Estimating treatment benefits for the elderly: the effect of competing risks.

To fully involve patients in treatment decisions, physicians need to communicate future health prospects that patients will have both with and without newly diagnosed disease. These prospects depend not only on the risks patients face from the new disease but also on the risks they face from other causes. Nowhere is an understanding of these competing risks more relevant than in the care of the elderly. In this study, we use the declining exponential approximation for life expectancy (DEALE) to provide a framework to help clinicians gauge the effect of competing risks as a function of age. Because older patients have many competing risks for death, the absolute effect of a new diagnosis on life expectancy is often relatively small. Consequently, the potential gain in survival even from perfect therapy may also be small. Moreover, no therapy is perfect, and the risks of therapy often increase with age. In the elderly, the combination of a high burden of competing risks and high rates of treatment-related complications conspires to reduce the net benefit of numerous interventions. We conclude that, compared with younger patients, the elderly should request only the more clearly effective treatments and should be willing to tolerate fewer associated complications before they agree to initiate therapy.