Actuarial Basis Research Articles

Application of Markov Model in Long-Term Care Insurance

The Markov process is not only the actuarial basis of pricing of long term care (LTC) insurance but also the fundamental for predicting the future elder population and disabled population. This article aims to summarize how the Markov processes or Semi-Markov processes are used in the Long-term care risk and Long-term care insurance. We also discuss the models based on the time-homogeneous and time-inhomogeneous. Moreover, under the GLM framework, some studies show Tweedie-GLM would give more accurate predictions compared with other GLM models and additive models. However, these models, whether based on the Markov process or Semi-Markov process or GLM, have theoretical advantages due to the natural features, the researchers would quickly build the multi-state models, there are still exits many challenges, and they provoke the researchers into some tries of how to deal with the limitations of data, the development of medical technology, and the longer expectancy of life.

Mathematical Techniques of Modelling Salary-Based Health Care Contribution

This paper is intended to support reforms counteracting the adverse health insurance contribution trends through constructing an actuarially equitable salary-based health care system for experienced health insurance underwriters. The focus is on contribution technique employed by experts who consult for health insurance funds especially when performing official duties as health insurance actuary. The objective is to construct actuarial models of computing employee’s, employer’s and government’s contribution for health insurance care program in a way that permits generally equitable cost-efficient health insurance coverage within the framework of obtainable health benefits policy. Nigeria’s low economic growth rate and primitive technology resulted in an increasing rate of health care costs and consequently, quality health care at affordable prices is far from the reach of enrollees because of inequitable distribution of costs. In order to solve this problem, we constructed a health care model with a deterministic salary function structure to compute contribution on behalf of enrollees as a paradigm shift to an actuarial system of modelling contribution with a goal to building a sustainable health insurance delivery that encourages good health outcomes. From our results, the rate derived from our current model is far below the official rating of on employee’s salary which is not footed on actuarial basis and hence cheaper and more equitable to adopt.

Problems of income and expenditure balance of the pension fund budget of Ukraine

The steady budget deficit of the Pension Fund of Ukraine necessitates balancing its budget and finding effective opportunities to improve the current pension system. The revenue and expenditure part of the budgets of the Pension Fund for the last 7 years has been analyzed, time series characterizing various aspects of its activity have been constructed, polynomial modeling of trend series of revenues and expenditures has been carried out. To improve the actuarial basis of the joint pension system, it has been suggested to segregate social pensions, which are not provided by insurance premiums, and therefore cannot be the object of insurance payments, but should be subject to state (budget) funding. The shadow sector of the economy and the arrears of enterprises for the payment of salary to employees have been identified as a significant factor in the disproportion of the budget of the Pension Fund of Ukraine, measures to respond to these violations have been identified and analyzed. Relevant recommendations included a revision of the institutional position on limiting the amount of salaries on which SSC (single social contribution) is accrued, the redistribution of relevant contributions between employees and employers, and the harmonization of the accrual base with the average salary. Further research is recommended to focus on the peculiarities of balancing the revenues and expenditures of the budget of the Pension Fund in the case of entrusting it with the functions of other social insurance funds of Ukraine, as well as in connection with the introduction of the second level of pension provision.

Transition Probability Matrices and Forecasting of Long-Term Care Demand

To provide an actuarial basis for the long-term care security system, and to research health state transition probability and the size of population with long-term care demand. Methods- Based on actuarial theory to construct transition probability matrixes, adopt the Markov process with transition intensities as piecewise constants to forecast the size of population needing long-term care. Innovation-The transition probability matrixes based on the actuarial theory can avoid the subjectivity of variable selection in the common regression analysis method; the piecewise constant Markov method can overcome the defect that the Markov time invariant hypothesis is not in conformity with the reality of health state varying with age. Results- In the coming decade, the number of disabled population in China will be increased to 1.5 times the current number, and the number of female disabled population will be around 2 times that of male disabled population; the women who are advanced in age and poor in health are the main group with a demand for long-term care in the future. Significance-This study is beneficial to the accumulation of basic information for the construction of China’s long-term care security system for the elderly, thereby, providing a decision basis for the government to develop an aging strategy.

