80 is the new 60: implications of irrational exuberance regarding longevity on prostate cancer treatment decisions.
80 is the new 60: implications of irrational exuberance regarding longevity on prostate cancer treatment decisions.
复制标题
80 岁是新的 60 岁：关于长寿的非理性繁荣对前列腺癌治疗决策的影响。
DOI：
10.1007/s11606-012-2006-8
复制
发表时间：
2012
影响因子：
5.7
通讯作者：
Walter,LouiseC
中科院分区：
文献类型：
--
作者：
Freedland,StephenJ;Walter,LouiseC
“Doc，我想永远活下去”。这不是一个罕见的想法，我们经常听到从老年人。我们不容易接受自己死亡的概念。人类一直在寻找青春之泉。对许多人来说，他们认为我们已经在现代医学中找到了它-抗生素，疫苗，阿司匹林，他汀类药物等。集体“现代医学”已经成功地延迟了死亡，以至于今天在美国出生的男孩可以预期活到70多岁。事实上，像“80岁是新的60岁”这样的俏皮话在媒体上太常见了。那么，当与被诊断患有前列腺癌的老年男性打交道时，这种长生不老的追求是如何实现的呢？Chamie及其同事在本期杂志中回顾了1997年至2004年期间在加州洛杉矶县的两家学术附属退伍军人医院诊断为非转移性前列腺癌的1,031名退伍军人的记录。1他们发现，除中重度慢性阻塞性肺疾病（COPD）外，患有合并症的男性与没有任何合并症的男性接受前列腺癌治疗的可能性相同。尽管治疗率相似，但非癌症生存率差异很大，正如预期的那样，患有合并症的男性总体生存率更差。换句话说，由于其他医疗疾病而导致非前列腺癌生存期较短的男性接受癌症治疗的比例与“健康”男性相同。它已经相对良好的记录，前列腺癌筛查是根据患者的健康状况不良的目标。2例如，Walter等人2使用2003年的VA数据（与Chamie等人研究1中的数据重叠）发现，在85岁或以上的男性中，健康状况最好的34%进行了PSA测试，而健康状况最差的36%进行了PSA测试。在该杂志发表的一项后续研究中，So等人3发现，在每个VA医疗中心内，健康和不太健康的男性之间PSA筛查的相关系数非常高（0.90）。从本质上讲，中心作为一个整体，要么筛选了很多人，要么筛选了很少的人，但“健康状况”并不是决定筛选谁的主要因素。虽然有些人可能会争辩说，筛查本身造成的伤害很小，因此“健康”不应该考虑在内，但很明显，前列腺癌治疗可能会有重大的副作用。因此，人们通常认为，虽然筛查可能有点不加选择，但关于治疗的决定应该高度适应患者的健康状况。1一些研究表明，患者的健康状况确实会影响治疗决策（Chamie等人1的参考文献11-15）。然而，其他研究表明，合并症恶化（Charlson评分高达2分）不能预测治疗模式（参考文献16-18，Chamie等人1）。鉴于这些混杂的文献，目前的发现告诉我们什么？虽然在某些合并症子集的数字是适度的，他们建议，在整体上，一个单一的查尔森合并症的存在并不影响治疗决定在两个VA医院在南加州。虽然Charlson合并症指数没有记录每种合并症的真实严重程度，但最初选择该指数中的所有合并症是因为它们会增加死亡率。然而，这些数据表明，医生可能不认为这些合并症中的许多是显著的，因为它们对治疗决策的影响很小。然而，治疗决定受到年龄的严重影响。这些发现提出的第一个问题是，“这些结果是否具有普遍性”？关于这些VA医院有几个独特的因素，往往会争论这个问题的双方。首先...
“D oc, I want to live forever”. This is not an uncommon thought that we hear frequently from older men. It is not easy to accept the concept of our own mortality. Mankind has perpetually been looking for the fountain of youth. For many, they believe we have found it in modern medicine—antibiotics, vaccines, aspirin, statins, etc. Collectively “modern medicine” has successfully delayed death such that a male child born in the United States today can expect to live into his mid-70s. Indeed, quips like “80 is the new 60” are all too common in the media. So how does this quest to live forever play out when dealing with older men diagnosed with prostate cancer? Chamie and colleagues in this issue of the journal reviewed the records of 1,031 veterans diagnosed with non-metastatic prostate cancer between 1997 and 2004 at two academically-affiliated VA hospitals in Los Angeles County, California. 1 They found that men with comorbidities, with the exception of moderate–severe chronic obstructive pulmonary disease (COPD), were equally likely to receive prostate cancer treatment as men without any comorbidities. Despite similar treatment rates, non-cancer survival differed dramatically with, as expected, men with comorbidities having worse overall survival. In other words, men with a shorter non-prostate cancer survival because of their other medical illnesses were receiving cancer treatment at equal rates as “healthy” men. It has been relatively well documented that prostate cancer screening is poorly targeted according to the health status of patients. 2 For example, Walter et al. 2 using VA data from 2003 (which would have overlapped with the data in the Chamie et al. study 1), found that among men aged 85 years or older 34% in the best health had a PSA test vs. 36% in the worst health. In a follow-up study published in this journal, So et al. 3 found that within each VA medical center, the correlation coefficient between PSA screening among healthy and less healthy men was extremely high (0.90). In essence, centers as a whole either screened many men or few men, but “healthiness” was not a major factor in deciding who to screen. While some might argue that screening itself poses little harm and therefore “healthiness” should not factor in, it is clear that prostate cancer treatments can have major side effects. Thus, it often assumed that while screening may be somewhat indiscriminate, decisions regarding treatment should be highly tailored to the patient’s health.Indeed, as noted by Chamie et al., 1 several studies have shown that health status of the patient does influence treatment decisions (references 11–15 in Chamie et al. 1). However, others have shown that worsening comorbidity (up to a Charlson score of 2) did not predict treatment patterns (reference 16–18 in Chamie et al. 1). Given this mixed literature, what do the current findings tell us? While the numbers in certain comorbidity subsets are modest, they suggest that on the whole, the presence of a single Charlson comorbidity does not influence treatment decisions within two VA hospitals in Southern California. While the true severity of each comorbidity is not captured by the Charlson Comorbidity Index, all comorbidities in this index were originally selected because they increase mortality. Yet, these data suggest physicians may not consider many of these comorbidities to be significant since they had little influence over treatment decisions. However, treatment decisions were very heavily influenced by age. The first question these findings raise is,“are these results generalizable”? There are several unique factors about these VA hospitals that would tend to argue both sides of this question. First …