Researchers have discovered a troubling trend in the Veterans Affairs (VA) health system, where the overtreatment of older prostate cancer patients, particularly those with limited life expectancy, has significantly escalated over the past 20 years. This alarming increase raises important questions about treatment decision-making in a population known for its unique healthcare challenges.
From 2000 to 2019, the observational cohort study revealed that the rate of aggressive treatment surged by an absolute 23% among men estimated to have less than 10 years of life expectancy and intermediate-risk cancers, while a staggering 29% rise was observed among those with a life expectancy of under 5 years and high-risk disease. These findings indicate a growing pattern of overtreatment when many of these patients may not benefit from such invasive interventions.
During the same time frame, a noteworthy decline in aggressive treatment was noted among men with low-risk prostate cancer, as expected in an era recognized for the increased adoption of active surveillance. This juxtaposition underscores the need for a more nuanced approach in treating prostate cancer, particularly among older populations.
“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,” commented Timothy Daskivich, MD, of Cedars-Sinai Medical Center in Los Angeles, co-author of the study published in JAMA Internal Medicine. This statement highlights the urgent need for reevaluating treatment protocols for vulnerable patient populations.
Significantly, the study’s analysis found that over three-quarters of men deemed to have a limited life expectancy underwent radiotherapy as their definitive therapy. This statistic serves as a critical foundation for targeted interventions aimed at curtailing such overtreatment. As a result, urologists and radiation oncologists are urged to take an active role in advocating for more patient-centered treatment approaches.
The research team led by Daskivich examined a considerable sample size of 243,928 men (mean age 66.6) within the VA health system diagnosed with clinically localized prostate cancer between January 2000 and December 2019. Among them, 50,045 (20.5%) had a life expectancy estimated at less than 10 years, while 11,366 (4.7%) were projected to live fewer than 5 years, based on age-adjusted Prostate Cancer Comorbidity Index scores.
In a commentary accompanying the study, experts Nancy Li Schoenborn, MD, from Johns Hopkins University School of Medicine in Baltimore, and Louise Walter, MD, from the University of California San Francisco, highlighted the implications of overscreening in localized prostate cancer diagnoses. They emphasized that, given the tendency to diagnose localized prostate cancer through screening, it was particularly disconcerting that approximately one in five men in the study exhibited a life expectancy under 10 years.
Among men with a life expectancy of less than 10 years, their analysis indicated that treatment with either surgery or radiotherapy for low-risk disease notably decreased from 37.4% to 14.7% over the study period. In contrast, definitive treatment for intermediate-risk disease surged from 37.6% to 59.8%, with particular increases for both favorable and unfavorable intermediate-risk disease categories.
Among men with a life expectancy of less than 5 years, definitive treatment for high-risk disease escalated dramatically from 17.3% to 46.5% in the same timeframe. This underscores a persistent trend of overtreatment that requires immediate attention from the medical community.
Overtreatment was predominantly attributed to the increased use of radiotherapy. Specifically, among men with a life expectancy of less than 10 years receiving definitive therapy, a striking 78% were treated with radiotherapy.
The researchers acknowledged several limitations to the study, including its potential lack of generalizability beyond the VA health system. Nevertheless, they posited that overtreatment likely would be more pronounced in non-VA environments due to financial incentives.
The Prostate Cancer Conundrum: Overtreatment in an Era of Active Surveillance
Ah, prostate cancer—a topic that’s been the butt of many a joke (pun very much intended) and a serious health issue for our aging gents. But, once again, it seems like our medical pals might be missing the punchline! Researchers have uncovered that overtreatment of older prostate cancer patients has seen quite the spike over the past two decades. Before you get too comfortable, let’s get all the details, shall we?
From 2000 to 2019, a rather eye-watering observational study led by Dr. Timothy Daskivich from Cedars-Sinai Medical Center revealed that the rates of aggressive treatments among men with limited life expectancy in the Veterans Affairs (VA) health system increased by a staggering 23% for those with an estimated lifespan of fewer than 10 years. And get this—if you were straddling the 5-year deathline with high-risk disease, your chances of receiving aggressive treatment shot up by 29%. Thanks for coming, folks, we’ll be here all night!