Peru's Selective Default: A Stain on its Creditworthiness

In the 1970s, while a leftist military dictatorship ruled Peru, more than 22 million acres of cultivated or grazing farmland -- one-third of Peru’s total agricultural acreage -- were expropriated from thousands of large owners as part of a property reform intended to benefit up to 400,000 landless peasant families. The compensation provided to landowners was miserly, however: on average, it was less than one-tenth the then-prevailing market price of water-accessible, cultivated land. Moreover, about 85 percent of total recognized land values were settled not in cash but with long-term Agrarian Debt Bonds, which committed future governments to honor fixed coupons on obligations maturing in 20 to 30 years. These bonds became worthless during the 1980s, however, because hyperinflation raged and the Peruvian currency lost most of its value. In the wake of the filing of hundreds of lawsuits seeking judicial redress, in 2001 the country’s Constitutional Tribunal ruled that the government should resume payment of the land-reform debt after updating its nominal value on an actuarial basis. And yet, successive administrations did not act on this ruling, despite the fact that since the mid-1990s Peru has exhibited vigorous economic growth, significantly strengthened public finances, and substantially improved creditworthiness, such that governments have had more than the necessary ample fiscal resources to redeem the land-reform bonds at their full, original value. This paper examines the evidence and concludes that we are in the presence of a case of blatant unwillingness to pay, one which undermines Peru’s claim to be a nation that is creditworthy, investor-friendly, and respectful of the rule of law.

Late Recurrence in Melanoma: Clinical Implications of Lost Dormancy

For patients with melanoma, if there has been no recurrence of disease 10 years after initial treatment, additional disease is believed to be very unlikely. However, such late recurrences are known to occur. The frequency of this phenomenon and its clinical significance are not well characterized due to the difficulty in obtaining relevant data. We examined a large, mature, institutional database to evaluate late recurrence. The late recurrence cohort was defined as having a disease-free interval of 10 or more years after potentially curative treatment and was compared with an early recurrence cohort recurring within 3 years. Actuarial late recurrence frequency and factors associated with late recurrence were examined. Post-recurrence overall and melanoma-specific survival and prognostic variables were analyzed. Among all patients, 408 exhibited late recurrence (mean disease-free interval 15.7 years). For patients who received primary treatment at our institution with 10 or more years follow-up, 327 of 4,731 (6.9%) showed late recurrence. On an actuarial basis, late recurrence rates were 6.8% and 11.3% at 15 and 20 years, respectively, for those with no recurrence at 10 years. Late recurrence was associated with both tumor (thin, non-ulcerated, non-head/neck, node negative) and patient (younger age, less male predominant) characteristics. Multivariate analysis confirmed younger age, thinner and node negative tumors in the late recurrence group. Late recurrences were more likely to be distant, but were associated with better post-recurrence survival on univariate and multivariate analyses. Late melanoma recurrence is not rare. It occurs more frequently in certain clinical groups and is associated with improved post-recurrence survival.

Measuring per Mile Risk for Pay-As-You-Drive Automobile Insurance

This study examines the relationship between accident costs and annual miles driven with mileage and claims data representing approximately 3 million individual car years of insurance exposure for private passenger automobiles in Massachusetts in the 2006 policy year. Poisson and linear models relating pure premium to annual mileage estimates demonstrate that mileage is a significant predictor of insurance risk, that mileage alone cannot replace traditional rating factors such as class and territory, and that mileage gains in explanatory power when used in conjunction with those traditional rating factors. These findings provide a strong actuarial basis for pay-as-you-drive insurance, in which drivers are charged rates per mile that differ depending on the driver's class and territory. A model of consumer response to pay-as-you-drive insurance based on studies of miles elasticity to gasoline prices suggests that if all drivers in Massachusetts switched to per mile insurance policies, aggregate vehicle miles traveled in the state would drop by 5.0% to 9.5%. Greenhouse gas emissions from private passenger automobiles would be reduced by a similar amount, and the social equity implications of pay-as-you-drive insurance would be positive. On the basis of sound actuarial justification and positive social benefits, this study finds a strong argument in favor of the regulatory approval of pay-as-you-drive insurance.

