Men with limited life expectancy (LE) have historically been overtreated for prostate cancer despite clear guideline recommendations. With increasing use of active surveillance, it is unclear if overtreatment of men with limited LE has persisted and how overtreatment varies by tumor risk and treatment type.

To determine if rates of overtreatment of men with limited LE have persisted in the active surveillance era and whether overtreatment varies by tumor risk or treatment type.

This cohort study included men with clinically localized prostate cancer in the Veterans Affairs health system who received a diagnosis between January 1, 2000, and December 31, 2019.

LE was estimated using the validated age-adjusted Prostate Cancer Comorbidity Index (PCCI). Treatment trends among men with limited LE were assessed using a stratified linear and log-linear Poisson regression in aggregate and across PCCI and tumor risk subgroups.

The mean (SD) age for the study population of 243 928 men was 66.8 (8.0) years. A total of 50 045 (20.5%) and 11 366 (4.7%) men had an LE of less than 10 years and LE of less than 5 years based on PCCI scores of 5 or greater and 10 or greater, respectively. Among men with an LE of less than 10 years, the proportion of men treated with definitive treatment (surgery or radiotherapy) for low-risk disease decreased from 37.4% to 14.7% (absolute change, -22.7%; 95% CI, -30.0% to -15.4%) but increased for intermediate-risk disease from 37.6% to 59.8% (22.1%; 95% CI, 14.8%-29.4%) from 2000 to 2019, with increases observed for favorable (32.8%-57.8%) unfavorable intermediate-risk disease (46.1%-65.2%). Among men with an LE of less than 10 years who were receiving definitive therapy, the predominant treatment was radiotherapy (78%). Among men with an LE of less than 10 years, use of radiotherapy increased from 31.3% to 44.9% (13.6%; 95% CI, 8.5%-18.7%) for intermediate-risk disease from 2000 to 2019, with increases observed for favorable and unfavorable intermediate-risk disease. Among men with an LE of less than 5 years, the proportion of men treated with definitive treatment for high-risk disease increased from 17.3% to 46.5% (29.3%; 95% CI, 21.9%-36.6%) from 2000 to 2019. Among men with an LE of less than 5 years who were receiving definitive therapy, the predominant treatment was radiotherapy (85%). Among men with an LE of less than 5 years, use of radiotherapy increased from 16.3% to 39.0% (22.6%; 95% CI, 16.5%-28.8%) from 2000 to 2019.

The results of this cohort study suggest that, in the active surveillance era, overtreatment of men with limited LE and intermediate-risk and high-risk prostate cancer has increased in the VA, mainly with radiotherapy.