Are we (still) over-treating older men with localized prostate cancer?

There is good reason to believe that a very high percentage of older men — particularly those over 75 years with low-risk prostate cancer who have a life expectancy of 10 years or less — will get little to no clinical or survival benefit from active therapeutic intervention (although they should clearly be carefully monitored and given all appropriate care).

However, it is also recognized that a high percentage of such men do, in fact, receive active therapeutic intervention.

Roberts et al. decided to conduct a structured analysis of the impact of clinical and non-clinical factors on the selection of active therapy for patients of 75 years and older who were newly diagnosed with localized prostate cancer in 2004 and 2005. To do this, they used data from the linked, population-based Surveillance, Epidemiology, and End Results (SEER) and Medicare databases. Active therapies included radical prostatectomy, external beam radiation therapy, brachytherapy, and/or androgen deprivation therapy.

The researchers were able to demonstrate the following:

  • In total, 81.7 percent of men of 75 years and older were treated with active therapy.
  • The application of active therapy varied by level of risk.
    • 86.4 percent of high-risk patients received active therapy.
    • 83.7 percent of intermediate-risk patients received active therapy.
    • 72.2 percent of low-risk patients received active therapy.
  • The overall impact of clinical and non-clinical factors on the decision to treat was minimal at 5.1 and 2.6 percent, respectively.
  • In men with low-risk disease, comorbidity status did not significantly affect treatment selection.
    • Low-risk patients with one comorbidity were just as likely to receive active therapy as healthy men (odds ratio [OR] =0.98).
    • Low-risk patients with two or more comorbidities were fractionally more likely to receive active therapy than healthy men (OR = 1.19).
  • Geographic location was the most powerful predictor of treatment selection (Northeast vs Greater California: OR = 2.41).

The authors conclude that, as of 2004/5, “Clinical factors play a limited role in treatment selection among elderly patients with localized prostate cancer.”

Whether we would see the same level of active treatment of men of 75 years and older today is perhaps open to question. In the past few years there has been much greater emphasis placed on the use of active surveillance in the management of men with a limited life expectancy and low-risk disease. However, it may be 5 years before we can obtain sufficient data from the SEER-Medicare linked database to establish whether there was a really significant increase in the use of surveillance as a method to manage low-risk prostate cancer in older men between 2005 and 2011.

2 Responses

  1. Both prostate cancer incidence and mortality rates are lower in Greater California than in any of the northeastern states. I am willing to bet (without having access to the full reference) that the great majority of “active treatment” in the study was related to androgen deprivation.

  2. There was a related article on this topic in a recent issue of JAMA. According to the research, in non-aggressive cases of prostate cancer, treatment provided no benefits to quality of life over active surveillance and similarly did not extend the life of the patient.

    $$ drives treatment far more than it should.

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