Steering Clear of Unnecessary Prostate Cancer Treatments: A Guide to Smart Choices

Jan. 15, 2025 – Prostate cancer is rather prevalent – almost 60% of males aged 65 and above are affected – yet it does not rank high on the list of priorities for cancer researchers.

A major factor is that most men diagnosed with prostate cancer eventually succumb to other illnesses, as the cancer develops at a sluggish pace. 

For the last 15 years, there has been a significant rise in “watchful waiting,” a strategy whereby doctors observe the patient’s status without initiating treatment until symptoms manifest or intensify.

However, overtreatment of prostate cancer continues, evident in a recent study conducted by the U.S. Department of Veterans Affairs health system. Investigators reviewing data from 2000 to 2019 determined that the rate of surgical or radiotherapeutic interventions for low-risk cancer decreased from 37.4% to 14.7% among patients with a life expectancy of fewer than 10 years.

This data indicates a shift towards watchful waiting. Nevertheless, researchers also discovered the following: For those diagnosed with intermediate-risk prostate cancer, the proportion undergoing aggressive treatment increased from 37.6% to 59.8%. Among men with high-risk prostate cancer and a five-year life expectancy, treatment escalated from 17.3% to 46.5%.

The researchers deduced that “the overtreatment of men with limited life expectancy [LE] who have intermediate-risk and high-risk prostate cancer has amplified within the VA, primarily involving radiotherapy.” 

This is a crucial finding. More than half of men aged 65 and older – the typical age for prostate cancer diagnosis – possess a life expectancy of under 10 years. 

Although confined to the VA system, specialists assert that the overtreatment of men suffering from prostate cancer is at least equally prevalent beyond the veterans’ healthcare framework.

What implications does this hold for men generally? It underscores the importance of understanding the fundamentals – and knowing how to talk to your physician about your circumstances – which can significantly influence both the quality and duration of your life.

Initial Indicators and Common Treatments

Most men exhibit no symptoms in the early phases of prostate cancer. The first indication frequently comes from a prostate-specific antigen (PSA) blood analysis. If your PSA level is elevated, you might undergo a biopsy to ascertain whether you have prostate cancer or another condition such as benign prostatic hyperplasia (an enlarged prostate). If you are diagnosed with prostate cancer that is localized to the gland, your five-year survival rate is nearly 100%.

Evidence indicates positive outcomes when men diagnosed with low-risk or certain intermediate-risk prostate cancers opt for watchful waiting, also referred to as “active surveillance,” instead of immediate treatment. In this approach, the patient regularly consults with their physician, who assesses the growth of the cancer through blood tests, rectal examinations, and biopsies. No growth? No intervention.

When treatment becomes necessary, the predominant therapies involve radiation treatment and surgery to excise the prostate gland. The procedure typically eradicates localized cancer, but it may lead to impotence or urinary incontinence – or both – which could be temporary or permanent.

Radiotherapy is generally safer compared to surgery and boasts a similar success rate. Nevertheless, potential side effects may encompass bowel, bladder, and sexual dysfunction, along with urinary burning, bleeding, and rectal bleeding occurring during or shortly after the procedure.

These are the fundamental aspects. Should you undergo screening for prostate cancer? And if diagnosed, what inquiries should you make to your doctor?

The Major Inquiry: Life Expectancy

While life expectancy plays a critical role in determining whether to treat prostate cancer, insufficient discussion regarding it occurs between physicians and patients, as stated by Michael Leapman, MD, MHS, an associate professor of urology at Yale School of Medicine. 

There are life expectancy calculators available, yet doctors seldom utilize them, he noted, which contributes to overtreatment. One issue is that longevity calculators are infrequently integrated into electronic health records. Consequently, a physician has to exit their electronic system, navigate to a website, and input all relevant patient information to obtain a life expectancy figure. “It can be somewhat challenging,” he commented.

The San Francisco VA Health Care System has an integrated multi-disease longevity calculator within the Epic electronic health record system it employs, according to Louise Walter, MD, head of geriatrics at the University of California, San Francisco, as well as at the San Francisco VA Health Care System.

However, she remarked that physicians seldom discuss life expectancy with patients, as the individuals may not wish to know their prognosis. “Some of my patients will inquire, ‘How long do I have left?’ and with others, when posed the question, ‘Do you want to know?’ they reply ‘No.’”

Leapman concurred. “Even when we possess a reliable estimate of life expectancy, I don’t feel we have a well-established method to communicate these matters to patients.”

