Overtreatment of older men with prostate cancer may reduce quality of life without increasing life length

According to a new study led by Cedars-Sinai, an increasing number of older men with intermediate- and high-risk prostate cancer are receiving treatment with a risk of side effects that can significantly reduce quality of life without increasing longevity. This trend is problematic because these men may not achieve a life span that would justify the benefits of more aggressive treatment.

The results of the study were published in the peer-reviewed journal JAMA Internal Medicine.

Prostate cancer is the second most common cancer, second only to breast cancer.

In most patients, tumors are slow growing, localized in the prostate gland, and hardly life threatening. Instead of immediate treatment, these low-risk patients may be kept under “active surveillance,” in which regular checkups and tests are needed to make sure the disease is not progressing.

Active surveillance for men with low-risk prostate cancer has become increasingly common over the past 15 years and is now the most common treatment option for these men. This approach allows these patients to avoid the risk of urinary incontinence, erectile dysfunction and other potential side effects of surgery and radiation therapy.

Conservative treatment, including active surveillance or a wait-and-see approach, is also recommended for men with a short life expectancy who are unlikely to live long enough to benefit from aggressive local treatment, even for high-risk cancers. However, for these men, the trend is reversed: in men with limited life expectancy and intermediate- to high-risk cancers, conservative treatment is used less often and aggressive local treatment with surgery or radiation is used more often.

“We found a surprising pattern,” said the responsible researcher. – “Patients with prostate cancer whose life expectancy is less than five or ten years were treated with treatments that can take up to ten years to significantly improve their chances of survival, despite recommendations against such treatments.”

For the study, researchers analyzed medical data on 243,928 men from the Veterans Administration health care system who were diagnosed with localized prostate cancer between 2000 and 2019.

Among patients with a mean life expectancy of less than 10 years, the proportion of those who underwent surgery or radiation treatment for low-risk prostate cancer in lieu of active surveillance decreased from 37.4% to 14.7%, while the proportion of patients treated for intermediate-risk disease increased from 37.6% to 59.8%.

Addressing overtreatment of high-risk prostate cancer patients with limited life expectancy requires a multifaceted approach that includes more accurate assessment, information, and consideration of life expectancy in decision-making, the researchers said. Researchers have proposed a “trifecta” method for informing the patient about cancer prognosis. This method involves the physician discussing the likelihood of dying from cancer with and without treatment at the endpoint of the patient’s life expectancy. This approach allows personalization of cancer risk relevant to each patient.

“Our goal is to encourage clinicians to make life expectancy part of the discussion about the best treatment options so that patients with prostate cancer with limited life expectancy can make an informed choice,” says the principal investigator. – “A patient may receive this data and decide on surgery or radiation therapy, despite the limited likelihood of benefit. Another patient may choose a different path.”

Each person is different, and statistical averages of life expectancy, treatment efficacy, and cancer risk cannot predict outcomes with certainty. But patients should be empowered to make informed decisions with as much information as possible.