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MSKCC Male Life Expectancy Nomogram

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Posted 3/16/2016 1:08 PM (GMT 0)
So, I was looking over Memorial Sloane Kettering's online prostate cancer prediction tools and came across the Male Life Expectancy (https://www.mskcc.org/nomograms/prostate) (bottom of page).

I go ahead and enter the specifics of my case (what I know now), and answer some general health questions, and at the end, it gives the probability of survival out 10 and 15 years WITHOUT treatment "to cure my cancer".

Quickly, me....54 years old, PSA 2.5 (5 months ago), 7-12 positive, one core 4+3, minimum T2b, no mets, no lymph involvement. I am in decent shape, non-smoker, 6'4", 215 lbs and exercise regularly (basketball, biking and walking). This nomogram states that 85% of men would be alive after 10 years and 71% after 15 years, again, WITHOUT treatment. Can that be correct? There has got to be a typo or something. I cannot believe that WITHOUT treatment, I, and those similar to me, have an 85% chance of living 10 years and 71% chance at 15 years. Can't be correct. Did I read something wrong?

This is what is stated at the top of the final page:

"Imagine that there were 100 men like you: the same age and overall health, and the same prostate cancer in terms of stage, grade and PSA. If none of these men received treatment intended to cure their cancer, this is what we would expect to happen:"

Do you think what is meant by 'cure' is either surgery or radiation (of some kind) and that these numbers do not necessarily mean NO TREATMENT, just non-curative treatment (i.e. drugs and chemo)? If that is the case, this is kind of misleading. But, I just found these "numbers" interesting. Makes me think that this cancer, for the most part, progresses slowly, and that I have a real chance to get some real good years out of this regardless of my "curative" treatment option I select.

I hope I didn't do something silly on this nomogram tool or read something into this that isn't there, and waste everyone's time. If I did, go easy on me! lol

Enjoy your hump-day (Wednesday).

J
Posted 3/16/2016 1:59 PM (GMT 0)
It means no treatment at all from my understanding. That doesn't mean your choice should be no treatment. There is a big difference between just being alive and quality of life. You are correct in the fact that most prostate cancers are slow growing. I was told when I was diagnosed that if I did nothing I could expect 10 years before major symptoms might appear. That really didn't impress me as I just wanted it out ASAP. Diagnosed on Jan. 23rd and prostate gone on Feb. 10th. Been a little over 4 years and no regrets and most importantly no cancer, no incontinence, and no ED.

Good luck to you,
Tom
Posted 3/16/2016 2:13 PM (GMT 0)
Memorial Sloane Kettering's prostate cancer prediction tools are NOT something to rely upon much less decide on a treatment plan.

Besides, at 54 years old and in otherwise good health, you have a much longer life expectancy WITH TREATMENT
Posted 3/16/2016 2:24 PM (GMT 0)
Jay,

It literally means no treatment at all, or simply watchful waiting. This nomogram is based upon large scale metrics/averages of course, but it underlies the mantra that PCa is one of the most overtreated cancers in the U.S. This is why so many argue for more emphasis on active surveillance (AS) unless the PCa is high risk.

When I went to Johns Hopkins, at the age of 41, Alan Partin told me that if I did nothing, I'd probably get 15-20 years before PCa caught up with me and actually started producing noticeable symptoms - that's how slow growing it is for most of us. This is why there is so much research ongoing in trying to identify methods to detect indolent/slow growth PCa vs high risk/fast growing PCa. We really don't even understand how PCa progresses from G6 to G7 to G8 and so forth scientifically. We've identified a number of different types of PCa at this point (25 or so different subtypes the last I looked), so hopefully we're getting closer to being able to identify markers/genes and then actual tests that can determine the true nature of the PCa and whether treatment is really necessary or not.

I'd be very curious to see how the nomogram would reflect 20, 25 and 30 year increments as well, given the slow growth nature of most PCa. I'd imagine those numbers would ramp up quite a bit as the years progressed without treatment. As Reltnie said, this nomogram also doesn't really address QOL issues either - especially if late term PCa goes untreated - QOL really suffers as end of life approaches.
Posted 3/16/2016 2:59 PM (GMT 0)
I would never NOT treat what I have based upon this, or any, nomogram. I just found the numbers interesting.