Your Role in ‘Shared Decision-Making’

Approximately 30 years ago, as watchful waiting began gaining traction as a viable and ethical alternative for prostate cancer, medical professionals started to acknowledge the significance of “shared decision-making” between doctors and patients. This approach recognizes that patient values may carry as much weight as the technical expertise of physicians.

However, numerous medical practitioners do not participate in authentic shared decision-making, Leapman asserted.

“Everyone engages in some level of it, but the conversation can be influenced by your viewpoint, depending on how you present the information,” he elaborated.

Extensive research indicates that the “primary influence” in determining whether to treat or monitor hinges on the specific physician you consult, Leapman stated: “If the dialogue initiates with theirrecommendation, it generally gets adhered to.”

Imagine that a biopsy reveals cancer. What’s your next step?

Consult your primary care physician first, rather than a urologist or a radiation oncologist.

Collaborative decision-making is more effective in this manner, stated Jen Brull, MD, president of the American Academy of Family Physicians (AAFP). “Those discussions tend to be more challenging for specialists because they lack an enduring relationship with the patient to establish this dialogue,” she mentioned.

A urologist usually performs the biopsy, so the patient may anticipate discussing possible treatments at that time. However, this often results in an incomplete conversation.

“Urologists and radiation oncologists assume, ‘The primary care physician referred them to me, so they must have already had that conversation,’” Walter observed. If a primary care physician makes a referral, she noted, “they should be very clear about needing the specialist’s assistance in deciding whether to recommend this treatment or not. Most specialists interpret a referral as, ‘We’re proceeding with this.’”

Express your values clearly. Brull has witnessed patients in succession with identical diagnoses and risk factors, “and they might make different choices based on what matters to them and how they interpret the same information. It’s crucial in these discussions to gather feedback from the patient: ‘Share your questions, share your concerns, and let’s delve deeper into that.’ That’s the kind of dialogue that assists patients in determining what decision they wish to make.”

Do some research. Gather as much information about the illness as possible so you can pose the appropriate questions. Useful resources include medical society websites such as the AAFP, the American Cancer Society, and the American Urological Association. Moreover, consider patient decision aids (PDAs) from Ottawa Hospital and the Washington State Health Care Authority. PDAs have demonstrated their ability to enhance patients’ understanding of health conditions, facilitate choices that align with their values, and cultivate more accurate perceptions of risk.

Should You Undergo Screening?

One approach to mitigate overtreatment, Walter indicated, might involve discussing potential repercussions prior to consenting to a PSA test. She advises that physicians inform patients that a positive result could lead to additional tests and procedures which may be unnecessary or not advised.

She emphasized that a national survey revealed nearly half of men over 70 with a life expectancy under 10 years reported being screened for the condition – despite clinical guidelines advising against it. Indeed, the guidelines from the AAFP and the U.S. Preventive Services Task Force recommend against PSA cancer screening for men at any age.

Older men generally deal with multiple health issues, and it could be more vital to concentrate on those, she remarked. In a commentary on the VA study, Walter stated that time devoted to diagnosing, observing, and treating asymptomatic prostate cancer in men with limited life expectancy “diverts attention from managing and treating their symptomatic life-limiting illnesses.”

In addition, she pointed out that the negative side effects of prostate cancer treatments are generally more severe in men with shorter longevity.

After the Preventive Services Task Force issued its recommendation, Brull remembered that her practice adopted a shared decision-making framework. She began asking patients if they wished to be screened, “given that our experience suggests that low-risk individuals likely endure more harm than benefit.”

Leapman concurs. “Screening is fundamentally the concern. The majority of these cancers referenced in that VA research – those that are treated unnecessarily – would likely never manifest during the patient’s lifetime. Furthermore, a significant amount of screening occurs outside of clinical guidelines. We’re screening individuals who surpass the recommended age threshold [70] and above the suggested life expectancy limit.”

Prioritize Key Concerns

Here are some essential takeaways for elderly men.

• Ensure that you have a primary care physician, and discuss the prostate cancer topics with that physician prior to undergoing a PSA test.
• Request a second test if the initial one is positive, as it may yield a false positive.
• If you receive a prostate cancer diagnosis, inquire with your doctors about watchful waiting.
• Demand shared decision-making with your doctor.
• “Have someone accompany you to the appointment because it’s a lot to take in,” Walter advised. “Do not hesitate to ask questions if you find something unclear with the doctor.”