Correspondence
Charlson Score and Competing Mortality We read with great interest the study by Daskivich et al determining the benefit of aggressive treatment in a huge sample of elderly men with early-stage prostate cancer.1 The authors concluded that men with a Charlson score of 3 did not benefit from aggressive prostate cancer treatment. Limiting the claim-based assignment of the Charlson score to a 12-month period prior to the prostate cancer diagnosis1 most likely caught preferably severe conditions (indicated by a percentage of 76% of patients having a Charlson score of 0,1 which is in contrast with lower rates even in samples from patients who underwent radical prostatectomy, who are known to be preselected by good health status2,3). This special feature could partly explain the strikingly high 10-year competing mortality rates noted in this study (71% for a Charlson score of 2 and 84% for a Charlson score 3).1 These data should be interpreted with caution. Populations with a more complete documentation of less severe Charlson score conditions may have lower competing mortality rates in the individual risk classes, particularly when the involved patients have been filtered by health status assessment during initial treatment decision-making. In our sample of patients selected for radical prostatectomy (947 men aged 66 years who were treated between 1992-2005), we calculated the following 10-year competing mortality rates: 21% for a Charlson score of 2 (201 patients; 95% confidence interval, 13%-30%) and 40% for a Charlson score 3 (62 patients; 95% confidence interval, 24%-55%). When considering these relatively low competing mortality rates, compared with the figures observed by Daskivich et al,1 it appears conceivable that appropriately selected elderly patients may benefit from aggressive treatment, even those with a Charlson score of 3. FUNDING SUPPORT No specific funding was disclosed.
CONFLICT OF INTEREST DISCLOSURES Dr. Froehner has received meeting participation support from Janssen and Pfizer for work performed outside of the current study. Dr. Wirth has acted as a paid lecturer and consultant for Bayer and Janssen-Cilag; a paid consultant for Merck, Dendreon, FarcoPharma, Ferring, Ipsen, and Teva; and as a paid lecturer for SanofiAventis, Apogepha, Orion, and Pfizer for work performed outside of the current study.
REFERENCES 1. Daskivich TJ, Lai J, Dick AW, et al; the Urologic Diseases in America Project. Comparative effectiveness of aggressive versus nonaggres-
Cancer
December 15, 2014
sive treatment among men with early-stage prostate cancer and differing comorbid disease burdens at diagnosis [published online ahead of print May 13, 2014]. Cancer. doi: 10.1002/cncr.28757. 2. Walz J, Gallina A, Saad F, et al. A nomogram predicting 10-year life expectancy in candidates for radical prostatectomy or radiotherapy for prostate cancer. J Clin Oncol. 2007;25:3576-3581. 3. Abdollah F, Sun M, Schmitges J, et al. Survival benefit of radical prostatectomy in patients with localized prostate cancer: estimations of the number needed to treat according to tumor and patient characteristics. J Urol. 2012;188:73-83.
Michael Froehner, MD Department of Urology University Hospital ‘‘Carl Gustav Carus’’ Technical University of Dresden Dresden, Germany
Rainer Koch, PhD Department of Medical Statistics and Biometry University Hospital ‘‘Carl Gustav Carus’’ Technical University of Dresden Dresden, Germany
Manfred P. Wirth, MD Department of Urology University Hospital ‘‘Carl Gustav Carus’’ Technical University of Dresden Dresden, Germany DOI: 10.1002/cncr.28958, Published online September 10, 2014 in Wiley Online Library (wileyonlinelibrary.com)
Reply to Charlson Score and Competing Mortality Claims-based comorbidity assessment methods, such as the Deyo-Klabunde approach (which uses both inpatient and outpatient Medicare claims 12 months prior to diagnosis to determine a Charlson score),1 are widely recognized and have been found to be comparable to chartbased abstraction in predicting survival.2 Our 10-year other-cause mortality estimates by Charlson score are similar to other mixed-treatment samples of men with prostate cancer obtained from administrative data or chart abstraction,3,4 and may appear high due to the inclusion of only men aged 66 years. To ensure that our findings were robust across all ages, we repeated our comparative effectiveness models in age subgroups and found that men with Charlson scores of 3 do not benefit from aggressive treatment, regardless of their age at the time of diagnosis.5 Comparing our results with a single-institution sample of healthier men who are preselected to be appropriate surgical candidates will certainly distort case mix and falsely inflate survival estimates by comorbidity score. Given the paltry benefits associated with the aggressive treatment of low-grade and intermediate-grade tumors in men with even modest comorbidity burdens (absolute risk reduction for aggressive vs nonaggressive treatment of 4003