I think most of you guys know where I am at, and I am always searching for 'good' numbers and 'good' outcomes. I would like to think I have a chance at making 10 years out, even 15 years out. Things like this nomogram make me feel a little better that I can treat this and survive well into the future.

I know every case is different, and I could be one of those numbers that end up not being 'good'. I can only hope that is not the case.

Take care,

J
Posted 3/16/2016 4:04 PM (GMT 0)
You have properly interpreted the nomogram in your original post, JayMot.

Perhaps you have just discovered these two facts which roll-up nicely into a clear, concise statement: Prostate cancer is amongst the most common and the least lethal of all cancers.

The nomogram statistics reveal, as has already been pointed out here, the outcomes of men with similar case characteristics, but it does not tell you exactly what will happen to you. I read a great phrase recently about how individuals should use nomograms: “What statistics tell you is whether you’re in a great big fight, a medium-sized fight, or a little fight. People win and lose all three, so it just tells you what your fighting mind-set is.”
Posted 3/16/2016 4:05 PM (GMT 0)
I too was told 10 years before symptoms by more than one source ( including JH).


That woulda been a tough 10 years for me.

Also...I'm unsold on these nomograms.
Posted 3/16/2016 4:46 PM (GMT 0)
I suppose another way of approaching the nomogram in question is to realize that by age 70, almost all men are purported to have PCa in some form or fashion - it just goes undiagnosed or undetected - therefore almost all men will die with some form of PCa. As JackH said, PCa is among the most common cancers for men. This is also why PCa is generally known to be an old man's disease - because it takes so long to progress - except for those that have more aggressive forms of PCa. Now, with modern testing and diagnostics, we are detecting it in younger men now - but there is a LOT of debate on the costs/benefits of early treatment. This is in part why the national healthcare task force recently recommended against PSA testing before age 50, exceptions being black men and those with a family history (like me).

I also happen to believe that the western diets contribute significantly to cancer prevalence in general, combined with environmental toxicities. There are some studies that show this link when comparing western diets that are high in animal proteins and fats with eastern diets that favor vegetables and fish.
Posted 3/16/2016 5:07 PM (GMT 0)
The nomograms provide sound data, yet it isn't uncommon, particularly at an online peer sites, to find real-live examples of what is frequently reported in the literature…men making emotion-based decisions regarding “cancer” rather than data-based decisions. “Cancer” is an emotionally charged word in our society, and examples abound here at HW/PC.

Are you familiar with the Stockholm Syndrome? It’s very interesting and you can Google it, but in brief it is a form of “cognitive dissonance” – I should stress that my example here is specific to the use of emotion/data by low-risk patients who choose aggressive treatment, and doesn’t directly apply to you, JayMot, with your intermediate-risk case. But the example here is that a “cognitive dissonance” can create an inability to accept that a terrible sacrifice did not result in extended survival…as is reflected in the MSKCC nomograms. Sometimes the data can be right in front of people, yet they still simply declare that they don’t believe it. What are ya gonna do…?
Posted 3/16/2016 5:19 PM (GMT 0)
Yes, of course it's correct. They mean with no curative treatment. I assume it surprises you because survival seems high to you. Prostate cancer has a long natural history. It can easily take 10-20 years for it to metastasize. After that, one has hormone therapy, radiologicals, immunotherapies, etc that prolong survival much further.

- Allen
Posted 3/16/2016 5:29 PM (GMT 0)

NKinney said...
The nomograms provide sound data, yet it isn't uncommon, particularly at an online peer sites, to find real-live examples of what is frequently reported in the literature…men making emotion-based decisions regarding “cancer” rather than data-based decisions. “Cancer” is an emotionally charged word in our society, and examples abound here at HW/PC.

Are you familiar with the Stockholm Syndrome? It’s very interesting and you can Google it, but in brief it is a form of “cognitive dissonance” – I should stress that my example here is specific to the use of emotion/data by low-risk patients who choose aggressive treatment, and doesn’t directly apply to you, JayMot, with your intermediate-risk case. But the example here is that a “cognitive dissonance” can create an inability to accept that a terrible sacrifice did not result in extended survival…as is reflected in the MSKCC nomograms. Sometimes the data can be right in front of people, yet they still simply declare that they don’t believe it. What are ya gonna do…?

