There is an old surgical adage that “the best surgeon knows when not to operate.” While much of early residency is focused on how to operate, there is an expectation that more senior trainees become more familiar with non-surgical strategies for indolent disease or patients with significant competing morbidities. This is particularly relevant for men with localized prostate cancer where the patient’s functional state and life expectancy must be integrated into screening, diagnostic, and management decisions.
While no resource is perfect, it is worthwhile to familiarize yourself with some contemporary methodology and predictive tools to integrate into clinical practice. Sammon et al published a well-done study in European Urology (2015; 68:756-65) in 2015 that is worth reviewing.
Age is the best predictor of life expectancy. According to the Social Security Administration (SSA) Actuarial Life Tables from 2013, life expectancy for newborn males and females in the United States is 76.28 and 81.05 years, respectively. And the longer one lives, the longer the overall life expectancy becomes so that the average 60-year-old man has a life expectancy of 81.48 years.
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In addition to age, comorbid conditions and functional limitations must be integrated. Validated indices including the Charlson comorbidity index and more recently the Elixhauser comorbidity index offer objective tools to quantify comorbidities. But it should be noted that neither was designed or validated to predict 20- to 30-year longevity. The Eastern Cooperative Oncology Group (ECOG) Performance Status and Karnofsky Performance Status are widely used functional classifiers, particularly in the medical oncology community, to guide prognosis and treatment strategies.
In recent years, there has been significant interest in the surgical community to better integrate objective tools to quantify perioperative risks. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) risk calculator and Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity (POSSUM) incorporate multiple clinical variables to predict complications and mortality after surgery. While these scores identify high-risk surgical patients, they were not designed to guide the other required management decisions.