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NEWS & VIEWS |
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Men with early-stage prostate cancer frequently choose treatments that worsen pre-existing dysfunction, according to a study published in Cancer (2008;112:61–68).
Researchers from Boston University School of Public Health, Dana-Farber Cancer Institute, Harvard Medical School, Harvard Radiation Oncology Program, and Massachusetts General Hospital found that of 438 men who completed the study, 389 (89%) reported pre-existing urinary, bowel, or sexual problems that are considered to be relative contraindications to certain treatment modalities, yet more than one-third opted for treatments the researchers labeled as "mismatched" to these comorbidities. The investigators defined a mismatch as a treatment choice that would be especially likely to worsen baseline dysfunction or would be unlikely to achieve the intended functional benefit.
"Prostate cancer patients experience the same fears and hard decisions as all cancer patients do, but prostate cancer treatment directly affects very personal things that most people aren’t comfortable talking about—urinary, bowel, and sexual function," lead researcher James Talcott, MD, SM, of the Center for Outcomes Research at Massachusetts General Hospital Cancer Center, said in a statement. "In this case, however, having that information matters because the 3 major treatments available to patients have different patterns of potential side effects. Knowing if patients already have problems in these areas should help guide treatment options."
The men were recruited from Boston-area multispecialty treatment centers and classified into 4 groups based on the clinical complexity of their cases. The first 2 groups presented with dysfunction in one organ domain that was considered a relative contraindication to one of the 3 common treatment modalities. The dysfunction was severe in Group I and moderate in Group II; this distinction was felt to influence the strength of these relative contraindications. Patients in Group III had dysfunction of multiple organ domains, relatively contraindicating more than one modality, but were felt to have at least one "appropriate" treatment option. Men for whom organ domain dysfunction constituted relative contraindications to all active treatments fell into Group IV. Researchers evaluated baseline dysfunction using validated survey instruments for urinary incontinence, urinary obstruction/irritation, bowel dysfunction, and sexual dysfunction. They also repeated these assessments for each man 3 months after treatment and again at 36 months.
Brachytherapy (BT), external beam radiation therapy (EBRT), and radical prostatectomy (RP)—the 3 most common active treatments for prostate cancer—have not been shown in controlled trials to differ in efficacy, though each is associated with specific urinary, bowel, and sexual side effects. BT, for example, can exacerbate baseline urinary obstruction and irritation and would likely be relatively contraindicated in a man with these symptoms before treatment. Likewise, baseline bowel dysfunction would be a relative contraindication to EBRT. Nerve-sparing RP is typically done in an effort to preserve sexual function but in some cases may increase the risk of incomplete tumor resection, so for men who already have erectile dysfunction, the risks of this procedure might outweigh any quality-of-life benefits.
Researchers found a surprising number of mismatched treatments among the study participants, regardless of the clinical complexity of their cases. The degree of mismatch across groups was similar: 34% of Group I patients received mismatched treatments compared with 37% in Group II and 40% in Group III.
Men who had bowel dysfunction before EBRT reported worsening bowel-related dysfunction after treatment: diarrhea (32% pretreatment compared with 43% post-treatment, P = .02), pain with bowel movements (7% versus 33%, P < .001), bowel urgency (32% versus 43%, P < .001), and rectal bleeding (8% versus 32%, P < .001). Patients who had urinary dysfunction before BT were more likely to report dysuria (8% versus 34%, P < .01). They also reported more nocturia, though the difference did not reach statistical significance (78% pretreatment versus 90% post-treatment, P = .06). Nearly all men with intermediate baseline sexual function had worse function in this domain after RP, regardless of whether a nerve-sparing procedure was used.
The authors offer several hypotheses to explain why pretreatment dysfunction did not appear to consistently influence treatment decision making. They note that "the patient decision-making process may in fact not conform to rational assumptions," and some patients may make "hurried decisions, based on unchallenged misconceptions and anecdotes."
Another explanation is that men might have a hard time talking to their doctors about sensitive issues, making it harder for physicians to determine the extent of any dysfunction. Talcott and his coauthors suggest physicians consider routine use of preconsultation questionnaires to illicit more candid responses to sensitive quality-of-life issues.
The authors also note that there are other factors that might legitimately enter into treatment decisions. For example, some men might not consider EBRT if radiotherapy centers are not close enough for daily treatments to be practical.
Mark S. Litwin, MD, Professor of Urology and Health Services at the David Geffen School of Medicine at the University of California, Los Angeles (UCLA), and the UCLA School of Public Health, respectively, and a researcher at UCLA’s Jonsson Comprehensive Cancer Center, calls this a "great study that provides real opportunities for quality improvement." He agrees that there’s a real need for a standardized preconsultation questionnaire. "We should use any tool we can to better understand and better inform our patients," says Litwin, who was not involved in the research.
But Litwin sees the problem in a slightly different light: "It’s not that men don’t tell their doctors about their pre-existing problems, but that they have a skewed perspective of them, and as a result, of their treatment outcome. We in medicine need to do a better job of sitting down with our patients and explaining how these treatments are going to affect quality of life."
Only around 5% of the men in each group chose "watchful waiting" or "active surveillance," a percentage Litwin and the researchers suggest is reflective of the tendency in the United States to overtreat prostate cancer. "We need to lay out the quality-of-life compromises associated with active treatment and help guide patients who should embrace active surveillance," Litwin said.
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