The trade-offs embodied in J-value safety analysis

The paper presents a new derivation of the J-value method for assessing health and safety expenditure that highlights the fact that two trade-offs are involved. The trade-off between safety spend and the resulting improvement in life expectancy rests on a prior trade between free-time fraction and income, made at a societal level. It is suggested that each trade is a specific instance of a more general exchange between expected free-time and income, and that the terms of the trade-off are similar, so that the percentage increase in life expectancy has the same value as a similar percentage increase in total expected free-time. The theoretical framework suggests that the average person values all his time equally, but perceives that he has sold his expected working time to an employer, so that, while he will still place a value on it, he does not see that value as coming to him, but rather going to his employer in exchange for the compensation he is being paid. Thus he values the extra years of life expectancy he obtains from a health and safety measure solely in terms of the extra years of free-time he expects to gain. The value of the exponent in the life-quality index has been shown to be equal to both the modulus of the elasticity of expected future free-time with respect to income and the modulus of the elasticity of life expectancy with respect to income. The indifference curves on the planes of income versus life expectancy and income versus discounted life expectancy have been shown to be the loci of J = 1. The actuarial basis for the calculation of working time fraction to the end of life has been explained, and data on the share of wages in Gross Domestic Product have been discussed. Based on recent statistics from the UK economy, the average person would be prepared to forego about 5½% of his income to the end of life in order to increase his life expectancy or discounted life expectancy by 1%, and would require his lifetime income to be increased by 5½% to compensate him for a loss of 1% in his life expectancy, discounted or otherwise. A small degree of asymmetry will, however, occur for larger percentage changes in life expectancy, with the average person requiring somewhat more compensation for a loss of life expectancy than he is prepared to pay for a gain.

The actuarial basis for financial risk in practice-based commissioning and implications to managing budgets

The aim of this paper is to be both educational and thought provoking. The financial risk associated with acute budgets is an issue which affects everyone in primary care, and the calculation of the size of the financial risk is explained in an easy-to-understand way.The shift in financial responsibility toward practice-based commissioning (PBC) opens the need for a deeper understanding of the actuarial basis of financial risk in healthcare purchasing. This paper first presents the statistical basis for this risk and then looks at the implications to the day to day running of practice budgets, such as what type of reports will be needed, budgets for practices in a group and the issue of overspends.Poisson, Negative Binomial and Extreme Value distributions lie behind the expression of overall financial risk. Low volume and hence, high-risk events, tend to have a high cost, and the high cost further magnifies the underlying chance risk. Particular diagnoses associated with emergency admissions have an even higher risk profile due to the influence of meteorological and environmental factors. In a capitation-funded environment, where the budget is fixed, the financial risk is higher than acceptable for populations of less then 100 000 head. A large proportion of the overall budget needs to lie within a large regional risk pool in order to allow PBC to flourish within a financially stable environment. These conclusions will also apply to health maintenance organizations in the USA.

The Downfall of Equitable Life in the United Kingdom: The Mismatch of Strategy and Risk Management

AbstractThis article considers the downfall of Equitable Life Assurance Society in the United Kingdom, founded in 1762 and the first life insurer to operate on an actuarial basis. Its failure to manage the risks implicit in guaranteed annuity options led to a financial crisis, and it ceased to write new business in 2000. We analyze the Society's risk management practices, and find that they were inconsistent with its strategy, which highlighted customer focus. It lacked the discipline to balance short‐term advantage to customers with the long‐term needs of the organization. We also highlight the use of participating policies, and the way in which they were used to transfer risk to policyholders. Finally, we draw some lessons for other life insurers from Equitable Life's experience.