Copyright of Cancer (0008543X) is the property of John Wiley & Sons, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Charlson Score and Competing Mortality We read with great interest the study by Daskivich et al determining the benefit of aggressive treatment in a huge sample of elderly men with early-stage prostate cancer.1 The authors concluded that men with a Charlson score of 3 did not benefit from aggressive prostate cancer treatment. Limiting the claim-based assignment of the Charlson score to a 12-month period prior to the prostate cancer diagnosis1 most likely caught preferably severe conditions (indicated by a percentage of 76% of patients having a Charlson score of 0,1 which is in contrast with lower rates even in samples from patients who underwent radical prostatectomy, who are known to be preselected by good health status2,3). This special feature could partly explain the strikingly high 10-year competing mortality rates noted in this study (71% for a Charlson score of 2 and 84% for a Charlson score 3).1 These data should be interpreted with caution. Populations with a more complete documentation of less severe Charlson score conditions may have lower competing mortality rates in the individual risk classes, particularly when the involved patients have been filtered by health status assessment during initial treatment decision-making. In our sample of patients selected for radical prostatectomy (947 men aged 66 years who were treated between 1992-2005), we calculated the following 10-year competing mortality rates: 21% for a Charlson score of 2 (201 patients; 95% confidence interval, 13%-30%) and 40% for a Charlson score 3 (62 patients; 95% confidence interval, 24%-55%). When considering these relatively low competing mortality rates, compared with the figures observed by Daskivich et al,1 it appears conceivable that appropriately selected elderly patients may benefit from aggressive treatment, even those with a Charlson score of 3. FUNDING SUPPORT No specific funding was disclosed.
CONFLICT OF INTEREST DISCLOSURES Dr. Froehner has received meeting participation support from Janssen and Pfizer for work performed outside of the current study. Dr. Wirth has acted as a paid lecturer and consultant for Bayer and Janssen-Cilag; a paid consultant for Merck, Dendreon, FarcoPharma, Ferring, Ipsen, and Teva; and as a paid lecturer for SanofiAventis, Apogepha, Orion, and Pfizer for work performed outside of the current study.
REFERENCES 1. Daskivich TJ, Lai J, Dick AW, et al; the Urologic Diseases in America Project. Comparative effectiveness of aggressive versus nonaggres-
Cancer
December 15, 2014
sive treatment among men with early-stage prostate cancer and differing comorbid disease burdens at diagnosis [published online ahead of print May 13, 2014]. Cancer. doi: 10.1002/cncr.28757. 2. Walz J, Gallina A, Saad F, et al. A nomogram predicting 10-year life expectancy in candidates for radical prostatectomy or radiotherapy for prostate cancer. J Clin Oncol. 2007;25:3576-3581. 3. Abdollah F, Sun M, Schmitges J, et al. Survival benefit of radical prostatectomy in patients with localized prostate cancer: estimations of the number needed to treat according to tumor and patient characteristics. J Urol. 2012;188:73-83.
Michael Froehner, MD Department of Urology University Hospital ‘‘Carl Gustav Carus’’ Technical University of Dresden Dresden, Germany
Rainer Koch, PhD Department of Medical Statistics and Biometry University Hospital ‘‘Carl Gustav Carus’’ Technical University of Dresden Dresden, Germany
Manfred P. Wirth, MD Department of Urology University Hospital ‘‘Carl Gustav Carus’’ Technical University of Dresden Dresden, Germany DOI: 10.1002/cncr.28958, Published online September 10, 2014 in Wiley Online Library (wileyonlinelibrary.com)
Reply to Charlson Score and Competing Mortality Claims-based comorbidity assessment methods, such as the Deyo-Klabunde approach (which uses both inpatient and outpatient Medicare claims 12 months prior to diagnosis to determine a Charlson score),1 are widely recognized and have been found to be comparable to chartbased abstraction in predicting survival.2 Our 10-year other-cause mortality estimates by Charlson score are similar to other mixed-treatment samples of men with prostate cancer obtained from administrative data or chart abstraction,3,4 and may appear high due to the inclusion of only men aged 66 years. To ensure that our findings were robust across all ages, we repeated our comparative effectiveness models in age subgroups and found that men with Charlson scores of 3 do not benefit from aggressive treatment, regardless of their age at the time of diagnosis.5 Comparing our results with a single-institution sample of healthier men who are preselected to be appropriate surgical candidates will certainly distort case mix and falsely inflate survival estimates by comorbidity score. Given the paltry benefits associated with the aggressive treatment of low-grade and intermediate-grade tumors in men with even modest comorbidity burdens (absolute risk reduction for aggressive vs nonaggressive treatment of 4003
Copyright of Cancer (0008543X) is the property of John Wiley & Sons, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
