THE "NEW" PROSTATE CANCER INFOLINK

Two newly published articles suggest that – among a small group of Canadian patients and a large cohort of US veterans — there was a significant time interval from initial suspicion of prostate cancer to definitive treatment (where necessary). But was this time interval appropriate?

Stevens et al. report on the experience of 41 consecutive Canadian patients referred for treatment of prostate cancer with radiation therapy at a single Canadian cancer center. They interviewed all 41 patients, calculated the time intervals from suspicion to definitive therapy and identified factors and common causes associated with delays along the pathway toward treatment.

Their study showed that:

• Median interval from suspicion of cancer to the first fraction of radiotherapy for all patients was 247 days.
• Median diagnostic interval (i.e., time from suspicion to actual diagnosis) was 53 days.
• Median treatment interval (i.e., time from diagnosis to initiation of treatment) was 127 days.
• Patients < 70 years of age and patients with a clinical stage of < T2c  had shorter intervals from suspicion to treatment.
• Patients with low-risk prostate cancer had longer treatment intervals.
• 70 percent  of the patients (29/41) perceived a delay in their care.
  • 13/29 (45 percent) thought this delay was due to the Canadian health care system.
  • 9/29 (31 percent) thought this delay was due to patient factors.
  • 7/29 (24 percent) thought this delay was due to physician factors.
• Only 12 percent of patients met wait time recommendations proposed by theCanadian Strategy for Cancer Control.
• No patients at all met wait time recommendations of the Canadian Association of Radiation Oncologists.

According to the authors, wait times for cancer diagnosis and treatment are a significant concern for Canadians. They also state that men with prostate cancer “experience longer waiting times for diagnosis and treatment than those observed for other cancers” and that extended wait times ”are associated with both patient and family psychosocial distress and may be associated with worse prognosis.” However, it is worth noting that 12/41 patients (30 percent) in this study did not perceive any delay in their care, and nine of the patients who did perceive a delay believe that this delay was associated in some way with patient factors. In other words 21/41 patients (51 percent) either didn’t perceive a delay or thought the delay might have a good reason.

The authors reasonably conclude that, “Alternate strategies should be developed and measured to shorten the intervals between the suspicion and treatment of prostate cancer.”

The second study is a retrospective analysis of the clinical experience of all 13,591veterans in the Pacific Northwest VA Network of the US who were assessed as having a  PSA level ≥ 4 ng/ml between 1998 and 2006 and who had had no previous elevated PSA result and no previous prostate biopsy.

Zeliadt et al. carried out a careful assessment of the patterns of care among this group of veterans, including additional PSA testing, urology consults, and biopsies. They also compared the clinical stage at diagnosis for men who were biopsied within 24 months with the stage of the men biopsied and diagnosed >24 months after the elevated PSA test. Their results are reported below:

• Two-thirds of patients received follow-up evaluation within 24 months of the elevated PSA test.
  • 32.8 percent of the men underwent a biopsy.
  • 15.5 percent attended a urology visit but were not biopsied.
  • 18.8 percent had a subsequent normal PSA test.
• Patients who were of younger age, had higher PSA levels, had had more prior PSA tests, had no co-payment requirements, had existing urologic conditions, had low body mass index, and had low comorbidity scores were more likely to receive a complete follow-up.
• Among men who underwent radical prostatectomy, a delayed diagnosis
  • Was not significantly associated with a finding of pathologically advanced prostate cancer (pT3/T4)
  • Was associated with an increased likelihood of presenting with clinical stage T2c as opposed to stage T2a or T2b.

The authors conclude that follow-up after an elevated PSA test had been highly variable. More than a third of the veterans appeared to have received care that could be considered “incomplete” and perhaps suboptimal. However, there was no evidence that delayed diagnosis was associated with poorer prognosis.

Because prostate cancer is commonly a slowly growing type of cancer, there is often no necessity to rush from suspicion to diagnosis to treatment, and the patient advocacy community will commonly tell newly diagnosed patients to take their time about making treatment decisions. It is therefore very difficult to be able to generalize about the appropriateness of apparent “delays” in the time from suspicion of the possibility of prostate cancer to actual diagnosis and the initiation of a mangement protocol or actual treatment — especially for older patients with low- or very low-risk disease.

The “New” Prostate Cancer Infolink believes that the critical issue is the time from suspicion to management decision in patients at significant risk for potentially progressive prostate cancer (whether localized to the prostate or more advanced at the time of diagnosis). This interval time should always be minimized. The hard part is the accurate and early identification of these patients and the clear differentiation of these patients from those with indolent disease.

Filed under: Diagnosis, Management, Risk, Treatment Tagged: | Diagnosis, interval, outcome, prognosis, risk, suspicion, Treatment