Older men receiving aggressive prostate cancer treatment growing in number

In the past 2 decades, more and more men have been overtreated for intermediate- and high-risk prostate cancer despite having limited life expectancy, according to a large study.

For men with a life expectancy of less than 10 years (n=50,045), the percentage of those who received a surgical procedure or radiation therapy as opposed to undergoing active surveillance for low-risk disease dropped from 37.4 percent to 14.7 percent between 2000 and 2019. However, the percentage of those who received aggressive treatment for intermediate-risk disease rose from 37.6 percent to 59.8 percent. [JAMA Intern Med 2024;doi:10.1001/jamainternmed.2024.5994]

Likewise, for men with a life expectancy of less than 5 years (n=11,366), the percentage of those who received a surgical procedure or radiation therapy for high-risk disease jumped from 17.3 percent to 46.5 percent during the same period.

More than three-quarters of men with limited life expectancy who were overtreated had received radiotherapy (78 percent to 85 percent). The use of radiotherapy alone in these populations increased over time—by 13.6 percent among men with a life expectancy of less than 10 years and by 22.6 percent among those with a life expectancy of less than 5 years.

The analysis was based on medical data from 243,928 men (mean age 66.8 years) with localized prostate in the Veterans Affairs (VA) health system.

“During the last decade, life expectancy has been formally incorporated into prostate cancer treatment guidelines, which recommend against aggressive therapy for those with a life expectancy of less than 10 years and low-risk and some intermediate-risk [disease] and those with a life expectancy of less than 5 years and high-risk [disease],” the investigators noted. [J Natl Compr Canc Netw. 2022;20(12):1288-1298; J Urol. 2022;208(1):10-18]

“The fact that such overtreatment exists in a non–fee-for-service setting such as the VA (which has been a national leader in reducing overtreatment based on disease risk) suggests that the problem of overtreatment of men with limited life expectancy has not been solved in the active surveillance era, despite increasing numbers of men with low-risk prostate cancer receiving active surveillance,” the authors wrote in their paper. [JAMA 2018;319:2231-2233]

Longevity factored into treatment discussion

For first study author Dr Timothy Daskivich from the Cedars-Sinai Medical Center, Los Angeles, California, US, the findings of the study come as a surprise. “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.” [J Urol 2022;208:10-18; J Natl Compr Canc Netw 2023;21:1067-1096; Eur Urol 2017;71:618-629]

Solving the issue of overtreatment for intermediate- or high-risk prostate cancer in men with limited life expectancy requires a multifaceted strategy that involves improved communication and factors life expectancy into decision-making, as Daskivich pointed out. As such, he and his team proposed the “trifecta method,” a communication strategy for conveying competing risks of mortality, wherein a clinician should (1) estimate the patient’s risk of cancer mortality (2) with and without treatment (3) within the patient’s life expectancy. [J Urol 2024;279:679-683] 

“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. 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,” Daskivich said.

“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,” he added.