NKinney, You and I and others could point out new studies and statistics on the downsides of over-treatment, but it will simply fall on deaf ears for many men, as you have noted. Maybe some men will try to re-program their "wiring" after reading of the very low risk of AS and the prevalent SE's of treatments. But, I have to concede that individual mindsets and influences of family to do something NOW will always drive many people's decisions. I have to respect that, and wish them well.
Posted 3/16/2016 6:21 PM (GMT 0)

ASAdvocate said...
But, I have to concede that individual mindsets and influences of family to do something NOW will always drive many people's decisions. I have to respect that, and wish them well.


I agree (of course I do; this was my point). What are ya gonna do? Wish them well...

...and hope that they don't influence the next guy.

Post Edited (NKinney) : 3/16/2016 12:24:11 PM (GMT-6)

Posted 3/16/2016 7:14 PM (GMT 0)
you could live a long time with a miserable and diminishing QOL. I think i'd rather be dead. you are intermediate to high risk according to you numbers.

ed
Posted 3/16/2016 7:19 PM (GMT 0)
"NKinney, You and I and others could point out new studies and statistics on the downsides of over-treatment, but it will simply fall on deaf ears for many men, as you have noted. Maybe some men will try to re-program their "wiring" after reading of the very low risk of AS and the prevalent SE's of treatments."

is that your mission here? one thing I do appreciate is you practice what you preach instead of trying to get a vicarious do-over because when it was your turn you "just wanted it out" but now deem you were overtreated.

ed
Posted 3/16/2016 7:34 PM (GMT 0)
Hi F8, Don't think that I have a "mission", and there is only one area where I have any qualification to preach about anything. But, I do often react when I read about someone with a low risk pathology being scheduled for surgery by their urologist.

I am influenced by studies like this new one that point out the disadvantages of over-treatment of low risk men:

http://prostatecancerinfolink.net/20...-surveillance/

And, yes, some folks also have strong opinions about what they've been through. But, as you know, a cancer diagnosis has dramatic impact, and we all try to learn and share from our experiences.
Posted 3/16/2016 8:54 PM (GMT 0)
Jay, another way to look at this would be to say...if you, with your numbers DON'T treat, then in 10-15 years you'll be looking at dealing with real nasty stuff. It doesn't say you'll die of something else if you don't treat.
Posted 3/16/2016 9:11 PM (GMT 0)
Evaluating when to get treatment is a difficult decision to be sure. I had all G6 cores however some of my core volumes were in excess of 50% and given my young age and higher hormone levels (T), , coupled with a long family history of PCa, I'm generally more prone to cancer growth than a comparably older man who had my same diagnosis, so I chose treatment sooner rather than later. Had I been older with my prognosis I might have continued with AS. There's always the concern that in the waiting the cancer grade will increase and that lowers the chances of remaining cancer free after treatment, especially for those of us with family history of PCa deaths. It's a balancing act at least IME. YMMV.

Here's a link to a recent article on attempting to identify the cancer grade based upon hormone levels, as one example of the need to have more granular tests that can differentiate between indolent and aggressive PCa:

Can we predict the aggressiveness of PCa before surgery with a blood test?

Post Edited (HitchHiker) : 3/17/2016 11:03:08 AM (GMT-6)

Posted 3/16/2016 9:36 PM (GMT 0)

halbert said...
Jay, another way to look at this would be to say...if you, with your numbers DON'T treat, then in 10-15 years you'll be looking at dealing with real nasty stuff.


Uh, no. The MSKCC nomogram definitely doesn't say this.

Let me help clarify one of your original questions about treatment with intent to cure: this means either removal (surgery) or destruction (radiation or cryosurgery) of the prostate. Other common treatments such as hormonal deprivation therapy, or other life extending treatments, are not in the category to "cure."

So, a correction of halbert's statement is that you might be realizing symptoms for which you would receive medical treatment; of course, you might not. This nomogram does absolutely nothing to predict probabilities of being symptom-free.



