The Pros and Cons of De-escalation of advanced treatments

Goddammit, Jeff, another option to consider...

Cancer is a disease. Treating it, however, has become an industry.

In modern healthcare, cancer over-treatment is not an unfortunate side effect—it is a design feature. From unnecessary screenings that detect "pre-cancerous" whispers never destined to shout, to aggressive interventions for slow-growing tumors unlikely to threaten life, the system hums along, converting human fear into billing codes and profit margins.

Over-treatment thrives where ambiguity meets anxiety. A prostate cancer with a Gleason score of 6? Likely indolent, possibly harmless. But why watch and wait when you can scan, slice, irradiate, and prescribe? Especially when reimbursement flows not for prudent restraint but for procedural enthusiasm. In this economic model, caution is not rewarded—intervention is.

Pharmaceutical giants, equipment manufacturers, and private healthcare systems all benefit from this overtreatment ecosystem. A single patient can represent tens of thousands of dollars in revenue—more if the treatment is prolonged, complicated, or ideally, both. Even non-profits swim in these waters, their pink ribbons and fundraising walks fueled by the same medical-industrial engine.

Meanwhile, outcomes often remain unchanged. Quality of life? Frequently worse. But the ledger balances, the board is pleased, and the illusion of progress continues.

The economics of healthcare no longer pivot on necessity but on capacity. If a machine exists that can scan at 3 AM , scan it must. If a drug can be administered, it shall. The fact that "less is more" often applies in cancer care is inconvenient for a system designed to reward "more is more."

In the end, over-treatment isn't just a medical misjudgment. It’s a symptom of a deeper pathology: a system where survival is sold, not supported. Where health is commodified, and restraint is unprofitable. And in that system, cancer is not just a diagnosis. It’s a business plan.

I'd think the challenge is the difference between ex-ante and ex-post knowledge. A certain percentage of patients with advanced PCa will get better with less treatment, but many don't. Eventually, with more research, they'll find ways to tell the two groups apart.

In the meantime, as Clint Eastwood asked in Dirty Harry, "Do you feel lucky?"

Another very interesting article, Jeff…And as usual, it poses many more questions that giving us any solid answers.
The two schools of thought couldn’t be further apart, especially the main proponent of NO de-escalation, who says that lifelong treatment should only be stopped in cases of “acute adverse cardiac events”….like a fatal heart attack or stroke?” That kind of doctor is more like a feverish apostle to a cause than an open minded man of science.
But I guess he would rather say that his patient “Died of a heart attack, poor guy” than have his death certificate state: “complications from prostate cancer”.
Personally, I would de-escalate and see what happens. Thanks for the article,
Phil

The rule of thumb I read in Dr Walsh's book (if I remember correctly) is to suggest advanced treatment only if the patient otherwise could expect at least 10 years of decent life without the cancer.

That seems sensible, and would rule out any zealots (if they exist) who would do something like recommend triplet treatment to a frail 90-year old with a failing heart.

Of course, the ideal would be for the oncology community to discover better ways to determine who needs and doesn't need the advanced threatment. Definitely some don't (or it's too dangerous for them, as Phil suggests), but those disgnostic tools are still relatively blunt. 😕

@hanscasteels i appreciate your insights and skepticism when it comes to treatment and “the business “ as you call it. I’m new at this game and I see what you are getting at. That said I’m in favor of knowing all treatment options. So far my experience has been at 4 COE’s that the Dr’s had strong opinions but I never felt pressured. I chose RP at NYU Langone after others suggested RT. Too early to tell but it was my choice. Not their business decision.

