Jan. 15, 2025 – Prostate cancer is quite common – over 60% of those diagnosed are men over the age of 65 – but it’s not a high priority for cancer researchers.
One big reason: Most men with prostate cancer will die of something else because the cancer grows so slowly.
So for the past 15 years, there’s been a big increase in “watchful waiting,” meaning doctors monitor the patient’s condition but don’t treat the disease unless symptoms appear or worsen.
But overtreatment of prostate cancer persists, as seen in a new study from the U.S. Department of Veterans Affairs health system. Researchers looking at the years 2000 to 2019 found that treatment with surgery or radiotherapy for low-risk cancer fell from 37.4% to 14.7% of patients with a life expectancy of less than 10 years.
That data reflects the tendency toward watchful waiting. But the researchers also found this: Among those with intermediate-risk prostate cancer, the percentage who received aggressive treatment climbed from 37.6% to 59.8%. For men with high-risk prostate cancer and a five-year life expectancy, treatment rose from 17.3% to 46.5%.
The researchers concluded that “overtreatment of men with limited LE [life expectancy] and intermediate-risk and high-risk prostate cancer has increased in the VA, mainly with radiotherapy.”
That’s a significant finding. More than half of men over 65 – the average age when prostate cancer appears – have a life expectancy of under 10 years.
Although the study was limited to the VA, experts say that overtreatment of men with prostate cancer is at least as widespread outside of the veterans’ health system.
What does that mean for men in general? It means that knowing the basics – and knowing how to discuss your situation with your doctor – can have a huge impact on the quality and length of your life.
Early Indicators and Common Treatments
Most men have no symptoms in the early stages of prostate cancer. The first sign is often from a prostate-specific antigen (PSA) blood test. If your PSA level is high, you may get a biopsy to find out whether you have prostate cancer or something else like benign prostatic hyperplasia (a swollen prostate). If you do have prostate cancer that is confined to the organ, your five-year survival rate is nearly 100%.
Evidence shows favorable outcomes when men diagnosed with low-risk or some intermediate-risk prostate cancers agree to watchful waiting, also known as “active surveillance,” rather than treatment. In this scenario, the patient regularly visits his doctor, who monitors the growth of the cancer using blood tests, rectal exams, and biopsies. No growth? No treatment.
If treatment is needed, the most common treatments are radiation therapy and surgery to remove the prostate gland. The operation usually eliminates an organ-confined cancer, but it can cause impotence or loss of bladder control – or both – and those can be temporary or permanent.
Radiotherapy is safer than surgery and has about the same success rate. But side effects can include bowel, bladder, and sexual dysfunction, as well as urinary burning and bleeding and rectal bleeding during or shortly after the treatment.
Those are the basics. Should you be screened for prostate cancer? And if you are diagnosed, what should you ask your doctor?
The Big Question: Life Expectancy
Though life expectancy is a huge part of deciding whether to treat prostate cancer, not enough doctors talk about it with their patients, according to Michael Leapman, MD, MHS, an associate professor of urology at Yale School of Medicine.
There are life expectancy calculators available, but doctors don’t often use them, he said, and that’s a big driver of overtreatment. One problem: Longevity calculators are rarely part of electronic health records. That means a doctor must exit their electronic health record system, go to a website, and enter all the patient’s info to get a life expectancy number. “It can be a little difficult,” he said.
The San Francisco VA Health Care System has a multi-disease longevity calculator plugged into the Epic electronic health record system it uses, said Louise Walter, MD, chief of geriatrics at the University of California, San Francisco, and the San Francisco VA Health Care System.
But she noted that doctors don’t often discuss life expectancy with patients because the patient may not want to know. “Some of my patients will ask me, ‘How long do I have to live?’ And with others, you ask, ‘Do you want to know?’ and they’ll say ‘No.’ ”
Leapman agreed. “Even if we have a solid estimate of life expectancy, I don’t think we have a well-developed manner for speaking to patients about these problems.”
