A recent cohort study examining prostate cancer treatments within the US Department of Veterans Affairs (VA) health system raises concerns about overtreatment, particularly among men with limited life expectancy (LE). Historically, these patients have been overtreated, contrary to guidelines which recommend cautious management to avoid exposing them to unnecessary side effects from aggressive therapies like surgery or radiotherapy. The advent of active surveillance – monitoring cancer progression closely rather than opting for immediate, aggressive treatment – has effectively reduced overtreatment in low-risk prostate cancer cases. However, for patients with intermediate-risk and high-risk prostate cancer and limited LE, overtreatment rates have paradoxically increased.
The study reviewed data from 243,928 men diagnosed with localised prostate cancer in the VA system between 2000 and 2019. It revealed that, over time, aggressive treatments for low-risk cases among men with LE under 10 years significantly decreased, from 37.4%–14.7%. This reduction is largely attributed to the VA’s adoption of active surveillance, which has shifted practice away from immediate, invasive interventions.
Conversely, in men with limited LE and intermediate or high-risk prostate cancer, overtreatment rates have risen sharply, primarily through increased use of radiotherapy. For instance, among those with an LE of fewer than 10 years and intermediate-risk disease, treatment rates rose from 37.6%–59.8%. The trend is even more pronounced in men with an LE of fewer than five years, where the rate of definitive treatment for high-risk disease escalated from 17.3%–46.5%. Radiotherapy accounted for the vast majority of treatments in these groups.
These findings underscore the need for clinicians to exercise caution when deciding on treatment for patients with limited LE, particularly in the active surveillance era. Although there has been progress in reducing overtreatment for low-risk prostate cancer, more careful consideration is needed for those with higher-risk tumours and reduced LE to prevent potentially harmful and unnecessary interventions.
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.