Normal tissue complications after radiation therapy

This paper describes the biological mechanisms of normal tissue reactions after radiation therapy, with reference to conventional treatments, new treatments, and treatments in developing countries. It also describes biological reasons for the latency period before tissue complications arise, the relationship of dose to incidence, the effect of increasing the size of the irradiated volume, early and late tissue reactions, effects of changes in dose fractionation and dose rate, and combined chemotherapy and radiotherapy responses. Examples are given of increases in knowledge of clinical radiobiology from trials of new protocols. Potential modification to treatments include the use of biological response modifiers. The introduction of "response prediction" modifications to treatments might also be available in the near future. Finally, the paper points out that in some radiotherapy centers, the biologically-effective doses prescribed for combined brachytherapy and teletherapy treatment of cervix cancer are lower than those prescribed in other centers. This issue needs to be addressed further. The wealth of preclinical and clinical data has led to a much greater understanding of the biological basis to radiotherapy. This understanding has underpinned a variety of new approaches in radiotherapy, including both physical and biological strategies. There is also the important issue of treatment of a large number of cancers in developing countries, for which efficacious resource-sparing protocols are being continuously developed. A unified scoring system should be widely accepted as the new standard in reporting the adverse effects of radiation therapy. Likewise, late toxicity should be reported on an actuarial basis as a mandatory endpoint.

Progression of flat low-grade dysplasia to advanced neoplasia in patients with ulcerative colitis

Background & Aims: Long-standing ulcerative colitis has long been recognized as a risk factor for colorectal cancer, but there is still no universal consensus on the optimal management of ulcerative colitis patients with low-grade dysplasia in flat mucosa. Some authorities favor prompt colectomy, whereas others recommend continued surveillance. The purpose of our study was to determine the frequency with which flat low-grade dysplasia in ulcerative colitis progresses to advanced neoplasia (high-grade dysplasia or colorectal cancer) and whether specific variables could predict such progression. Methods: We reviewed the medical histories, colonoscopic findings, and surgical and pathology reports of 46 patients with ulcerative colitis diagnosed with flat low-grade dysplasia on a surveillance colonoscopy. The rates of neoplastic progression, as well as the frequency of advanced neoplasia, were tabulated. We correlated progression with several clinical and colonoscopic variables: the number of biopsy samples positive for flat low-grade dysplasia, the duration and anatomic extent of disease, patient age, and medication use. Results: Among these 46 patients, there were 7 cases of colorectal cancer, 5 of which were stage II or higher. Unexpected advanced neoplasia occurred in 4 of 17 (23.5%) patients who underwent colectomy for flat low-grade dysplasia. On an actuarial basis, the rate of neoplastic progression was 53% at 5 years. No clinical features predicted progression to advanced neoplasia. Cancers, including 2 at advanced stages, developed despite frequent follow-up surveillance examinations. Conclusions: A finding of flat low-grade dysplasia during ulcerative colitis surveillance is a strong predictor of progression to advanced neoplasia. Early colectomy should be recommended for such patients.

Cliometric metatheory: II. Criteria scientists use in theory appraisal and why it is rational to do so.

Definitive tests of theories are often impossible in the life sciences because auxiliary assumptions are problematic. In the appraisal of competing theories, history of science shows that scientists use various theory characteristics such as aspects of parsimony, the number, qualitative diversity, novelty, and numerical precision of facts derived, number of misderived facts, and reducibility relations to other accepted theories. Statistical arguments are offered to show why, given minimal assumptions about the world and the mind, many of these attributes are expectable correlates of verisimilitude. A statistical composite of these attributes could provide an actuarial basis for theory appraisal (cliometric metatheory).

UK Pension Fund Management: How is Asset Allocation Influenced by the Valuation of Liabilities?

