Two new studies have revealed alarming trends in prostate cancer treatment, highlighting both increasing overtreatment among older men and significant long-term complications from common interventions.
Research from Cedars-Sinai Medical Center shows that despite efforts to promote "active surveillance" for men with limited life expectancy, aggressive treatment approaches are becoming more common. Meanwhile, a separate study published in JAMA Oncology documents substantial long-term risks associated with prostate cancer treatments that many patients may not fully understand before making treatment decisions.
Overtreatment Trends in Older Men with Limited Life Expectancy
An analysis of nearly 244,000 men diagnosed with prostate cancer in VA hospitals between 2000 and 2019 revealed concerning patterns of overtreatment. While treatment for low-risk prostate cancers appropriately decreased from 37% to 15% during this period, interventions for intermediate-risk prostate cancer increased from 38% to 60%.
Most troubling was the finding that treatment for high-risk prostate cancer in men with average life expectancies of less than five years increased dramatically from 17% to 47%. Radiation therapy, which accounts for 80% of these treatments, saw usage increase from 16% to 39% among men with life expectancies under five years.
"We found this pattern surprising," said lead researcher Dr. Timothy Daskivich, director of urologic oncology research at Cedars-Sinai. "Prostate cancer patients with life expectancies of less than five or 10 years were being subjected to treatments that can take up to a decade to significantly improve their chances of surviving cancer, despite guidelines recommending against treatment."
This trend contradicts medical guidance promoting "active surveillance" or a "watch-and-wait" approach for patients who will likely die from other causes before their prostate cancer becomes life-threatening.
Serious Long-Term Complications from Treatment
The second study, published in JAMA Oncology, provides compelling evidence of the significant risks associated with prostate cancer treatments. Researchers analyzed data from more than 29,000 men who participated in National Cancer Institute studies, including 3,900 diagnosed with prostate cancer.
The findings were stark: men who underwent prostate surgery had more than six times greater risk of experiencing at least one major complication within 12 years compared to those who opted for no treatment. These complications included erectile dysfunction, incontinence, and other serious issues affecting quality of life.
Radiation therapy, while less risky than surgery, still tripled the 12-year risk of complications compared to foregoing treatment. These complications included similar urinary and sexual issues, as well as an increased risk of bladder cancer.
"Our study is distinguished by long follow-up, out to 12 years, looking at a broad spectrum of key complications," explained lead researcher Joseph Unger, an associate professor at Fred Hutch Cancer Center. "Critically, we were able to compare treated men to a representative control group of untreated men, which prior studies have not included."
Improving Patient Decision-Making
In response to these findings, researchers are advocating for better patient education before screening and treatment decisions are made.
"This study throws down a major gauntlet to all physicians to give patients this information before they even begin the process of drawing a PSA test," said Dr. Ian Thompson Jr., a urologist with the University of Texas Health Science Center at San Antonio who co-authored the complications study.
The Cedars-Sinai team has proposed a "trifecta" method for discussing prostate cancer prognosis with patients. This approach would include discussing the likelihood of dying from cancer with treatment versus without treatment, given the patient's individual life expectancy.
"Our goal is to encourage clinicians to make longevity part of the discussion about the best treatment options so that prostate cancer patients with limited life expectancies can make educated choices," Dr. Daskivich explained.
Implications for Clinical Practice
These studies highlight the critical importance of personalized medicine in prostate cancer care. While some patients may benefit significantly from aggressive interventions, others—particularly older men with limited life expectancy or those with low-risk disease—may suffer unnecessary harm from treatments that are unlikely to extend their lives.
The findings suggest that the current approach to prostate cancer treatment may be driven by factors beyond clinical necessity, potentially including financial incentives, defensive medicine practices, or insufficient consideration of patient quality of life.
"Every individual is different, and statistical averages for lifespan, treatment effectiveness and cancer risk cannot predict outcomes with certainty," Dr. Daskivich noted. "But patients should be given the opportunity to make informed decisions with the best possible information."
As the medical community continues to refine prostate cancer treatment guidelines, these studies underscore the importance of shared decision-making that fully accounts for both the potential benefits and harms of intervention, particularly for older patients and those with competing health risks.
