Study indicates overtreatment of men with prostate cancer and limited life expectancy

Findings from a recent cohort study indicate that men with intermediate- to high-risk prostate cancer and a limited life expectancy may be increasingly overtreated in the Veterans Affairs (VA) health system.¹

Timothy J. Daskivich, MD

In the era of active surveillance, the investigators sought to evaluate the use of definitive treatment (surgery or radiation) across different stages of prostate cancer.

“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,” explained lead author Timothy J. Daskivich, MD, director of Urologic Oncology Research for the Cedars-Sinai Department of Urology, Los Angeles, California, in a news release on the findings.² “This approach allows these patients to avoid the risks of urinary incontinence, erectile dysfunction, and other potential side effects of surgery and radiation therapy.”

This approach is also recommended for patients with limited life expectancies so that they may avoid unnecessary toxic effects when they have insufficient longevity to enable them to benefit from treatment, the authors note.

For the study, the investigators identified 243,928 men with clinically localized prostate cancer in the VA health system. The average age of patients was 66.8 years. In total, 50,045 patients (20.5%) had a life expectancy less than 10 years, and 11,366 patients (4.7%) had a life expectancy of less than 5 years.

Among those with a life expectancy of less than 10 years, the proportion of men who received definitive treatment for low-risk disease decreased from 37.4% in 2000 to 14.7% in 2019 (absolute change, −22.7%; 95% CI, −30.0% to −15.4%). However, the proportion of men receiving definitive treatment for intermediate-risk disease increased from 37.6% to 59.8% in the same timespan (absolute change, 22.1%; 95% CI, 14.8%-29.4%). These increases were noted both among patients with favorable (32.8%-57.8%) and unfavorable intermediate-risk disease (46.1%-65.2%).

Similarly, of those men with a life expectancy less than 5 years, the proportion of patients who received definitive treatment for high-risk disease increased from 17.3% in 2000 to 46.5% in 2019 (absolute change, 29.3%; 95% CI, 21.9%-36.6%).

Radiotherapy was the predominant treatment used in both men with a life expectancy of less than 10 years (78%) and a life expectancy less than 5 years (85%). The use of radiotherapy in patients with a life expectancy less than 10 years increased from 31.3% in 2000 to 44.9% in 2019 (13.6%; 95% CI, 8.5%-18.7%). Increases were noted both in patients with favorable and unfavorable intermediate-risk disease. Additionally, the use of radiotherapy in patients with a life expectancy of less than 5 years increased from 16.3% in 2000 to 39.0% in 2019 (absolute change, 22.6%; 95% CI, 16.5%-28.8%).

“We found this pattern surprising,” Daskivich added in the news release.² “Prostate cancer patients with life expectancies of less than 5 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.”

According to the authors, these findings highlight the importance of communication with patients regarding the risks and benefits of treatment for their own situation.

“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 concluded in the news release.² “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. But patients should be given the opportunity to make informed decisions with the best possible information.”

References

1. Daskivich TJ, Luu M, Heard J, Thomas IC, Leppert JT. Overtreatment of prostate cancer among men with limited longevity in the active surveillance era. JAMA Intern Med. 2024:e245994. doi:10.1001/jamainternmed.2024.5994

2. Study: Older adult prostate cancer patients are increasingly being overtreated. News release. November 11, 2024. Accessed November 19, 2024. https://www.newswise.com/articles/study-older-adult-prostate-cancer-patients-are-increasingly-being-overtreated