A single valuation basis (using market values) now dominates the valuation of pension scheme assets and has replaced the previously dominant actuarial and accounting bases. The same cannot be said for pension scheme liabilities. There are three different valuation bases for liabilities currently in use: a statutory basis (specified in the 1986 Finance Act), an actuarial basis (the Minimum Funding Requirement, specified in the 1995 Pensions Act) and an accounting basis (specified in Financial Reporting Standard 17). Since each of these uses different underlying assumptions, the three bases are not consistent with each other and produce substantially different measures of pension scheme liabilities. None of these measures corresponds to an economic valuation. Moves should be made to develop a single valuation basis for pension liabilities. A key difference relates to the discount rate used to calculate the present value of future pension payments. The Accounting Standards Board’s new FRS17 and the recent MFR Review conducted by the Faculty and Institute of Actuaries have both proposed a bond-based discount rate. Anecdotal evidence suggests that this is pushing pension fund asset allocations towards bonds in an attempt to reduce the short-term volatility mismatch between assets and liabilities. Moves should be made to ensure that the valuation basis for pension liabilities does not distort pension fund asset allocations. As a consequence, asset allocations are being pulled away from the asset classes most suitable for the long-term asset allocation of pension funds, namely equities and property. This raises the long-term cost to the sponsor of delivering defined benefit pensions, further encouraging the switch to defined contribution schemes. Various insurance-based mechanisms have recently been proposed in the event of scheme insolvency, namely a central discontinuance fund and mutual or commercial insurance. Experience from the US suggests that moral hazard risks are such that commercial insurance might provide the best chance of reflecting accurately the insolvency risk associated with a scheme’s particular funding stance should the MFR be replaced.

Social security: the phony crisis

Is it true that the Social Security system is in serious trouble and must be repaired? As baby boomers begin to retire, will they inevitably, by force of their sheer numbers, bankrupt the system? Is Social Security a big Ponzi scheme that will leave future generations with little to show for their lifetime of contributions? Is the only way to solve the Social Security crisis through radical changes like privatization or bolstering it with massive new taxes? According to the authors of this study, the answer to these questions is a resounding no. Economists Dean Baker and Mark Weisbrot argue that there is no economic, demographic or actuarial basis for the widespread belief that the programme needs to be fixed. As the authors emphasize, there is virtually no disagreement about the facts of Social Security's finances, or even the projections for its future. Rather, the Social Security debate has been foundering on misconceptions, confusion and lack of agreement on the meaning of crucial terms. The authors also take on related issues: that privatization would help save Social Security, that America has a pressing need to increase its national savings, and that future generations will suffer from the costs - especially for health care - of supporting a growing elderly population.

Off-Label Uses of Drugs in Children

As we approach the new millennium, very little has changed regarding the labeling of prescription drugs for use in infants and children. Along with pregnant women, infants and children remain therapeutic orphans. This condition is understandable because there are very few therapeutic indications that are unique to this patient population and the absolute quantities of drugs required by these patients remains relatively small. On an actuarial basis, humans spend only approximately 16 years as children, whereas they spend another 60 to 80 years as adults. As a result, there is very little incentive for pharmaceutics companies to develop drugs and drug dosing guidelines for infants and children. Careful review has revealed that >70% of all the Physicians' Desk Reference (PDR) entries have either no existing dosing information for pediatric patients or explicit statements that the safety and efficacy in children have not been determined. In the best of circumstances, there are age-specific admonitions because of lack of dosing information for infants and children. The resulting conundrum can be illustrated best by a case presentation. A 6-month-old infant, born 29 weeks premature, presents to a physician's office in respiratory distress. His medical history is significant for developing bronchopulmonary dysplasia as well as for prematurity. Vital signs are temperature: 37.7°C; pulse: 180; respiration: 72; blood pressure: 84/56; physical examination: intercostal retractions, increased anteroposterior diameter, bilateral diffuse expiratory wheezing, nasal flaring; treatment: albuterol 2.5 mg in 2 mL normal saline by nebulization. While receiving the aerosol, the patient's pulse rate climbs to 215 beats per minutes and he becomes cyanotic despite theo2 used to nebulize the drug. The physician is called by the nurse and witnesses the patient turn black with eyes rolled back. He then suffers a respiratory arrest. Resuscitation is unsuccessful. When confronted with a similar clinical emergency, most … Address correspondence to Jeffrey L. Blumer, PhD, MD, Pediatric Pharmacology and Critical Care, Rainbow Babies and Children Hospital, 11100 Euclid Ave, Cleveland, OH 44106.

