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Abstract

The primary contribution of this paper, 1 Daskivich T.J. Lai J. Dick A.W. et al. Questioning the 10-year rule for high-grade prostate cancer: comparative effectiveness of aggressive vs nonaggressive treatment of high-grade disease in older men with differing comorbid disease burdens. Urology. 2016; 93: 68-76 Abstract Full Text Full Text PDF Scopus (18) Google Scholar and its companion piece analyzing the same question in low- and intermediate-grade disease, 2 Daskivich T.J. Lai J. Dick A.W. 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: 2432-2439 Crossref PubMed Scopus (21) Google Scholar is to suggest that a one-size-fits-all approach to treatment decision-making for older men with prostate cancer may be inadvisable. Treatment choice should take into account both health status and tumor risk, as both appear to strongly influence the absolute benefit of treatment. Randomized clinical trial data have not provided a clear answer to this question, because neither trial of surgery nor watchful waiting was powered to detect differences in survival among subgroups of tumor risk and age and/or health status in combination. The PIVOT trial showed a trend toward survival benefit for surgery over watchful waiting for intermediate- and high-risk tumors, although some of these patients were younger than 65. 3 Wilt T.J. Brawer M.K. Jones K.M. et al. Radical prostatectomy versus observation for localized prostate cancer. New Engl J Med. 2012; 367: 203-213 Crossref PubMed Scopus (1454) Google Scholar The SPCG-4 trial showed no benefit for surgery in men older than 65, but it did not analyze smaller subgroups of age and/or health status and tumor risk in combination. 4 Bill-Axelson A. Holmberg L. Ruutu M. et al. Radical prostatectomy versus watchful waiting in early prostate cancer. New Engl J Med. 2011; 364: 1708-1717 Crossref PubMed Scopus (708) Google Scholar For these reasons, we feel that further consideration of treatment effectiveness among health status and tumor risk subgroups using nonrandomized data is warranted, although the data may be imperfect.