To Predict the Future, Consider the Present as Well as the Past

Download To Predict the Future, Consider the Present as Well as the Past

Post on 05-Sep-2016




1 download


issthter,postoperatively and the other is using only one pad, their who barely misses the threshold definition for continence,E U RO P E AN URO LOGY 6 2 ( 2 0 1 2 ) 5 3 5 4ava i lable at www.sciencedirect .comjournal homepage: www.europeanurology.comoccurs in the first year after surgery, with a lower likelihoodof normalization of function subsequently.respective likelihoods of eventually reaching full conti-nence are no longer equivalent. This concept of conditionalsurvival outcomes is naturally intuitive, and surgeonsbroadly recognize that the greatest functional improvementand these two men should not receive the same counseling.The findings with respect to robot-assisted versus opensurgery are dramatic, particularly in terms of urinaryfunction recovery, but they should be interpreted withsubstantial caution. The patients were not randomizedbetween the two approaches, and it seems quite likely thatrecovery to date. For example, two 60-yr-old men in similaroverall health treated by the same surgeon may have hadcomparable a priori risks of long-term incontinence beforeprostatectomy, but if one is using five pads a day at 6 moinformation can be lost in this approach [5]. There is aclear clinical implication here: A man with a very lowurinary function score at 12 mo naturally has differentprospects for eventual complete urinary recovery than onrating the considerable information content reflected in thePlatinum Priority EditorialReferring to the article published on pp. 4252 of thisTo Predict the Future, ConsiderMatthew R. Cooperberg *Department of Urology, UCSF Helen Diller Family Comprehensive Cancer CenPublished and publicized rates of urinary and sexualdysfunction following radical prostatectomy and othertreatments for prostate cancer vary wildly, reflecting suchvariables as who ascertains the outcome, via what medium(paper, phone, electronic, etc.), and using what specificquestions and definitionsnot to mention wide variation inbaseline patient functional status and surgical technique andquality. For themost part, regardless of thesemethodologicaldetails, quality-of-life outcomes are analyzed and reportedbasedoncross-sectionalanalysisof resultsat somefixedtimepoint following treatmentfor example, likelihood of beingpad free or meeting a score threshold on a given quality-of-life instrument at 6 or 12 mo after surgery. Ideally,analyses may use repeated measures techniques to reflectboth short- and long-term impacts of intervention. Thesestudy designs are optimal for assessing the overall impact ofan intervention over time, and in some cases they are usefulfor counseling patients before treatment [1].For a patient who has already been treated, however,counseling tools may be personalized further by incorpo-However, fewprevious studieshaveattempted toquantifythis effect. In this issue of European Urology, Abdollah et al.analyzed a relatively large cohort of prostatectomy patientsDOI of original article:* Tel. +1 415 885 3660; Fax: +1 415 885 7443.E-mail address:$ see back matter# 2012 European Association of Urology. Published byuee Present as Well as the PastBox 1695, 1600 Divisadero Street, A624, San Francisco, CA 94143-1695, USAtreated over a 10-yr period in an effort to develop counselingtools that would reflect duration of follow-up as well asbaseline function and technical aspects of surgery [2]. Onenoteworthy finding was that continence recovery >1 yrpostoperativelywashardly rare:Amongmenstill incontinentat 1, 2, and 3 yr, 41%, 25%, and 13%, respectively, recoveredwithin the subsequent 6 mo. This observation is consistentwith a recent report that men incontinent after prostatec-tomy benefit from behavioral interventions at a mean of5 yr and at asmany as17yr following surgery [3]. Conversely,comparatively few men with persistent erectile dysfunction1 yr following surgery eventually recovered, highlighting theneed for rehabilitation strategies early in the recovery period[4]. Trajectories of recovery also varied between open androbot-assisted surgical patients.The analysis is marked by a few notable limitations,some of which the authors acknowledged. Continence andpotency were defined by