Can Old-Age Social Insurance Be Justified?

While in America most people think of “welfare” as means-tested programs such as Aid to Families with Dependent Children, in reality in the United States and other affluent democracies the heart of the welfare state is social insurance programs, such as health insurance, old-age or retirement pensions, and unemployment insurance. They are insurance programs in the sense that they protect against common risks of a loss of income if and/or when certain events come to pass (illness, old-age or retirement, unemployment); they are “social” because unlike market insurance they are not run on a sound actuarial basis, the premiums are not voluntarily incurred but compulsory, and there is very limited choice or flexibility concerning the type of policy one can purchase. Why have social insurance rather than market insurance? In this essay, I take up this question with regard to old-age or retirement pensions, which at present absorb around 9 percent of the gross domestic product (GDP) and 25 percent of government spending of the affluent industrial countries comprising the Organization for Economic Cooperation and Development (OECD). My aim is to show that old-age or retirement social insurance (henceforth “SI”) is worse in virtually every relevant normative respect than its alternative, some form of market or private pensions. By relevant normative respect, I mean those values or principles which are used by contemporary political philosophers in their discussions and justifications of welfare-state policies, and which are applicable to assessments of different systems of old-age or retirement pensions. (Although they areapplicable, almost no contemporary political philosophers have in fact applied them—an amazing state of affairs which I hope to remedy here.)

Boron neutron capture therapy (BNCT) for high-grade gliomas of the brain: A cautionary note

Purpose/Objective : Boron neutron capture therapy (BNCT) is a method of treating high-grade gliomas of the brain that involves incorporating 10B into the tumor using appropriate phamacological agents and then irradiating the tumor with thermal or epithermal neutron beams. To date, over 120 patients have been treated in this manner by Japanese investigators using a thermal beam from a nuclear reactor. Favorable reports on outcome have motivated considerable current research in BNCT. The purpose of this study is to provide an independent analysis of the Japanese data by identifying the subset of patients from the United States who received this treatment in Japan and comparing their outcomes relative to a matched cohort who received conventional therapy in various Radiation Therapy Oncology Group (RTOG) studies. Methods and Materials : The principal referral sources of patients to Japan for BNCT were identified and the names of patients sent for treatment obtained. The treating physicians in Japan were also contacted to see if additional patients from the United States had been treated. Either the patients or their next of kin were contacted, and permission was obtained to retrieve medical records including tumor pathology for central review. Prognostic variables according to an analysis of the RTOG brain tumor database by Curran et al. were determined from these records and used to construct a matched cohort of patients treated conventionally. Results : A total of 14 patients were identified who had traveled to Japan for BNCT treatment between July, 1987 and June, 1994. In the case of one patient (deceased), it was not possible to contact the next of kin. Material was obtained on the other 13 patients and review of the pathology indicated that 1 patient had a central nervous system lymphoma rather than a high-grade glioma. Survival data was analyzed for the other 12 patients on an actuarial basis, and this showed no difference compared to survival data for a matched set of patients constructed according to the classification schema of Curran et al. Median survivals were 10.5 months for both groups: survival at 3 years was 22% for the BNCT group compared to 13% for the conventionally treated group ( p = NS). The only long-term survivors in the BNCT group had anaplastic astrocytomas and favorable prognostic criteria (Classes I and II of Curran et al.). The actuarial survival curves for the patients for the patients with glioblastoma multiforme (strict histological criteria) who received BNCT and their counterparts who received conventional therapy are virtually superimposable. The respective 2-year survivals are 20 v. 10% ( p = NS). Patterns of failure, toxicity, and analysis of the results according to histology are discussed. Conclusions : Analysis of patients from the United States who received BNCT treatment in Japan does not support a clinically meaningful improvement in survival attributable to this form of therapy. The implications of this for future BNCT research directions are discussed.