Your Role in ‘Shared Decision-Making’
Around 30 years ago, when watchful waiting was starting to be seen as a viable, ethical option for prostate cancer, doctors began to recognize the value of “shared decision-making” between doctors and patients. This acknowledges that patients’ values can be as important as doctors’ technical knowledge.
But many doctors don’t engage in true shared decision-making, Leapman said.
“Everyone does some degree of it, but you can sway the conversation with your opinion, depending on how you present things,” he said.
Numerous studies show that the “main driver” in deciding whether to treat or monitor is the doctor you see, Leapman said: “If the conversation starts with their recommendation, it tends to be followed.”
Let’s say a biopsy finds cancer. What’s your move?
Talk to your primary care doctor first, not a urologist or a radiation oncologist.
Shared decision-making works better that way, said Jen Brull, MD, president of the American Academy of Family Physicians (AAFP). “Those conversations are likely harder for specialists to have because they don’t have a long-term relationship with the patient on which to found this conversation,” she said.
A urologist typically does the biopsy, so the patient may expect to learn about their treatment options then. But this is often less than a complete discussion.
“Urologists and radiation oncologists think, ‘The primary care doc is sending them to me, so they must have had that discussion already,’ ” Walter noted. If a primary care doctor makes a referral, she said, “they need to be very explicit if they want the specialist’s help in deciding whether to recommend this treatment or not. Most specialists interpret a referral to mean, ‘We’re doing this.’ ”
Make your values clear. Brull has seen patients back-to-back with the same diagnosis and risk factors, “and they’ll make different decisions based on what’s important to them and the way they interpret the same information. So it’s important in these conversations to solicit feedback from the patient: ‘Tell me what your questions are, tell me what your worries are, and let’s talk more about that.’ That’s the sort of conversation that helps patients in deciding what choice they want to make.”
Do some homework. Learn as much about the disease as you can so you can ask the right questions. Good starts are medical society websites like those of the AAFP, the American Cancer Society and the American Urological Association. But check out patient decision aids (PDAs) from Ottawa Hospital and the Washington State Health Care Authority. PDAs have been shown to help patients improve their knowledge of health conditions, make choices that line up with their values, and form more accurate perceptions of risk.
Should You Get Screened?
One way to reduce overtreatment, Walter said, might be talking about potential consequences before agreeing to a PSA test. She suggests that doctors tell patients that a positive result can lead to more tests and procedures that may not be needed or are not recommended.
She pointed out that a national survey showed that nearly half of men over 70 with a life expectancy of under 10 years reported being screened for the disease – although clinical guidelines recommend against it. In fact, the guidelines of the AAFP and the U.S. Preventive Services Task Force recommend against PSA cancer screening of men at any age.
Older men typically have multiple health conditions, and it can be more important to focus on those, she said. In a commentary on the VA study, Walter wrote that time spent diagnosing, monitoring, and treating prostate cancer without symptoms in men who have limited life expectancy “distracts from monitoring and treating their symptomatic life-limiting illnesses.”
Also, she noted, the adverse side effects of prostate cancer treatments are typically more serious in men with limited longevity.
After the Preventive Services Task Force made its recommendation, Brull recalled, her practice went to a shared decision-making model. She began asking patients whether they wanted to be screened, “given that our experience tells us that low-risk people probably have more harm than benefit.”
Leapman agrees. “Screening is really the issue. The majority of these cancers that they talk about in that VA study – the ones that are unnecessarily treated – would never become apparent in the patient’s lifetime. And a lot of screening happens outside of clinical guidelines. We’re screening people who are above the recommended age cut-off [70] and above the recommended life expectancy cut-off.”
First Things First
Here are some take-home lessons for older men.
- Make sure you have a primary care doctor, and discuss the prostate cancer issues with that doctor before you get a PSA test.
- Have a second test done if the first one is positive, because it may be a false positive.
- If you’re diagnosed with prostate cancer, ask your doctors about watchful waiting.
- Insist on shared decision-making with your doctor.
- “Have someone come with you to the appointment because it’s a lot of information,” Walter said. “Don’t be afraid to ask questions if you don’t understand the doctor.”