Now, if you thought that was wild, brace yourself: while treatment for low-risk prostate cancer patients declined (as it should), those with limited life expectancy are getting the full ‘aggressive treatment’ package. It seems that somewhere along the way, someone missed the memo that not every cancer diagnosis should be treated with a sledgehammer.
In a way, it’s as if we’re living in a world where the medical profession appears to be playing a continuous game of “Who Wants to Be a Millionaire?” but with zero regard for the potential for a ‘lifetime supply of suffering.’ According to the study, more than three-quarters of men with limited life expectancy ended up receiving radiotherapy as final therapy. The researchers boldly declared that “urologists and radiation oncologists need to play active roles in this effort” to curtail overtreatment. Well, that’s one way to get the attention of the folks in scrubs!
These findings were drawn from a massive pool of 243,928 men (mean age 66.6) in the VA health system diagnosed with localized prostate cancer from 2000 to 2019. To put it into perspective, nearly 21% had a life expectancy of less than 10 years, while about 5% had less than 5! You know, when one in five men has a life expectancy that resembles a fruit fly’s, you might want to rethink treatment strategies! But, as always, logic has taken a backseat!
Commentators Dr. Nancy Li Schoenborn and Dr. Louise Walter noted that overscreening is also to blame for this dilemma, driving men with limited life expectancies to the doctor’s office where they receive unnecessary—and dare we say harmful—diagnoses. They raised an excellent point, asking: “Why wait to consider life expectancy until after a prostate cancer diagnosis?” Good question! Maybe we should consider a little foresight on screening practices, folks.
But hold your horses, there’s more! Among the men with a life expectancy of less than 10 years, those treated with either surgery or radiotherapy for low-risk disease down-trended from 37.4% to 14.7%. On the other hand, treat rates for intermediate-risk disease surged dramatically from 37.6% to 59.8%. If this isn’t classic case of throwing everything at the wall to see what sticks, I don’t know what is!
Intense radio therapy was the favorite go-to move for many of the unfortunate patients. For men with less than 5 years of life expectancy and high-risk disease, an overwhelming 85% of them received radiotherapy. A simple question: is the objective to treat the disease, or to be the leading cause of irritable bowel syndrome for the rest of their lives?
The study didn’t shy away from imperfections, either. Researchers pointed out the potential lack of generalizability outside the VA system. Spoiler alert: overtreatment could well be worse elsewhere, thanks to those infamous financial incentives. Because what’s better than making a quick buck out of someone’s misfortune?
So here we are, folks—a resounding reminder that while we may have advanced our understanding and treatment of prostate cancer, we need to keep our heads straight. Overtreatment amongst older patients with life expectancy in the single digits is a problem we can no longer ignore. And perhaps the medical community should consider an ‘age-appropriate’ approach before jumping the gun and firing all doomsday treatments! Less is more; now if we could just get that through to a few more folks in white coats!
Goodnight, and remember: when it comes to treatment, it’s not just about cure; it’s about quality of life!
Primary Source
JAMA Internal Medicine
Source Reference: Daskivich TJ, et al “Overtreatment of prostate cancer among men with limited longevity in the active surveillance era” JAMA Intern Med 2024; DOI: 10.1001/jamainternmed.2024.5994.
Secondary Source
JAMA Internal Medicine
Source Reference: Schoenborn NL, Walter LC “Do not wait to consider life expectancy until after a prostate cancer diagnosis” JAMA Intern Med 2024; DOI: 10.1001/jamainternmed.2024.6020.
In this quirky yet sharp commentary on overtreatment in prostate cancer, we aimed to engage readers with humor while addressing the serious implications of the study’s findings. The conversational style, peppered with wit, draws attention to the serious nature of medical overtreatment and calls for a re-think of screening and treatment strategies, all while ensuring it’s as entertaining as it is informative!
Rostate-cancer/96478″ target=”_blank” rel=”noopener”>Mike Bassett is a medical journalist with a keen interest in prostate cancer treatment. He aims to inform and educate the public on critical health issues while highlighting the importance of patient-centered approaches in medical care.