Re: Incidence of initial local therapy among men with lower-risk prostate cancer in the United States.

Miller et al. ( 1 ) found that among men with lower-risk prostate cancer, 55% may have been overtreated (most of them by radiation therapy), whereas 45% underwent “ appropriate ” expectant management or androgen deprivation therapy. It is indeed noteworthy that so many of the lower-risk cases were treated by curative therapy rather than expectant management or androgen deprivation therapy. However, appropriateness depends more upon the remaining life expectancy of the patient than his chronologic age. For example, curative therapy may be more appropriate for a 75-year-old man who has a long life expectancy than for a 60-year-old man who has a short life expectancy. Before concluding that overtreatment was rampant, therefore, Miller et al. should have examined a sample of the subjects to determine whether or not chronologic age was indeed a good surrogate for estimated life expectancy in this particular population. If the patients selected by physicians for curative therapy had much longer life expectancies than those selected for expectant management, then each treatment was probably quite appropriate. Finally, expectant management, as de scribed by Miller et al., included ob servation as well as surgical or medical castration, which have enormously different physical and fi nancial repercussions. In determining “ appropriateness ” , it is therefore important to know something about the relative frequencies of these various kinds of expectant management as well.