Many older men with prostate cancer and limited life expectancy are overtreated
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Key takeaways:
- Many men with lower life expectancy and localized prostate cancer get overtreated.
- Rates of definitive treatment have increased for men with intermediate-risk and high-risk disease.
More men with limited life expectancy and certain localized prostate cancers have received definitive treatment over the past 2 decades despite shifts toward active surveillance, according to results of a retrospective study.
Clinicians treated veterans with limited life expectancy and low-risk disease at significantly lower rates in 2019 compared with 2000, but those with intermediate- or high-risk tumors received therapy more often.
“Physicians and patients should be aware that the risk for overtreatment is not just due to overly aggressive treatment of low-risk cancers, but also due to overly aggressive treatment of men who may not live long enough to benefit from treatment — even for higher-risk cancers,” Timothy J. Daskivich, MD, MSHPM, associate professor and director of health services research in the surgery department at Cedars-Sinai Medical Center, told Healio.
Background and methods
Men with localized prostate cancer do not gain a mortality benefit from treatment for roughly 8 to10 years, Daskivich said.
Consequently, prostate cancer guidelines have recommended against definitive treatment for men who have intermediate-risk disease and a life expectancy of less than 10 years, as well as for those with high-risk cancer who have a life expectancy of less than 5 years, he added.
“However, these men often pursue local treatment to avoid potential risk of the cancer, even if the risks of the cancer are low or negligible over their projected longevity,” Daskivich said. “We initially published on this topic 10 years ago and showed that roughly half of men with life expectancies of less than 10 years were treated with definitive local treatment in the early 2000s era. However, since that time, there has been a sea change in how men with low-risk cancers are managed — now favoring active surveillance as an upfront approach.”
Daskivich and colleagues investigated whether the shift toward watchful waiting has led to a decrease in overtreatment.
Their analysis included men in the Veterans Affairs health system who had been diagnosed with localized prostate cancer between 2000 and 2019.
The cohort consisted of 243,928 men (mean age, 66.8 years; standard deviation, 8). Of those, 20.5% had a life expectancy of less than 10 years, and 4.7% had a life expectancy of less than 5 years.
Trends of definitive treatment, surgery or radiotherapy for men with limited life expectancy served as the primary endpoint.
Results and next steps
The percentage of men with life expectancy of less than 10 years and low-risk disease who received definitive treatment declined from 2000 to 2019 (37.4% vs. 14.7%; absolute change = 22.7%; 95% CI, 30 to 15.4; P < .001).
However, the percentage of men with life expectancy of less than 10 years and intermediate-risk cancer who received definitive treatment increased from 2000 to 2019 (37.6% vs. 59.8%; absolute change = 22.1%; 95% CI, 14.8-29.4; P < .001). This trend persisted for those with favorable intermediate-risk disease (32.8% vs. 57.8%; P < .001) and unfavorable intermediate-risk disease (46.1% vs. 65.2%; P = .01).
Most men (78%) with life expectancy of less than 10 years who received definitive therapy underwent radiotherapy. Radiotherapy use increased among men with a life expectancy of less than 10 years and intermediate-risk cancer from 2000 to 2019 (31.3% vs. 44.9%; absolute change = 13.6%; 95% CI, 8.5-18.7; P < .001).
The percentage of veterans with a life expectancy of less than 5 years and high-risk disease who received definitive treatment increased from 2000 to 2019 (17.3% vs. 46.5%; absolute change = 29.3; 95% CI, 21.9-36.6; P < .001), as well.
Most of these men received radiotherapy (85%), and radiotherapy usage increased among this population from 2000 to 2019 (16.3% vs. 39%; absolute change = 22.6%; 95% CI, 16.5-28.8; P < .001).
“Physicians may fail to include average life expectancy when advising patients on treatments because they believe that the patients do not want to discuss this topic,” Daskivich said. “In fact, recent research by our team found that providers often do not provide quantified information on average life expectancy when counseling patients with prostate cancer. Yet, in interviews with patients, we found that patients with prostate cancer reported they wanted this information. Efforts at solving this issue will no doubt require a multifaceted approach, including improving access to life expectancy data at the point of care for providers, educating providers on how to communicate this information, and improving data sources to predict longevity.”
Researchers acknowledged study limitations, including the cohort consisting of only veterans and lack of data to determine the cause of these trends.
“We need more data on the drivers of this problem — whether it is primarily a patient-driven phenomenon or doctor-driven phenomenon,” Daskivich said. “We are also doing work to help doctors improve their communication of key factors for decision making such as cancer risk and life expectancy.”
The first step to stopping overtreating is the cessation of overscreening, Nancy Li Schoenborn, MD, associate professor of medicine at Johns Hopkins University School of Medicine, and Louise C. Walter, MD, professor of medicine at University of California, San Francisco, wrote in an accompanying editorial.
“We need to integrate existing tools into routine practice to help clinicians determine life expectancies at the time of decision-making, promote multifaceted messaging to patients about the nontrivial harms that may emanate from cancer screening and treatment, and help everyone remain focused on a patient’s current life-limiting illnesses rather than distracting from this care by searching for asymptomatic localized prostate cancer,” they wrote.
References:
- Daskivich TJ, et al. JAMA Intern Med. 2024;doi:10.1001/jamainternmed.2024.5994.
- Schoenborn NL, et al. JAMA Intern Med. 2024;doi:10.1001/jamainternmed.2024.6020.
For more information:
Timothy J. Daskivich, MD, MSHPM, can be reached at timothy.daskivich@cshs.org.
Reference:
Fox Chase Cancer Center. Cancer prediction tools. Available at: https://cancernomograms.com/nomograms.
Perspective
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J. Ryan Mark, MD, FACS
Prostate cancer treatment can significantly impact a man's urinary and sexual function. These risks are justified when the aim is to cure a life-threatening condition or prevent future metastatic symptoms. However, when prostate cancer is unlikely to cause symptoms or lead to death, the potential disadvantages of treatment may surpass its benefits.
For indolent, low-risk prostate cancer, active surveillance is endorsed by all major treatment guidelines and widely recognized and accepted by the public, but the aggressiveness of the cancer is not the sole consideration. The likelihood of prostate cancer progressing to symptomatic disease or death also depends on the life expectancy of the man diagnosed.
Discussing these issues with my patients can be difficult, but I have found the tools available from Fox Chase Cancer Center at www.cancernomograms.com to be very helpful. These resources include life expectancy calculators that factor in a man's risk for prostate cancer progression, age and other health considerations, offering men and their families the essential context needed to make informed decisions regarding prostate cancer treatment.
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