Overtreatment of Prostate Cancer in the Active Surveillance Era

Kenny Lin, MD, MPH
Posted on December 9, 2024

Concerns about overdiagnosis of clinically insignificant prostate cancer through prostate specific antigen (PSA) screening motivated the 2018 American Academy of Family Physicians’ (AAFP) recommendation against routine screening for prostate cancer. Explaining the AAFP’s position, Drs. James Stevermer and Kenneth Fink wrote in an AFP editorial:

Few men diagnosed with and treated for prostate cancer will experience a mortality benefit, and an estimated 20% to 50% of those treated will never become symptomatic, even without treatment. This high rate of overdiagnosis from prostate cancer screening exposes many men to harms without any potential benefit.

Active surveillance is a management strategy that is intended to limit overtreatment of localized prostate cancer by monitoring patients with periodic PSA measurements and prostate biopsies to delay or avoid curative therapy (radical prostatectomy or radiation therapy) and its adverse effects. Watchful waiting refers to clinical observation only. A recent analysis of the U.S. Surveillance, Epidemiology, and End-Results (SEER) prostate cancer database found that among men with intermediate-risk prostate cancer (based on pathology and a PSA level lower than 20 ng/mL), active surveillance or watchful waiting increased overall from 5% in 2010 to 12.3% in 2020, with higher percentages of patients with more favorable pathology or lower PSA levels choosing one of these strategies. Of note, men older than 80 years were more than four times as likely to choose observation than men in their 50s (24.9% and 6.1%, respectively).

Another study of patients in the Veterans Affairs health system examined changes in the likelihood of curative therapy in men with prostate cancer and limited longevity. Guidelines recommend against PSA screening or curative treatment for prostate cancer in men with life expectancies of less than 10 years because the benefits take more than a decade to appear, whereas the harms manifest in the short term. Nonetheless, among men with intermediate-risk prostate cancer and life expectancies of less than 10 years, overtreatment rose from 37.6% in 2000 to 59.8% in 2019, with 78% receiving radiation therapy and 22% undergoing surgery.

Radiation therapy may be viewed by patients and physicians as having fewer adverse effects than surgery, but it is hardly benign. A prospective cohort study of nearly 30,000 men who participated in two prostate cancer prevention trials found that compared with untreated participants, men who had radiation therapy were 2.76 times more likely to develop urinary or sexual complications, 2.78 times as likely to develop bladder cancer, and 100 times as likely to develop radiation cystitis and proctitis. It makes no sense to expose patients to these risks who have little opportunity to benefit, two geriatricians wrote in a JAMA Internal Medicine commentary titled “Do Not Wait to Consider Life Expectancy Until After a Prostate Cancer Diagnosis”:

Limited life expectancy increases the likelihood of experiencing harms all along the diagnostic and treatment cascade following screening. Time spent diagnosing, monitoring, and treating asymptomatic prostate cancer in men with limited life expectancy distracts from monitoring and treating their symptomatic life-limiting illnesses. Also, limited life expectancy increases the likelihood of complications from most procedures, including radiation therapy.

A previous AFP article that reviewed treatment options for localized prostate cancer, including active surveillance, included the patient-administered Charlson Comorbidity Index and a life expectancy table for U.S. men. A 2019 AFP editorial provided more guidance for estimating and having conversations about life expectancy with older patients.