dichotomizing scores that areintended to be analyzed as continuous variables. Althoughthe conditional survival analysis required this recoding,these outcomes are not truly binary, and significantunmeasured confounding may be significant. Patient ageand extent of nerve sparing were dichotomized in themultivariable analysis, and baseline erectile function wasElsevier B.V. All rights reserved. categorized. Within these broad categories, robot-assisted surgery patients may have been younger and mayhave received more complete nerve sparing; alternatively,they may have been treated more recently and/or by highervolume surgeons. Certainly it stretches credibility some-what to suggest, as does the urinary function nomogram,that undergoing robot-assisted versus open surgery shouldbe worth the same number of points in terms of recoveryprediction as being 45 rather than 85 yr of age at the time ofsurgery.Another important caveat with respect to interpretationof the nomograms is the fact that theywere developed usingdata from a single relatively high-volume center, and theyhave not been externally validated. A man treated inanother center by a different surgeon may have asubstantially different likelihood of recovery. Indeed, theerectile recovery prediction model, appears somewhatUltimately, whether or not the specific predictions from themodels of Abdollah et al. eventually prove reliable, theconceptof predictions conditional ondurationof observationandon short-termoutcomes should in the future yield betterguidance for men as they transition from early recovery tolong-term survivorship.Conicts of interest: The author has nothing to disclose.References[1] Alemozaffar M, Regan MM, Cooperberg MR, et al. Prediction oferectile function following treatment for prostate cancer. JAMA2011;306:120514.[2] Abdollah F, SunM, Suardi N, et al. Prediction of functional outcomesafter nerve-sparing radical prostatectomy: results of conditionalsurvival analyses. Eur Urol 2012;62:4252.[3] Goode PS, Burgio KL, Johnson 2nd TM, et al. Behavioral therapy withE U RO P E AN URO LOG Y 6 2 ( 2 0 1 2 ) 5 3 5 454interesting to determine whether variation across surgeonsand across centers tends to attenuate as time passes. Forexample, likelihood of continence recovery in the first 6 mopostoperatively may vary substantially across providers,but the conditional likelihood of recovery at 18 mo may beconsistent for a man still using one pad per day at 12 mo.Specific validation issues aside, if novel predictionmodelsare to develop from research instruments into clinicallyuseful tools, the expression of themodels will need to evolvebeyond static nomograms tomore dynamic systems that canroutinely collect patient-reported data at baseline and infollow-up, and then can integrate this data in real time topredict outcomes based on data from contemporary patientstreated at a given center [6,7]. Of course, the first prerequisiteis that all men managed for prostate cancer completevalidated quality-of-life questionnaires at regular intervals,regardless of their participation in research studies [8].trolled trial. JAMA 2011;305:1519.[4] Mazzola C, Mulhall JP. Penile rehabilitation after prostate cancertreatment: outcomes and practical algorithm. Urol Clin North Am2011;38:10518.[5] Cooperberg MR, Koppie TM, Lubeck DP, et al. How potent is potent?Evaluation of sexual function and bother in men who report poten-cy after treatment for prostate cancer: data from CaPSURE. Urology2003;61:1906.[6] Vickers AJ, Fearn P, Scardino PT, KattanMW.Why cant nomogramsbe more like Netix? Urology 2010;75:5113.[7] Vickers AJ, Salz T, Basch E, et al. Electronic patient self-assessmentand management (SAM): a novel framework for cancer survivor-ship. BMC Med Inform Decis Mak 2010;10:34.[8] Chang P, Szymanski KM, Dunn RL, et al. Expanded prostate cancerindex composite for clinical practice: development and validation ofa practical health related quality of life instrument for use in theroutine clinical care of patients with prostate cancer. J Urol 2011;186:86572.derived from two multicenter cohorts [1]. If and whenexternal validation studies are conducted, it would beor without biofeedback and pelvic oor electrical stimulationfor persistent postprostatectomy incontinence: a randomized con-more optimistic than another recently published model


View more >