Neutron versus photon irradiation for unresectable salivary gland tumors: Final report of an RTOG-MRC randomized clinical trial

Purpose : To compare the efficacy of fast neutron radiotherapy versus conventional photon and/or electron radiotherapy for unresectable, malignant salivary gland tumors a randomized clinical trial comparing was sponsored by theRadiation Therapy Oncology Group in the United States and the Medical Research Council in Great Britain. Methods and Materials : Eligibility criteria included either inoperable primary or recurrent major or minor salivary gland tumors. Patients were stratified by surgical status (primary vs. recurrent), tumor size (less than or greater than 5 cm), and histology (squamous or malignant mixed versus other). After a total of 32 patients were entered onto this study, it appeared that the group receiving fast neutron radiotherapy had a significantly improved local/regional control rate and also a borderline improvement in survival and the study was stopped earlier than planned for ethical reasons. Twenty-five patients were study-eligible and analyzable. Results : Ten-year follow-up data for this study is presented. On an actuarial basis, there continues to be a statistically significant improvement in local/regional control for the neutron group (56% vs. 17%, p = 0.009) but there is no improvement in overall survival (15010 vs. 25010, p = n. s.). Patterns of failure are analyzed and it is shown that distant metastases account for the majority of failures on the neutron arm and local/regional failures account for the majority of failures on the photon arm. Long-term, treatment-related morbidity is analyzed and while the incidence of morbidity graded “severe” was greater on the neutron arm, there was no significant difference in “life-threatening” complications. This work is placed in the context of other series of malignant salivary gland tumors treated with definitive radiotherapy. Conclusions : Fast neutron radiotherapy appears to be the treatment-of-choice for patients with inoperable primary or recurrent malignant salivary gland tumors.

The Frequency and Morbidity of Local Tumor Recurrence after Definitive Radiotherapy for Stage C Prostate Cancer

Radiotherapy is reported to provide good control of locally advanced prostate cancer. However, few long-term studies have assessed the morbidity related to local tumor recurrence in patients treated with radiotherapy alone (without hormonal manipulation). To determine the frequency and severity of morbidity related to local recurrence we reviewed the course of all patients with clinical stage C prostate cancer treated at our institution between 1966 and 1979 with bilateral pelvic lymph node dissection, radioactive gold seed implantation and external beam irradiation therapy to the prostate. Of the 121 patients 60% died and the 40% still alive at the time of review were followed for a mean of 8.1 years (range 3.3 to 14.8 years).Over-all, 64 patients (53%) had local recurrence, which was defined as a clinical event causing signs or symptoms and was proved by biopsy. On an actuarial basis the risk of local recurrence was 43 ± 10% (mean ± 2 standard errors) at 5 years and 74 ± 11% at 10 years. Any symptomatic episode requiring active intervention or causing morbidity was denoted an adverse event. There were 162 adverse events among the 73 patients (2.2 adverse events per patient): 69% of these were severe (requiring surgical intervention) and 55% were chronic (more than 3 months in duration). The most common cause of an adverse event was bladder outlet obstruction requiring transurethral resection of the prostate (44 patients); 16 patients (13%) became incontinent. Hydronephrosis developed in 24 patients (20%). Local recurrence after definitive radiotherapy for our patients with stage C prostate cancer was common and was associated with serious morbidity, frequently requiring surgical intervention. Radiotherapy alone may not be sufficient to provide long-term local control of stage C prostate cancer.