The bigger picture, however, is that you seem to have been diagnosed with unfavorable-risk PC as a result of your one core of 4+3. (Very important note: I looked through your other posts and didn't see which prostate pathology expert read/confirmed your biopsy slides...this is an important step BEFORE considering treatments. See the "Newly diagnosed..." sticky thread.) But if you do, indeed, have confirmed unfavorable intermediate-risk PC, then a curative treatment is certainly recommended for your case. Yours would likely be the 3rd type of case Dr Paul Shellhammer was thinking about when he wrote:

1. There is the kind [of PC] that can be cured, but need not be cured.
2. There is the kind that needs to be cured and cannot be cured.
3. We all hope there is the kind that needs to be cured and can be cured.
Posted 3/16/2016 9:36 PM (GMT 0)
I have three know close relatives who died from prostate cancer. Great Uncle, Father and Younger brother. Wonder why this variable was left out of the nomogram

There's a lot of Genetics in this disease.
Posted 3/16/2016 9:43 PM (GMT 0)

Manfred said...
I have three know close relatives who died from prostate cancer. Great Uncle, Father and Younger brother. Wonder why this variable was left out of the nomogram.



Prostate cancer is so ubiquitious that age significantly overrides other factors. Prostate cancer, and most cancers, are mostly sporadic. Hereditary PC, when a gene mutation is passed within a family from one generation to the next, only accounts for about 5% of cases.

Dr Patrick Walsh himself said: "Prostate cancer is so common that even if there is a hereditary factor, there will be other members of the family who will get the disease sporadically."

Having a friend or relative diagnosed with PC tends to increase one's diagnostic activity...increased diagnostic activity leads to diagnosis.
Posted 3/16/2016 10:03 PM (GMT 0)
For most men, about two-thirds, this disease does not progress, does not kill and does not cause problems. Those are the true low risk G6. Most of us wish that more, if not all men would simply not treat at that level.

For the other one-third it is a mixed bag. We know of G9 men than live 10 or more years and we know of G7 men that don't make it but a few years after dx. Many can do well for a significant time with no treatment, but they could do even better for a longer time with the appropriate treatment when first diagnosed.

Problem is that the nomograms don't have your name on them. So, at the end of the day, they can only be one of many data sets to be used to decide what to do. I certainly don't think they should be the significant influencer.

Your wild card is the G4. That is what can and often does cause real problems. It can become increasingly aggressive and continue to mutate in a very damaging way. It is what does kill about 30,000 men a year in the USA. You are currently in a great position to beat this disease down with appropriate treatment to hopefully cure, or at least defer additional treatment and significant symptoms for a very long time. Hopefully in such a way that the PCa in no way limits your otherwise normal lifespan.

I have no doubt that most experts would prescribe appropriate treatment for you at the present time. If you are a candidate for AS and are concerned about treatment decisions then by all means pursue AS as a treatment method. That is not, however, what I am understanding from your posts.

I know you are troubled by the options.....join a very big club......most men facing this are troubled by the options and the difficult decisions that need to be made. I was a fortunate one in a way. Due to my dx, all my consults said the same thing and after speaking with 5 doctors all telling me the same thing I acted.

Your situation is much more nuanced and I empathize with you. However, please don't use something like the nomograms to delay, defer or rationalize away the decisions that need to be made.

Best wishes in your search,

jack
Posted 3/16/2016 10:09 PM (GMT 0)
"But, I do often react when I read about someone with a low risk pathology being scheduled for surgery by their urologist"

how about the guys with low risk numbers who after surgery find the risk was higher than tests showed? there are many of them here! once that 3+3 turns into A 3+4 or 4+3 or even higher what do you say?

my take is if you "just wanted it out" and now you're cured don't ***** about it. because you know only the guys who are "cured" claim they were overtreated.

ed
Posted 3/16/2016 10:10 PM (GMT 0)
I don't know anyplace that would offer AS to a man once GS 4+3 is detected. That's just plain crazy.
Posted 3/16/2016 11:28 PM (GMT 0)
As I recall one of Jay's earlier posts, (or maybe it was someone else...maybe I'm mis-remembering) that JH did his pathology. That's Epstein and his team. No argument there.

I think we need to take care here. Jay's pathology is definitely NOT low risk, and all the commentary in his direction about low risk cases could steer him in the wrong direction. Telling a guy with a 4+3 all this opinion about low risk cases and overtreatment do not apply to him.

Jay, I'll say it this way directly. If you have a true, confirmed G4+3, then treatment is in your future, sooner instead of later...you have weeks or months, not longer, to figure out what to do and get things moving. All this sidebar stuff about AS and overtreatment don't apply to you.
Posted 3/17/2016 12:10 AM (GMT 0)
Yea I punched in my stats and got the message" this nomogram doesn't apply to you " 😟 Lol(not).
Bob
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