A new review of U.S. data on prostate cancer finds that despite established guidelines, a growing number of men who should not be getting aggressive treatment are getting it anyway.
Men with low-risk tumors and a life-expectancy of less than 10 years—for instance, men in their 80s or 90s—are not candidates for so-called curative therapies like radiation or prostate surgery because there’s little evidence it would benefit them.
Yet the proportion of men in that category receiving curative treatment rose between the late 1990s and late 2000’s, the study found. “In our society, cancer is probably the most feared disease.
The problem with prostate cancer is that most patients have a very non-aggressive form of cancer,” said Dr. Cary Gross of the Yale School of Medicine in New Haven, Conn.
According to Gross, the study’s senior author, the team expected to find that people less likely to benefit from treatment would receive fewer treatments, not more, over time. “What we found was the opposite of what we expected,” he said.
“These trends are actually moving in the opposite direction.” According to the American Cancer Association, there will be about 242,000 new cases of prostate cancer diagnosed in the U.S. in 2012.
They project about 28,000 men will die from the disease this year.
Practice guidelines from the National Comprehensive Cancer Network recommend active surveillance of men with low-risk tumors and a life expectancy of less than 10 years, but not active treatment.
For their research, Gross and his colleagues examined a database of cancer patients linked with Medicare information to identify men between 67 and 84 years old diagnosed with localized prostate cancer between 1998 and 2007.
They then looked at those who received treatment within nine months of their diagnoses.
Overall, of about 40,000 men with low-risk tumors, about 64 percent received treatment. Gross’ team used standard actuarial tables to determine the men’s life expectancy, and among those expected to live less than five years—about 3,600 men—the number who got treatment increased from about 38 percent in 1998-1999 to about 52 percent in 2006-2007.
The opposite trend was seen for about 12,000 men with longer life expectancies of ten years or more. In 1998-1999, about 81 percent of them received treatment but by 2006-2007 that number dropped to about 80 percent.
According to the researchers, not treating a potentially fatal illness can reflect poor care, but treating people with little hope for benefit puts the patients at an increased risk of disease and increased costs.
“Given widespread concerns about the rate of increase in Medicare expenditures, it is notable that the most substantial increase in treatment in our sample was noted among the patients who were least likely to benefit,” they write.
Gross said men should talk to their doctors about their risks and benefits after being diagnosed with prostate cancer. “When men are talking to their doctors, they should not just be asking ‘what type of treatment should I receive,’” he said.
The alternative for those with low risk cancer could be active surveillance, which means regular monitoring to make sure the cancer is not progressing. Even for doctors, the choice between treatment and active surveillance can be a tough one to make.
Dr. Charles Bennett, a practicing academic oncologist specializing in prostate cancer from South Carolina, wrote about his own experience of being diagnosed and treated for prostate cancer in the same issue of Archives of Internal Medicine.
Bennett wrote that at age 50 he decided to have prostatectomy, which is the removal of all or part of the prostate, after a blood test revealed increased prostate-specific antigen levels and a biopsy confirmed he had cancer. Five years after his surgery, Bennett writes that his right arm and leg are weak, making his former practice of jogging five miles daily impossible.
“If I could do it all over again, I would not undergo the surgery; instead, I would opt for active surveillance,” wrote Bennett. “Even the most informed patient (me in this case) has difficulty making a truly informed decision.” Dr. Eric Klein, chairman of the Glickman Urological and Kidney Institute at the Cleveland Clinic Lerner College of Medicine in Ohio, told Reuters Health that both patients and doctors don’t do enough surveillance.
“Patients and their families hear the word ‘cancer’ and think we need to treat it,” he said. A prostatectomy can cost over $12,000. Klein, who was not involved with the new study, said patients should not only discuss their blood tests with their doctor. They should also discuss how other risk factors, such as age and race, could affect their outcomes.
SOURCE: Archives of Internal Medicine, online February 27, 2012.
