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Men with short life expectancies often undergo aggressive prostate cancer treatment
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Men with low- or intermediate-risk prostate cancer who had life expectancies of fewer than 10 years frequently underwent aggressive treatment with radiation therapy or less frequently with surgery, according to results of a SEER analysis.
Timothy J. Daskivich, MD, MSHPM, of the department of urology at the University of California, Los Angeles, and colleagues used the SEER database to identify 96,032 men diagnosed with early-stage prostate cancer between 1991 and 2007. All men were aged at least 66 years and had a Gleason score of 7 or lower.
Fifty-two percent of the study population (n=50,049) had a life expectancy that was shorter than 10 years.
Results showed life expectancy decreased with older age and greater Charlson Comorbidity Index score. Life expectancy was less than 10 years among the following cohorts: men aged 66 to 69 years with a Charlson score ≥2; men aged 70 to 74 years with a Charlson score ≥1; and all men aged 75 to 79 years, as well as those aged at least 80 years, regardless of Charlson score.
The researchers evaluated the use of aggressive treatment — including surgery, radiation or brachytherapy — among men with life expectancies shorter than 10 years. Among this group, researchers identified aggressive treatments in 68% of men aged 66 to 69 years; 69% of men aged 70 to 74 years; 57% of men aged 75 to 79 years; and 24% of men aged at least 80 years.
Radiation therapy was the most frequent form of aggressive treatment. Its use ranged from 50% in men aged 66 to 69 years to 69% in those aged at least 80 years. Surgery was the least common form of aggressive treatment used. Rates of surgery declined with age, from 30% for those aged 66 to 69 years to 9% among those aged at least 80 years.
In each age subgroup, researchers observed substantial differences in 10-year cumulative incidence of other-cause mortality based on comorbidity status. Among men aged 66 to 69 years, 10-year incidence of other-cause mortality was 30% in those with a Charlson score of 0 and 81% among those with a Charlson score ≥3. Among men aged at least 80 years, 10-year incidence of other-cause mortality was 73% in those with a Charlson score of 0 and 96% among those with a Charlson score ≥3.
However, multivariate models suggested little variation in the likelihood of aggressive treatment within each age group based on comorbidity status.
“Greater than half of men aged ≥66 years had life expectancies <10 years and … nearly half of them received aggressive treatment,” Daskivich and colleagues wrote. “Because of their low likelihood of 10-year survival, these men are unlikely to live long enough to substantially benefit from aggressive treatment, but they still incur its associated side effects and financial burden. We hope that this information will promote greater awareness of the role of life expectancy in treatment decision-making for men with low- and intermediate-risk prostate cancer.”
The fact radiation therapy was used more frequently than surgery suggests that physicians may underestimate the treatment effects of radiation, Matthew R. Danzig, BS, and James M. McKiernan, MD, of the department of urology at Columbia University, wrote in an accompanying editorial.
“The implication made by the authors is that, in older patients and in those with more comorbid conditions, clinicians are restricted in their ability to recommend surgery because of the clear and apparent deterrent of the risk of perioperative morbidity and mortality,” Danzig and McKiernan wrote. “However, no such inherent barrier exists to limit treatment with radiotherapy; therefore, some patients are being diverted from surgery to radiation when the true best practice in many cases may be conservative management.”
Physicians also should strive to reduce patient anxiety associated with surveillance in order to prevent overtreatment, they added.“Cultivating close, trusting relationships with patients will be a critical component of the effort to shift the paradigm for the treatment of early-stage, localized prostate cancer,” Danzig and McKiernan wrote.
Disclosure: One researcher reports a cofounder role with Wiser Care LLC. Danzig and McKiernan report no relevant financial disclosures.
Perspective
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Robert Abouassaly, MD, MSc
In the case of aggressive malignancy, the decision to treat is fairly straightforward. On the other hand, when malignancies tend to be more slow-growing, as is the case in prostate cancer, the decision of whether to treat the patient can be much more challenging. Most men diagnosed with prostate cancer are aged older than 65 years, and they often have significant medical comorbidity. As a result, patients often are more likely to die of other causes than of prostate cancer.Currently, clinicians lack the tools to adequately estimate patient life expectancy, making it difficult to determine the likelihood of dying of malignancy vs. other causes. This leads to clinicians erring on the side of treatment, perhaps influenced by the patients’ anxiety associated with “watching” cancer. This contributes to the significant overdiagnosis and overtreatment seen in prostate cancer, and it has led to some organizations discouraging screening of asymptomatic men for prostate cancer.
The authors of this manuscript used SEER-Medicare data to examine the impact of age and comorbidity on the aggressive treatment of prostate cancer. Their results highlight the overtreatment of men with advanced age and comorbidity, finding that nearly a quarter of men aged ≥80 years with less than a 10-year life expectancy are treated aggressively. Another interesting finding was that these patients most often were treated with radiation therapy, perhaps because of the perceived low short-term morbidity of this modality. However, the decision to treat a patient with prostate cancer should be based on patient and disease factors rather than the morbidity of the particular treatment.
Future research is needed to more clearly identify the factors that contribute to the overtreatment of prostate cancer in patients with limited life expectancy. Furthermore, more accurate, easy-to-use clinical tools are needed to help physicians estimate life expectancy when considering therapy for these men. Hopefully, with increased education of both patients and providers, the burden of overtreatment of prostate cancer will be lessened, leading to a more favorable risk–benefit ratio in the management of this prevalent disease.
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