Older Men Increasingly Overtreated for Prostate Cancer, Study Suggests

Overtreatment of older prostate cancer patients with a limited life expectancy has increased over the past two decades among men receiving care in the Veterans Affairs (VA) health system, researchers found.

From 2000 to 2019, their observational cohort study showed the rate of aggressive treatment increased by an absolute 23% among men with an estimated life expectancy less than 10 years and intermediate-risk cancers and by an absolute 29% among those with a life expectancy less than 5 years and high-risk disease.

At the same time, aggressive treatment declined in men with low-risk prostate cancer as might have been expected in an era marked by the increased use of active surveillance, reported Timothy Daskivich, MD, of Cedars-Sinai Medical Center in Los Angeles, and colleagues.

"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 researchers wrote in JAMA Internal Medicine.

More than three-quarters of the men with limited life expectancy got radiotherapy as definitive therapy, they found, an observation that "is critical to targeting interventions to curtail such overtreatment, and urologists and radiation oncologists need to play active roles in this effort."

The study from Daskivich and team included 243,928 men (mean age 66.6) in the VA health system who received a diagnosis of clinically localized prostate cancer from January 2000 to December 2019. A total of 50,045 (20.5%) men had an estimated life expectancy of less than 10 years, while 11,366 (4.7%) had a life expectancy of less than 5 years based on age-adjusted Prostate Cancer Comorbidity Index scores.

In a commentary accompanying the study, Nancy Li Schoenborn, MD, of the Johns Hopkins University School of Medicine in Baltimore, and Louise Walter, MD, of the University of California San Francisco, noted that because localized prostate cancer is likely diagnosed through screening, and that about one in five men in the study had a life expectancy under 10 years, the study also highlights the persistence of overscreening for prostate cancer.

"The authors discuss multiple suggestions for reducing overtreatment by considering life expectancy during treatment decision-making, but why wait to consider life expectancy until after a prostate cancer diagnosis?" Schoenborn and Walter asked. "Life expectancy should be considered during screening decision-making to reduce the number of men with limited life expectancy being diagnosed with asymptomatic localized prostate cancer in the first place."

Among men with a life expectancy of less than 10 years in the study, the proportion treated with either surgery or radiotherapy for low-risk disease decreased from 37.4% to 14.7% from 2000 to 2019. However, definitive treatment among men with intermediate-risk disease increased from 37.6% to 59.8%, with increases observed for both favorable intermediate-risk disease (32.8% to 57.8%) and unfavorable intermediate-risk disease (46.1% to 65.2%).

Among men with a life expectancy of less than 5 years, definitive treatment for high-risk disease increased from 17.3% to 46.5% from 2000 to 2019.

Overtreatment was mainly attributed to the use of radiotherapy.

Among men with life expectancy of less than 10 years who were receiving definitive therapy, 78% were treated with radiotherapy. Use of radiotherapy for men with a life expectancy of less than 10 years decreased from 30.9% to 10.1% for low-risk disease over the study period. However, use of radiotherapy in the same group of men increased from 31.3% to 44.9% for intermediate-risk disease, which included absolute increases of 19.7% and 14.5% in the use of radiotherapy for favorable intermediate-risk and unfavorable intermediate-risk disease, respectively.

In men with a life expectancy of less than 5 years with high-risk disease who received definitive treatment, the predominant treatment (85%) was radiotherapy. Use of radiotherapy in men with high-risk disease and a life expectancy of less than 5 years increased from 16.3% to 39%.

The researchers acknowledged several limitations to the study, including its potential for lack of generalizability outside the VA health system, "although overtreatment outside of the VA would be expected to be worse due to financial incentives."

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