Association of functional status and treatment choice among older men with prostate cancer in the Medicare Advantage population

Abstract

Background There are several effective treatments for prostate cancer. To what extent a patient's functional status influences the treatment decision is unknown. We sought to examine the association of functional status with treatment among older men with prostate cancer. Methods Using Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey (SEER-MHOS) data, we identified men 65 years or older diagnosed with prostate cancer between 1998 and 2009. Our primary outcome was treatment choice: conservative management, surgery, or radiation within one year of diagnosis. Our exposure was functional status assessed as 4 measures within three domains: 1) physical function (activities of daily living [ADL] and physical component summary [PCS] score), 2) cognitive function (who completed the survey [self vs. proxy]), and 3) emotional well-being (mental component summary [MCS] score). We fit a multivariable multinomial logistic regression adjusting for several patient, tumor, and regional characteristics. Results We identified 508 conservative management, 195 surgery, and 603 radiation patients. Compared to men with no ADL dependency, those with any ADL dependency had lower odds of receiving surgery (odds ratio [OR] 0.61; 95% confidence interval [CI] 0.38-0.99) and radiation (OR 0.58; 95% CI 0.43-0.78) relative to conservative management. ADL dependency did not differ when comparing surgery and radiation. Patients with proxy survey response were less likely to receive surgery or radiation compared with conservative management. Conclusions Functional status is associated with treatment choice for men with prostate cancer. Future research should examine whether this is due to physicians’ recommendations, patient preferences, or a combination.

Barthel Index-based functional status as a prognostic factor in young and middle-aged adults with newly diagnosed gastric, colorectal and lung cancer: a multicentre retrospective cohort study

“…In the first mechanism, functional disability is thought to shift the treatment course away from more aggressive options. 29 This concept is supported by the significant associations between severe functional disability and increased mortality irrespective of cancer stage in our analyses. In particular, patients with severe functional disability may be limited to less aggressive treatments.…”

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A flexible approach for causal inference with multiple treatments and clustered survival outcomes

“…For example, patient functional status has been shown to be strongly associated with both treatment choices and survival among men with prostate cancer. 40,41 The performance status measured by Eastern Clinical Oncology Group (ECOG) score may also be a confounder as it both affects the likelihood of clinicians choosing AD 42 and predicts survival for prostate cancer. 43 Futhermore, magnetic resonance imaging findings and the number of positive biopsy cores are both likely confounders as they are related to patient selection for RP or brachytherapy and indicate the degree of agressiveness of high-risk prostate cancer.…”