Men with early-stage prostate cancer frequently choose treatments that worsen problems they already have, according to a new study published in Cancer.
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, yet more than one-third opted for treatments that made them more vulnerable in those areas.
"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 (MGH) 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."
A High Degree of Mismatch
The 3 most common active treatments for prostate cancer -- brachytherapy, external beam radiation therapy, and radical prostatectomy -- have been shown to be about equally effective in clinical trials. But each has its own unique set of urinary, bowel, and sexual side effects that need to be taken into consideration when choosing a treatment.
A man with urinary irritation or difficulty passing urine, for example, might be advised against brachytherapy because it can make these symptoms worse. Likewise, men with bowel problems would likely be discouraged from external beam radiation therapy because it can affect the rectum as well as the prostate. Nerve-sparing radical prostatectomy is typically done in an effort to preserve sexual function. In some cases, though, this approach might reduce the chance that a surgeon can remove the entire tumor, so for men who already have erectile dysfunction, the risks of this procedure might outweigh any quality-of-life benefits.
The men in the study were recruited from Boston-area multi-specialty treatment centers. They answered questions about their urinary, bowel, and sexual function before they underwent treatment.
The researchers then classified the men into 4 groups. The first 2 groups had a urinary, bowel, or sexual problem that would likely make 1 of the 3 most common prostate cancer treatments inappropriate. The inappropriate treatment was more clear-cut for men in Group I than those in Group II. Patients in Group III had problems in several areas, but were felt to have at least one "appropriate" treatment option. Men who had problems that would be further aggravated by all of the treatments fell into Group IV.
The researchers found a surprising number of mismatched treatments among the study participants, regardless of the clinical complexity of their cases. About 34% of Group I patients received a treatment that might have worsened a pre-existing problem, compared to 37% in Group II and 40% in Group III.
Not surprisingly, choosing a mismatched treatment had negative effects. More men who had bowel problems prior to external beam radiation therapy reported diarrhea, pain with bowel movements, bowel urgency, and rectal bleeding. Patients who had urinary problems prior to brachytherapy were more likely to report painful urination. They also reported more need to urinate at night, though the difference did not reach statistical significance. Nearly all men with sexual dysfunction continued to have trouble in that regard after radical prostatectomy, regardless of whether a nerve-sparing procedure was used.
Emphasizing Quality-of-Life Concerns
The authors offer several hypotheses to explain why many men didn't seem to take these problems into account as part of their treatment decision-making. Some men may make decisions hurriedly and base their decisions on anecdotes and misconceptions (see "Fear, Anecdotes Often Trump Facts When Men Make Prostate Treatment Decisions.")
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 co-authors suggest physicians consider using questionnaires to get more candid responses to sensitive quality-of-life questions.
The authors also note that there are other factors that might legitimately enter into treatment decisions. For example, some men might not consider external beam radiotherapy if radiotherapy centers are not close enough for daily treatments to be practical.
Mark S. Litwin, MD, professor of urology at the David Geffen School of Medicine at the University of California, Los Angeles (UCLA), and the UCLA School of Public Health 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 pre-consultation 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 outcomes. 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 reflects the tendency in the United States to over-treat prostate cancer in some cases. "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.
Citation: "Treatment 'Mismatch' in Early Prostate Cancer." Published online Nov. 26, 2007, and in the Jan 2008 issue of Cancer (Vol. 112, No.1). First author: James Talcott, MD, SM, Center for Outcomes Research at Massachusetts General Hospital (MGH) Cancer Center.
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, yet more than one-third opted for treatments that made them more vulnerable in those areas.
"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 (MGH) 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."
A High Degree of Mismatch
The 3 most common active treatments for prostate cancer -- brachytherapy, external beam radiation therapy, and radical prostatectomy -- have been shown to be about equally effective in clinical trials. But each has its own unique set of urinary, bowel, and sexual side effects that need to be taken into consideration when choosing a treatment.
A man with urinary irritation or difficulty passing urine, for example, might be advised against brachytherapy because it can make these symptoms worse. Likewise, men with bowel problems would likely be discouraged from external beam radiation therapy because it can affect the rectum as well as the prostate. Nerve-sparing radical prostatectomy is typically done in an effort to preserve sexual function. In some cases, though, this approach might reduce the chance that a surgeon can remove the entire tumor, so for men who already have erectile dysfunction, the risks of this procedure might outweigh any quality-of-life benefits.
The men in the study were recruited from Boston-area multi-specialty treatment centers. They answered questions about their urinary, bowel, and sexual function before they underwent treatment.
The researchers then classified the men into 4 groups. The first 2 groups had a urinary, bowel, or sexual problem that would likely make 1 of the 3 most common prostate cancer treatments inappropriate. The inappropriate treatment was more clear-cut for men in Group I than those in Group II. Patients in Group III had problems in several areas, but were felt to have at least one "appropriate" treatment option. Men who had problems that would be further aggravated by all of the treatments fell into Group IV.
The researchers found a surprising number of mismatched treatments among the study participants, regardless of the clinical complexity of their cases. About 34% of Group I patients received a treatment that might have worsened a pre-existing problem, compared to 37% in Group II and 40% in Group III.
Not surprisingly, choosing a mismatched treatment had negative effects. More men who had bowel problems prior to external beam radiation therapy reported diarrhea, pain with bowel movements, bowel urgency, and rectal bleeding. Patients who had urinary problems prior to brachytherapy were more likely to report painful urination. They also reported more need to urinate at night, though the difference did not reach statistical significance. Nearly all men with sexual dysfunction continued to have trouble in that regard after radical prostatectomy, regardless of whether a nerve-sparing procedure was used.
Emphasizing Quality-of-Life Concerns
The authors offer several hypotheses to explain why many men didn't seem to take these problems into account as part of their treatment decision-making. Some men may make decisions hurriedly and base their decisions on anecdotes and misconceptions (see "Fear, Anecdotes Often Trump Facts When Men Make Prostate Treatment Decisions.")
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 co-authors suggest physicians consider using questionnaires to get more candid responses to sensitive quality-of-life questions.
The authors also note that there are other factors that might legitimately enter into treatment decisions. For example, some men might not consider external beam radiotherapy if radiotherapy centers are not close enough for daily treatments to be practical.
Mark S. Litwin, MD, professor of urology at the David Geffen School of Medicine at the University of California, Los Angeles (UCLA), and the UCLA School of Public Health 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 pre-consultation 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 outcomes. 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 reflects the tendency in the United States to over-treat prostate cancer in some cases. "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.
Citation: "Treatment 'Mismatch' in Early Prostate Cancer." Published online Nov. 26, 2007, and in the Jan 2008 issue of Cancer (Vol. 112, No.1). First author: James Talcott, MD, SM, Center for Outcomes Research at Massachusetts General Hospital (MGH) Cancer Center.
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