Overtreatment of older men with prostate cancer raises concerns

Increasing percentages of some older U.S. men with intermediate-risk and high-risk prostate cancers are undergoing treatments that carry risks of side effects that can significantly reduce the quality of life without extending life, according to a new study led by Cedars-Sinai. This trend is problematic because these men may not have life expectancies that would allow them to receive the benefits of more aggressive treatments.

The research findings were published in the peer-reviewed journal JAMA Internal Medicine.

Prostate cancer is the second-most common cancer in the U.S., exceeded only by breast cancer. About one-eighth of U.S. men are diagnosed with prostate cancer at a median age of 67 according to the National Cancer Institute. Most patients have slow-growing, localized tumors, confined to the prostate gland, that are unlikely to threaten their lives. Instead of immediate treatment, these low-risk patients can be monitored through "active surveillance," in which examinations and tests are performed on a regular schedule to make sure the disease is not progressing.

Use of active surveillance has increased over the last 15 years for men with low-risk prostate cancer, and it is now the most common treatment for these men. This approach allows these patients to avoid the risks of urinary incontinence, erectile dysfunction and other potential side effects of surgery and radiation therapy."

Timothy Daskivich, MD, director of Urologic Oncology Research for the Cedars-Sinai Department of Urology and corresponding author of the new study

Conservative management, which includes active surveillance or watchful waiting, is also recommended for men with limited life expectancies who likely will not live long enough to benefit from aggressive local treatment, even for higher-risk cancers. However, for these men, the trend is going in the opposite direction, as measured by the investigators' analysis of extensive data from the Veterans Affairs health system. They found that for men with limited life expectancies and intermediate- and high-risk cancers, conservative management was being employed less often and that more were receiving aggressive local treatment with surgery or radiation.

"We found this pattern surprising," Daskivich said. "Prostate cancer patients with life expectancies of less than five or 10 years were being subjected to treatments that can take up to a decade to significantly improve their chances of surviving cancer, despite guidelines recommending against treatment."

For their study, the investigators analyzed medical data on 243,928 men in the Veterans Affairs health system who were diagnosed with localized prostate cancer between 2000 and 2019.

Among patients with average life expectancies of less than 10 years, the proportion who underwent treatments such as surgery or radiation for low-risk prostate cancer rather than receiving active surveillance decreased from 37.4% to 14.7%; but treatment for intermediate-risk disease increased from 37.6% to 59.8%. Among patients with average life expectancies of less than five years, treatment for high-risk disease increased from 17.3% to 46.5%. Among men who were overtreated, roughly 80% were treated with radiation therapy.

Solving the issue of overtreatment in higher-risk prostate cancer patients with limited longevity requires a multifaceted approach involving better estimation, communication, and integration of life expectancy into decision-making, Daskivich said. He and his team have proposed a "trifecta" method for communicating cancer prognosis to the patient. This method involves the physician discussing the likelihood of dying from the cancer with treatment versus without treatment at the endpoint of the patient's life expectancy. This approach personalizes the risk of the cancer that is relevant to each patient.

"Our goal is to encourage clinicians to make longevity part of the discussion about the best treatment options so that prostate cancer patients with limited life expectancies can make educated choices," Daskivich said. "A patient may be given this data and choose to pursue surgery or radiation treatments regardless of a limited probability of benefit. Another patient may take a different course."

"Every individual is different, and statistical averages for lifespan, treatment effectiveness and cancer risk cannot predict outcomes with certainty," Daskivich added. "But patients should be given the opportunity to make informed decisions with the best possible information."

Hyung L. Kim, MD, chair of the Department of Urology at Cedars-Sinai, said the JAMA Internal Medicine study reflects a signature strength of Cedars-Sinai: the close cooperation among researchers and clinicians. "Many of our investigators are themselves clinicians, which ensures that their research addresses real-life problems in healthcare with an emphasis on finding solutions," he said.

Other Cedars-Sinai authors include Michael Luu and John R. Heard. Other authors include I-Chun Thomas from Stanford University and senior author John T. Leppert from Stanford University in Stanford, California, and the VA Palo Alto Health Care System in Palo Alto, California.

This work was supported in part by VA Merit Review (I01 HX0021261 to JL). The Department of Veterans Affairs Health Services Research and Development Service work was supported using resources and facilities at the VA Informatics and Computing Infrastructure (VINCI), VA HSR RES 13-457. The contents do not represent the views of the U.S. Department of Veterans Affairs or the U.S. Government.