Men with low life expectancy continue to be overtreated for prostate cancer

Men with lower life expectancy (LE) who have intermediate to high-risk prostate cancer are being over-treated. And talking to patients about LE is still something doctors grapple with.Overtreatment is something that can adversely impact the quality of life for these men’s remaining years with little to no benefit, according to Dr. Timothy Daskivich. He is the lead author of a study investigating whether or not conservative management is being appropriately used in patients with limited LE. Dr. Daskivich is a urologist and associate professor of urology at Cedars-Sinai Medical Center in Los Angeles.The study, published in JAMA Internal Medicine, found that over the past two decades the numbers of men with limited life expectancy being over-treated have skyrocketed in those who have intermediate to high-risk disease. On the other hand, it also found that overtreatment of low-risk prostate cancer with surgery or radiotherapy has decreased across the board in men with both longer and shorter LE.Higher morbidityThe issue is that men with limited LE are not only less likely to live long enough to benefit from treatment, but they have higher morbidity after treatment, and decreased treatment effectiveness, he told CHN in an interview.Since the early 2000s, there has been increasing use of active surveillance as the primary treatment option for men with low-risk prostate cancer. In the U.S., low-risk cases represent about half of the cases overall. The question was whether overtreatment of men with limited LE was reduced.And yet, as the study points out, “During the last decade, LE has been formally incorporated into PC (prostate cancer) treatment guidelines, which recommend against aggressive therapy for those with an LE of less than 10 years and low-risk and some intermediate-risk PC and those with an LE of less than five years and high-risk PC.” According to Dr. Daskivich, there are two basic issues. “One is focused on not treating a cancer that is not likely to be harmful, ever. The other is avoiding treatment of cancer in men who won’t live long enough to get harmed from the cancer. Even if that cancer is higher risk there are still some men who are at risk of dying before they even get harmed by a cancer,” he said.“So why treat it and expose themselves to the morbidities of treatment?” he said.The study was conducted to determine whether the trend toward active surveillance for low-risk cancer impacted the overtreatment of men with limited LE. The issue is that men with limited LE are not only less likely to live long enough to benefit from treatment, but they have higher morbidity after treatment, and decreased treatment effectiveness, he told CHN in an interview.Since the early 2000s, there has been increasing use of active surveillance as the primary treatment option for men with low-risk prostate cancer. In the U.S., low-risk cases represent about half of the cases overall. The question was whether overtreatment of men with limited LE was reduced.And yet, as the study points out, “During the last decade, LE has been formally incorporated into PC (prostate cancer) treatment guidelines, which recommend against aggressive therapy for those with an LE of less than 10 years and low-risk and some intermediate-risk PC and those with an LE of less than five years and high-risk PC.” According to Dr. Daskivich, there are two basic issues. “One is focused on not treating a cancer that is not likely to be harmful, ever. The other is avoiding treatment of cancer in men who won’t live long enough to get harmed from the cancer. Even if that cancer is higher risk there are still some men who are at risk of dying before they even get harmed by a cancer,” he said.“So why treat it and expose themselves to the morbidities of treatment?” he said.The study was conducted to determine whether the trend toward active surveillance for low-risk cancer impacted the overtreatment of men with limited LE.When trends from 2000 to 2019 were analyzed, it was found that when it came to men who were expected to live less than 10 years, the proportion who were treated with definitive therapy for low-risk disease decreased significantly from 37.4% to 14.7%. But it increased for intermediate-risk disease from 37.6% to 59.8%. You can read the full study in JAMA Internal Medicine.Among patients with an LE of less than 10 years who got definitive therapy, 78%, were treated with radiotherapy. Not only that, but the use of radiotherapy increased from 31.3% to 44.9% in those with intermediate-risk disease. Increases were seen for both favourable and unfavourable intermediate-risk disease. Using data from the Veterans Affairs health system, the study included 243,928 men with clinically localized prostate cancer who had received a diagnosis between January 1, 2000, and December 31, 2019. Their mean age was 66.8 (8.0) years. Of the population, 50,045 (20.5%) and 11,366 (4.7%) had an LE of less than 10 years and LE of less than 5 years respectively. Determination of LE was based on the age-adjusted Prostate Cancer Comorbidity Index (PCCI). The PCCI, developed by Dr. Daskivich in 2011, is modeled after the Charlson Comorbidity Index and uses a combination of age and comorbidities to create a score used to estimate risk of death from other non-prostate cancer causes over the long-term. The PCCI is used just for prostate cancer patients.The treatments the men underwent were divided into two groups: definitive local treatment which consisted of radical prostatectomy and radiotherapy; conservative management which consisted of active surveillance or watchful waiting. Data were also sorted according to tumor severity: low, intermediate or high risk.Among men with an LE of less than five years, the proportion of men treated with definitive treatment for high-risk disease jumped from 17.3% to 46.5%. And among these men, 85% got radiotherapy. The findings were a surprise. “As physicians got more comfortable with surveillance and conservative management over the last 10 years, I thought the problem would have potentially not have been resolved, but maybe not have gotten worse,” Dr. Daskivich said.And yet guidelines use LE as a first triage point in deciding who should get treatment.The trend may reflect physician discomfort with communicating life expectancies with patients, he speculated. He noted that doctors are not trained in how to communicate this information.Arbitrary time pointIn a previous study in the Journal of Urology, Dr. Daskivich and his team studied what doctors actually said to patients. It was found that about a third of the time doctors either omit LE information or overgeneralize it by saying things like “Your LE is long or short,” without more details. Another third of the time they quote LE as being some arbitrary time point such as 10 or 15 years, which is not patient-specific.“Only about 20% of the time do they do it in a way that we think is best. And that’s where you quote the risk of the cancer at the patient’s actual life-expectancy,” he said. While some may consider that harsh, it turns out most patients want the gritty details. This was determined in another study he worked on in which prostate cancer patients were interviewed.“We found about 80% of patients want to hear life expectancy in their consultation, and they wanted it quantified so they could wrangle with the numbers. It is something patients want to hear. This may not be what’s wanted with other conditions, but with prostate cancer it is,” he said. They are very interested in maximizing a better quality of life.“I counsel a lot of these people. It’s not such a weighty thing. A lot of people, especially when they’re older, realize they’re not going to live forever. And when you get diagnosed with a cancer that might harm you in 15 or 20 years and you’re 75 or 80 years old, you think ‘why would I risk the quality of my life for my remaining years to chase after something that’s highly unlikely to harm me during my lifetime?’. People do see the logic of this,” he said.Dr. Laurence Klotz of the Canadian Urological Association stated that overall, “Canadian physicians have adopted active surveillance more consistently than any other country in the world. About 90% of low grade (Grade Group 1) prostate cancer patients in Canada are offered this approach.” And that generally this is about the right proportion. “Doctors should provide patients with accurate information on the pros and cons of the various treatment options and help them make an appropriate decision that aligns with their values and priorities,” he said.

Men with low life expectancy continue to be overtreated for prostate cancer

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