Increasing percentages of older men in the U.S. with intermediate-risk and high-risk prostate cancers are opting for treatments that carry potential side effects that can greatly diminish their quality of life without prolonging it, as reported in a recent study conducted by Cedars-Sinai. This trend raises concerns since these individuals may not live long enough to reap the benefits of more intensive treatments.
More older men in the U.S. diagnosed with intermediate-risk and high-risk prostate cancers are choosing therapies that pose significant risks of side effects, which can heavily impact their quality of life without extending their lifespan, according to a new Cedars-Sinai study. This growing trend is concerning, as many of these men may not have life expectancies sufficient to benefit from more aggressive treatment options.
The results of the study were published in the peer-reviewed journal JAMA Internal Medicine.
Prostate cancer ranks as the second-most prevalent cancer in the United States, second only to breast cancer. Approximately one in eight American men will be diagnosed with prostate cancer, with the average diagnosis age being 67, according to the National Cancer Institute. Most cases involve slow-growing tumors that are localized and unlikely to pose a significant threat to survival. Instead of immediate intervention, low-risk patients can opt for “active surveillance,” where regular exams and tests monitor the disease to ensure it is not advancing.
“Over the past 15 years, the adoption of active surveillance has risen for men with low-risk prostate cancer, making it the most common management strategy,” stated Timothy Daskivich, MD, director of Urologic Oncology Research at Cedars-Sinai’s Department of Urology and the corresponding author of the study. “This strategy helps patients evade the risks associated with urinary incontinence, erectile dysfunction, and other side effects linked to surgery and radiation therapy.”
Conservative management, which encompasses active surveillance and watchful waiting, is also advised for men with limited life expectancies who likely won’t benefit from aggressive local treatments, even for higher-risk cancers. However, the study noted a concerning shift in this area. Researchers analyzed extensive data from the Veterans Affairs health system and discovered that men with limited life expectancies and intermediate- and high-risk cancers are less frequently receiving conservative management and more often opting for aggressive treatments such as surgery or radiation.
“We found this trend unexpected,” Daskivich remarked. “Prostate cancer patients expected to live less than five or ten years are undergoing treatments that may not show significant survival benefits for up to a decade, despite guidelines recommending against such interventions.”
For their study, researchers reviewed medical data from 243,928 men within the Veterans Affairs health system who were diagnosed with localized prostate cancer from 2000 to 2019.
Among patients with an average life expectancy of less than 10 years, the percentage opting for treatments like surgery or radiation for low-risk prostate cancer dropped from 37.4% to 14.7%. In contrast, treatment for intermediate-risk prostate cancer rose from 37.6% to 59.8%. For patients with a life expectancy of less than five years, treatment for high-risk prostate cancer increased significantly from 17.3% to 46.5%. Notably, around 80% of those who received unnecessary treatments were subjected to radiation therapy.
Addressing the problem of overtreatment in higher-risk prostate cancer patients with limited longevity demands a comprehensive approach that includes improving life expectancy assessments, communication, and the integration of these estimates into treatment decisions, according to Daskivich. He and his team have put forward a “trifecta” approach for conveying cancer prognosis, where physicians discuss the likelihood of dying from cancer with and without treatment based on the patient’s estimated lifespan. This personalized method helps clarify the specific cancer risks pertinent to each patient.
“We aim to inspire healthcare providers to incorporate longevity into the treatment discussions, enabling prostate cancer patients with limited life expectancies to make informed choices,” Daskivich noted. “A patient may choose to proceed with surgery or radiation based on the information presented, while another may select a different path.”
“Each individual is unique, and average statistics about lifespan, treatment efficacy, and cancer risks do not guarantee specific outcomes,” Daskivich emphasized. “However, patients deserve the chance to make informed choices based on the best available information.”
Hyung L. Kim, MD, chair of the Department of Urology at Cedars-Sinai, mentioned that the JAMA Internal Medicine study underscores a key strength of Cedars-Sinai: the strong collaboration between researchers and clinicians. “Many of our investigators are also practicing clinicians, which helps ensure their research addresses real-world healthcare challenges and prioritizes finding effective solutions,” he stated.
Additional authors from Cedars-Sinai include Michael Luu and John R. Heard. The research also included contributions from I-Chun Thomas and senior author John T. Leppert from Stanford University and the VA Palo Alto Health Care System.
This study was partially funded by the VA Merit Review (I01 HX0021261 to JL). The Department of Veterans Affairs Health Services Research and Development Service supported this research using resources and facilities at the VA Informatics and Computing Infrastructure (VINCI), along with VA HSR RES 13-457. The findings do not represent the views of the U.S. Department of Veterans Affairs or the U.S. Government.