I read the article, and I'm glad I do not (yet, anyway) have to make this decision for myself. Still, I wanted to add a comment because I'm not sure the discussion here has fully captured the thrust of the article.
One, the article was intended to report a debate and it did. This indicates that both the (research) doctors participating and the doctors in the audience considered it something worth deliberation and debate. This was not a marketing discussion per se, but rather MDs wrestling with exactly what this thread is wrestling with.
Two, the majority was in favor of continued treatment for the patient case in part because he did NOT experience a robust response based on the SINGLE reliable marker of progress, PSA. In spite of all the searching for other markers of progress (or remission), this is still what we're stuck with. At least it's nice we have that, including ultrasensitive PSA's. (The remission the MD's were looking for was >0.2 within 6-8 months of ADT+ treatment.) And I hope the day comes when there are other good indicators readily available, even though it will further complicate (but also inform) all research and decision-making.
Three, we all know that treatment is no fun and costly, and urologists know this as well. MDs like happy clients as well as anyone else, so one way to increase (current) happiness among clients is to advocate for less treatment. Along with concerns about the medical-industrial ecosystem taking on a life of its own, I would also weigh this concern. Personally I don't need an MD who will tell me what I want to hear because I already have myself for that. I want to hear the hard truth so I can better make the hard decisions.
Four, I'll add this comment because my sister and my father died from cancer and I watched their decision-making up close. We start out wanting to eliminate unnecessary treatment, but when the [dirty stuff] hits the fan, we are often vulnerable to any glimmer of hope, no matter how faint. Depending on our personalities, we might even be applying heavy pressure to our medical team to come up with hope of some sort. In my dad's case, eventually I had to make the decisions and at least one I look back at as foolish--authorizing an operation the day before he died. Let's be aware that doctors long to save lives and caregivers are no different, but death will usually come to us all and in some cases it will come from PC.

Absolutely. That makes perfect sense. The hail-Mary passes in the final months of cancer are an entirely different thing. They are (and should be) a very-personal decision.

My childhood friend was still well under 65, with lymphoma metastasised to his pancreas, and other treatments had failed. He choose CAR-T, fully understanding that it was a long shot even to get him an extra year. He went in with his eyes open, the treatment was brutal, and he accepted that he was out of options when it didn't work.

Others would not have made that decision, and opted for less pain and more presence in their final months. Both are reasonable choices.

But a de-novo stage-4 prostate cancer diagnosis isn't necessarily like that. Oncologists can now often keep someone alive for many years (even indefinitely, maybe?) just with radiation therapy followed by a few pills every morning, that — for many patients — cause nothing worse than mild fatigue, hot flushes, gynocomastia, and sexual dysfunction. There's chemo and Pluvicto to fall back on if/when the cancer progresses.

Not everyone is that lucky: sometimes the cancer is already in vital organs (rather than bones or lymph nodes), and some patients develop severe complications like heart disease from the hormone therapy. But for many stage-4 PCa patients now, especially those in their 50s, 60s, and even 70s these days, there's a huge potential upside and small downside to so-called "aggressive" treatment (not really all that aggressive compared to most other stage-4 cancers).

So my point is that it's good doctors are talking about this — they should *always* be talking about this — but for many cases, it's not the same hand-wringing, soul-crushing problem it is for other advanced cancers. We *know* innovations over the past few years like the -lutamides, doublet therapy for oligometastatic cancer, and triplet therapy for polymetastatic cancer work for either a majority or large pluralty of patients with advanced PCa, buying years (sometimes decades?) rather than just weeks or months when they succeed, so we've passed the "hail Mary pass" phase for many cases of stage-4 prostate cancer.

That does feel a bit like a miracle. ❤️

Well said, North. How many other Stage 4 cancer patients survive as long as PCa patients?
You ARE a Stage 4 patient yourself so you have a very personal stake and point of view in this whole debate.
At what point would you opt for an ADT vacation? And more importantly, do you even want one? Best,
Phil

Thanks for asking. I would opt for an ADT vacation if

- the evidence supported it (it does not yet, for stage 4) and my oncologist recommended it,

- there were a test available that could determine that I was actually cancer free (doesn't exist yet), or

- the mortality risk from continuing ADT outweighed the risk from cancer progression (no sign of that yet for me🤞).

Two old buddies sitting on a park bench. Both named Tom. One of the buddies is me, my name is Tom, the other is buddy Tom, not me another Tom. We became buddies during treatment. Our diagnosis was three months apart. The first two years we walked the same triplet treatment path and talked the same triplet treatment talk. Years three and four he, the other Tom quit all cancer treatments and went in the otters direction. You know, weight lifting, long walks, biking, nutritional value measured in every bite, even started reading Zen type book. We are still old park bench buddies.
For two years his health kept improving, he looked great with a low PSA, no side effects other than living a Wonderfull healthy life.
Then one morning about a year ago he shows up, greets me with an "ah-F-it" laugh and smile. He's back on ADT, and other stuff, with a PSA climbing slowly upward like mine. We are two old buddies just happy to be still upright, laughing and talking about old rock songs. His take is his treatment sabbatical gave him new perspectives on the Eagles "Hotel California" song. I'm still trying to figure that out.