Is Overtreatment of Prostate Cancer Still a Concern for Men with Limited Life Expectancy in the Active Surveillance Era?

In a retrospective cohort study conducted within the Veterans Affairs (VA) health system, researchers evaluated whether overtreatment of prostate cancer persists in men with limited life expectancy (LE) during the active surveillance era and how treatment trends vary by tumor risk and modality. The findings revealed a decline in overtreatment for low-risk disease but an increase for intermediate- and high-risk disease, predominantly through radiotherapy.

Prostate cancer management has evolved significantly during the past two decades, particularly with the adoption of active surveillance for low-risk disease. Despite these advancements, men with limited LE, or a LE of less than 10 years, remain at risk of overtreatment. This study aimed to quantify that risk for this population, and identify other populations at risk of overtreatment.

Researchers analyzed data from 243,928 men diagnosed with clinically localized prostate cancer between 2000 and 2019. LE was calculated using the Prostate Cancer Comorbidity Index (PCCI), a validated age-adjusted tool. The cohort's mean age was 66.8 years, and 20.5% of participants had an estimated LE of less than 10 years. Researchers assessed treatment trends over time using stratified regression models, examining variations across tumor risk levels (low, intermediate, high) and by treatment type (surgery or radiotherapy).

Over the study period, the proportion of men with limited LE receiving definitive treatment for low-risk prostate cancer dropped from 37.4% to 14.7%, reflecting a 22.7% absolute decrease (95% CI, −30.0% to −15.4%). Conversely, treatment rates for intermediate-risk disease increased from 37.6% to 59.8% (22.1%; 95% CI, 14.8%-29.4%), with rises in both favorable (32.8%-57.8%) and unfavorable (46.1%-65.2%) intermediate-risk categories.

Among men with high-risk disease and an LE of less than 5 years, definitive treatment increased from 17.3% to 46.5% (29.3%; 95% CI, 21.9%-36.6%). Radiotherapy was the predominant treatment modality; it was used in 78% of cases for those with LE under 10 years and 85% for those with LE under 5 years. Its use expanded particularly for intermediate-risk disease, rising by 13.6% (95% CI, 8.5%-18.7%) among men with LE under 10 years and by 22.6% (95% CI, 16.5%-28.8%) among those with LE under 5 years.

“The results of this cohort study suggest that, in the active surveillance era, overtreatment of men with limited LE and intermediate-risk and high-risk prostate cancer has increased in the VA, mainly with radiotherapy,” the study authors concluded.

Reference

Daskivich TJ, Luu M, Heard J, Thomas I, Leppert JT. Overtreatment of prostate cancer among men with limited longevity in the active surveillance era. JAMA Intern Med. Published online November 11, 2024. doi:10.1001/jamainternmed.2024.5994