One size does not fit all for prostate cancer treatment

Some men with prostate cancer may be getting too much treatment, according to Yale School of Medicine researchers.

In a study published Jan. 27 in the journal Archives of Internal Medicine, Yale researchers found that over the past decade in the United States, there has been a rise in prostate cancer treatments among patients who may not need them. According to Cary Gross, the paper’s lead author, they found that men who are the least likely to benefit from treatment — those with short life expectancies and nonaggressive cancers — are more likely to be treated for their cancer now than they were a decade ago. Medical experts say that this study is the latest in a growing body of literature highlighting that not all patients diagnosed with prostate cancer are endangered by a life-threatening disease, and not all need treatments.

“When a patient’s initial assessment shows what looks like a nonaggressive tumor, then it’s unlikely that the cancer is going to progress during the patient’s lifetime,” Gross said. “The majority of men with these nonaggressive tumors are likely to die with their prostate cancer but not from their prostate cancer.”

He said that more than half of men who die over the age of 75 would have some evidence of prostate cancer, but that fewer than 5 percent of them die from the disease.

Gross contrasted prostate cancer with leukemia and pancreatic cancer, which are much more likely than prostate cancer to be life-threatening. The vast majority of patients with leukemia or pancreatic cancer would benefit from treatment, he said.

Prostate cancer is one of most challenging cancers in the medical field because it does not meet the normal public perception of what a cancer is, said Jonathan Simons, president and chief executive officer of the Prostate Cancer Foundation, an organization that funds and aids research on prostate cancer. There are more than 20 types of prostate cancer, and while some are fatal, many are inactive.

“This paper highlights the further importance of offering patients choices, because not one size fits all for prostate cancer,” Simons added.

He said that patients with nonaggressive and local tumors should be carefully watched and observed rather than treated.

Simons attributed the rise in treatment rates for patients who are unlikely to benefit from the treatment to the “terror of the word ‘cancer.’”

“The problem is that when most patients hear cancer, they don’t hear anything else,” Simons said. “If you tell someone they have cancer, it’s hard for them to hear anything else other than ‘I have cancer. I could die.’”

Gross, by contrast, said that excessive treatments were the result of their increased availability to patients and financial incentives for doctors and hospitals to conduct more costly treatments. He said that paying health care providers for the quality, not the quantity, of their care would help to remedy this problem.

Doctors should take into account their patients’ life expectancies in addition to the attributes of tumors when making recommendations, said James Yu ’99, a member of Yale’s Cancer Outcomes, Public Policy, and Effectiveness Research Center and one of the authors of the paper.

“Low-risk men with short life expectancy should have a very frank discussion about watchful waiting and a frank discussion about the potential side effects of treatment,” Yu said. “They should be reassured that they may not need treatment.”

Mark Schoenberg, director of urologic oncology at Johns Hopkins Medical School, said that treatments often have large negative side effects, so doctors should offer treatments only to those patients who need it and will live long enough to derive the benefit it.

Schoenberg said this study further calls attention to the fact that many patients who are being offered therapy may not need it.

“How do we identify the important cancers that could be treated early and cured for the benefit of the patient and how do we differentiate those cancers from cancers that have no real clinical significance?” Schoenberg asked.

The study analyzed 39,270 patients in a Medicare-linked database who were diagnosed with localized prostate cancer between 1998 and 2007.

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