Prostate cancer, a condition affecting countless men worldwide, often prompts immediate concern. However, recent insights reveal that many cases of prostate cancer are unnecessarily treated. These treatments, frequently sparked by initial screenings such as the prostate-specific antigen (PSA) blood test, may not be essential in a patient's lifetime. Life expectancy plays a crucial role in determining whether to undergo treatment, yet many men over 65 face decisions without considering their limited life expectancy.
Studies indicate that the primary driver for deciding whether to treat or monitor prostate cancer is the doctor's recommendation. Unfortunately, true shared decision-making between doctors and patients is often lacking. "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," said Leapman. This highlights a critical gap in patient care, where longevity calculators are rarely integrated into electronic health records.
More than half of men over 65 have a life expectancy of under 10 years, making it vital to weigh the benefits and risks of treatment. Despite this, a national survey showed nearly half of men over 70 with a life expectancy of less than 10 years reported undergoing PSA screening, contrary to clinical guidelines. The American Academy of Family Physicians (AAFP) and the U.S. Preventive Services Task Force recommend against PSA cancer screening at any age, citing concerns over overtreatment.
The introduction of shared decision-making around 30 years ago aimed to bridge this communication gap. "Urologists and radiation oncologists think, ‘The primary care doc is sending them to me, so they must have had that discussion already,’" explained Walter. However, the reality is that many specialists assume referrals come with a pre-existing agreement on treatment. Walter further remarked, "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.’"
The slow growth of most prostate cancers means that many men will die of other causes. For those with cancer confined to the organ, the five-year survival rate is nearly 100%. In light of this, it becomes imperative for patients to engage actively in their healthcare decisions.
Walter advises patients, "Have someone come with you to the appointment because it’s a lot of information." He also encourages patients not to shy away from seeking clarity: "Don’t be afraid to ask questions if you don’t understand the doctor." Brull echoes the importance of patient engagement: "Tell me what your questions are, tell me what your worries are, and let’s talk more about that."
Despite advancements in patient-doctor communication, challenges remain. "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," noted Brull. The initial framing of treatment discussions significantly influences patient decisions. Leapman observed, "If the conversation starts with their recommendation, it tends to be followed."
Recent studies underscore the impact of informed discussions on treatment trends. Treatment with surgery or radiotherapy for low-risk cancer fell from 37.4% to 14.7% among patients with a life expectancy of less than 10 years. By talking about potential consequences before agreeing to a PSA test, overtreatment can be reduced.
However, screening practices remain contentious. "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," emphasized Leapman. The prevalence of screenings outside clinical guidelines necessitates a reevaluation of current practices.
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