-year mortality (death) depending on the number and severity of coexisting conditions.
The authors report that patient age, comorbidity and prostate cancer T stage were independent predictors of overall survival. In other words, the older the patient, the worse his health, and the greater the tumor extent are the factors that most predict survival after radical treatment. For this population, the researchers noted that the overall 10-year survival was 72.2% (441 patients lived 10 years after treatment) and of those, 89% (392) were relapse-free. Among those 392 patients, the factors associated with predicting disease-free survival were tumor grade or aggressiveness, PSA at diagnosis, T stage and comorbidity. Low comorbidity as assessed by the Charlson index was significantly associated with disease-free survival. The authors concluded that for patients considering radical treatment, any comorbidity should be assessed and taken into account by their doctors.
All of the patients in this study were diagnosed with localized PCa, and those in the low risk category were in the minority. While it’s understandable that a rather aggressive radiation protocol would have been prescribed for intermediate-to-high risk patients, it seems somewhat disproportionate for those with much less aggressive disease – especially since radiation is itself associated with post-treatment morbidities (side effects) like bowel irritation and late-onset problems with urination, sexual function, and rectal problems. In addition, radiation is associated with increased risk of secondary cancers of the bladder and bowel.
This paper serves as a reminder that we should all take better care of our health, since many cormorbidities are preventable with positive lifestyle choices such as diet, exercise, and stress management. For those whose cormorbidities already exist, there’s good treatment news. Many may be excellent candidates for outpatient Focal Laser Ablation (FLA). As the Sperling Prostate Center performs this MRI-guided minimally invasive treatment, there is no general anesthesia – good news for certain coexisting conditions in which general anesthesia is contraindicated. FLA has minimal side effects. Unlike surgery and radiation, normal work and social activities are quickly resumed, and there’s no loss of work time due to recovery from surgery or weeks of radiation treatments.
All prostate cancer patients hope for a smooth road from diagnosis to full recovery. Those with comorbidities need to know that our Center can facilitate the journey without the draining, damaging impact of radical treatment.
NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.
[i] Daskivich TJ, Thomas IC, Luu M, Shelton JB et al. External Validation of the Prostate Cancer Specific Comorbidity Index: A Claims Based Tool for the Prediction of Life Expectancy in Men with Prostate Cancer. J Urol. 2019 Sep;202(3):518-524.
[ii] Hjälm-Eriksson M, Ullén A, Johansson H, Levitt S et al. Comorbidity as a predictor of overall survival in prostate cancer patients treated with external beam radiotherapy combined with HDR brachytherapy boosts. Acta Oncol. 2017 Jan;56(1):21-26.
About Dr. Dan Sperling
Dan Sperling, MD, DABR, is a board certified radiologist who is globally recognized as a leader in multiparametric MRI for the detection and diagnosis of a range of disease conditions. As Medical Director of the Sperling Prostate Center, Sperling Medical Group and Sperling Neurosurgery Associates, he and his team are on the leading edge of significant change in medical practice. He is the co-author of the new patient book Redefining Prostate Cancer, and is a contributing author on over 25 published studies. For more information, contact the Sperling Prostate Center.
