Sommers Benjamin D, Beard Clair J, D'Amico Anthony V, Dahl Douglas, Kaplan Irving, Richie Jerome P, Zeckhauser Richard J
Division of General Medicine, Brigham & Women's Hospital, Boston, Massachusetts 02115, USA.
Cancer. 2007 Nov 15;110(10):2210-7. doi: 10.1002/cncr.23028.
Selecting treatment for clinically localized prostate cancer remains an ongoing challenge. Previous decision analyses focused on a hypothetical patient with average preferences, but preferences differ for clinically similar patients, implying that their optimal therapies may also differ.
A decision model was constructed comparing 4 treatments for localized prostate cancer: 1) radical prostatectomy (RP); 2) external beam radiation (EB); 3) brachytherapy (BT); and 4) watchful waiting (WW). Published data were used regarding treatment success, side effects, and noncancer survival, and 156 men with prostate cancer were surveyed to elicit preferences in quality-adjusted life years (QALYs). The clinical scenarios were determined (age, tumor grade, and prostate-specific antigen [PSA]) for which variations in patient preferences led to different optimal treatments and those for which the optimal treatment was unaffected by preferences.
Patient preferences were critical in determining treatment for low-risk cancers (Gleason score <or=6, PSA <or=10 ng/mL) and for patients aged 75 years and older. In younger patients with more aggressive tumors, RP and EB were always superior to WW or BT, regardless of preferences (average gain in quality-adjusted life expectancy vs WW for a 60-year-old with a medium-risk tumor = +1.4 years for RP and +1.7 for EB; for a high-risk tumor = +2.1 years for RP and +2.4 for EB). BT was a reasonable option for low-risk tumors at any age. WW was only reasonable for patients aged 70 and older with low-risk tumors or those aged 80 years and older with medium-risk tumors. Selecting treatment based on average preferences leads to suboptimal choices for 30% of patients.
The optimal treatment for prostate cancer depends on both the clinical scenario (patient age and tumor aggressiveness) and the patient's preferences. Decision analyses taking individualized preferences into account may be a useful adjunct in clinical decision-making.
为临床局限性前列腺癌选择治疗方案仍然是一项持续存在的挑战。以往的决策分析聚焦于具有平均偏好的假设患者，但临床相似的患者偏好各异，这意味着他们的最佳治疗方案可能也有所不同。
构建了一个决策模型，比较局限性前列腺癌的4种治疗方法：1）根治性前列腺切除术（RP）；2）外照射放疗（EB）；3）近距离放射疗法（BT）；4）观察等待（WW）。使用已发表的关于治疗成功率、副作用和非癌症生存率的数据，并对156名前列腺癌男性进行了调查，以得出质量调整生命年（QALYs）方面的偏好。确定了临床情况（年龄、肿瘤分级和前列腺特异性抗原[PSA]），其中患者偏好的变化导致不同的最佳治疗方案，以及最佳治疗方案不受偏好影响的情况。
患者偏好对于确定低风险癌症（Gleason评分≤6，PSA≤10 ng/mL）以及75岁及以上患者的治疗至关重要。在肿瘤更具侵袭性的年轻患者中，无论偏好如何，RP和EB始终优于WW或BT（对于一名60岁中度风险肿瘤患者，与WW相比，RP的质量调整预期寿命平均增加1.4年，EB为1.7年；对于高风险肿瘤患者，RP为2.1年，EB为2.4年）。BT对于任何年龄的低风险肿瘤都是一个合理的选择。WW仅对于70岁及以上低风险肿瘤患者或80岁及以上中度风险肿瘤患者是合理的。基于平均偏好选择治疗方案会导致30%的患者做出次优选择。
前列腺癌的最佳治疗方案取决于临床情况（患者年龄和肿瘤侵袭性）以及患者偏好。考虑个体偏好的决策分析可能是临床决策中的一个有用辅助手段。
