Over the past two decades, many older men with prostate cancer and limited life expectancy have been receiving overtreatment, particularly those with intermediate- and high-risk disease, according to a retrospective study. Despite a broader shift toward active surveillance for low-risk cancers, the trend of definitive treatment for men with localized prostate cancer has remained prevalent, raising concerns about overmedicalization in a population with limited projected survival.
Key Findings and Trends
The study, which included nearly 244,000 veterans diagnosed with localized prostate cancer between 2000 and 2019, revealed a significant shift in treatment patterns. Although the percentage of men with low-risk disease and a life expectancy of less than 10 years receiving definitive treatment declined (from 37.4% in 2000 to 14.7% in 2019), those with intermediate- and high-risk cancers have increasingly received definitive treatments, such as surgery or radiotherapy.
The treatment rate for men with intermediate-risk cancer and less than 10 years of life expectancy increased dramatically from 37.6% in 2000 to 59.8% in 2019.
Similarly, the rate of definitive treatment for men with high-risk cancer and life expectancy of less than 5 years rose from 17.3% in 2000 to 46.5% in 2019.
The increase in radiotherapy use was particularly notable: among men with a life expectancy of less than 10 years and intermediate-risk cancer, radiotherapy usage rose from 31.3% in 2000 to 44.9% in 2019.
The Issue of Overtreatment
Experts like Dr. Timothy J. Daskivich, associate professor and director of health services research at Cedars-Sinai, argue that overtreatment is a problem not only for men with low-risk cancers but also for those who might not live long enough to benefit from treatment, even with higher-risk cancers. Prostate cancer treatment, particularly for localized forms, offers limited benefits for patients with less than 10 years of life expectancy, as survival improvements are often not seen until 8-10 years post-treatment.
“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,” Dr. Daskivich explained.
This raises the question of whether physicians are adequately considering patients’ life expectancy when recommending treatment options. Many older men, faced with the fear of cancer progression, still pursue aggressive treatments despite the fact that the cancer may not significantly affect their overall health in the near term.
Challenges in Communication
One of the key issues identified by the study is the gap in communication between doctors and patients. Dr. Daskivich pointed out that many physicians fail to provide quantified life expectancy information when counseling patients. Research from Daskivich’s team found that patients with prostate cancer expressed a desire for clear life expectancy data, but providers often fail to deliver it. Improving access to life expectancy data and enhancing communication between doctors and patients could be crucial steps in addressing overtreatment.
Call for Systemic Changes
Experts are calling for changes in clinical practice to reduce overtreatment, starting with improving how physicians communicate life expectancy and cancer risk with their patients. Both Dr. Nancy Li Schoenborn and Dr. Louise C. Walter, experts in geriatric medicine, emphasized the importance of integrating tools to estimate life expectancy into routine practice. They also called for a shift away from excessive screening, which could contribute to overtreatment by identifying cancers that would otherwise remain asymptomatic.
“Efforts must focus on educating clinicians about the harms of unnecessary treatment, promoting tools to predict life expectancy, and shifting the focus to managing patients’ current health status rather than seeking out asymptomatic localized cancer,” the two researchers wrote in an accompanying editorial.
Next Steps
While the study offers valuable insights, researchers stress the need for further investigation into the drivers of overtreatment, including whether it is primarily driven by patient demand or physician practices. Additionally, there is a need to explore ways to help doctors incorporate key factors—such as life expectancy—into their decision-making processes, ultimately aiming to improve the quality of care for older men with prostate cancer.
Reducing overtreatment in prostate cancer could significantly improve patients’ quality of life by focusing on treatment plans that better align with their overall health status and life expectancy. Moving forward, both clinical and cultural shifts will be essential in ensuring that men receive care that is not just aggressive but also appropriate to their circumstances.
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