THE "NEW" PROSTATE CANCER INFOLINK

The American Society for Clinical Oncology (ASCO) has just released a formal “provisional clinical opinion” on the integration of palliative care into standard care for patients with cancer. The full text of this article is available on line.

As Smith et al. note early in this provisional clinical opinion,

Palliative care is frequently misconstrued as synonymous with end-of-life care.

However, in fact,

Palliative care is focused on the relief of suffering, in all of its dimensions, throughout the course of a patient’s illness.

This is a particularly important aspect of the management of progressive prostate cancer — which is an incurable condition, but one that men may live with for 20 years and longer. It is also a critical factor in the management of localized and potentially curable cancer, where the application of unnecessary treatment may profoundly impact the quality of a patient’s life with no definable benefit in terms of his overall or prostate cancer-specific survival.

For many men with a rising PSA after first-line therapy for what was initially believed to be truly localized prostate cancer, palliative care begins with second line therapy that is given in an additional attempt to actually cure the cancer (salvage surgery after first-line radiation; salvage radiation — with or without androgen deprivation therapy (ADT) — after first-line surgery, etc.). Such second-line therapies may indeed be curative, but often they are not. All they do is delay progression for a while, and they are the beginning of a need for further treatments designed to optimize the patient’s quality of life over time as his disease progresses.

Look carefully at the approved indications for all of the LHRH agonists, just as one example. Here is the approved indication (here in the USA) for Trelstar:

Trelstar^® is indicated for the palliative treatment of advanced prostate cancer.

(We have added the bold black type for emphasis.) Standard forms of ADT alone (with drugs like the LHRH agonists and the antiandrogens) are never curative. They are always palliative. They are primarily intended to prevent the bone pain associated with metastatic prostate cancer. Do we use such treatments to try to prevent disease progression in men with rising PSA levels? Yes, we do, but the evidence that they actually do prevent disease progression in this way in most patients is extremely limited. This is why some physician believe that overly early use of ADT in men with only slowly rising PSA levels is highly inappropriate (because the side effects associated with the ADT may far outweigh any actual clinical benefit in terms of delaying the onset of metastatic disease).

Chemotherapy with drugs like docetaxel and cabazitaxel is not palliative at all. It is designed to extend survival. Indeed, such chemotherapy actually comes with a significant risk for serious side effects that decrease quality of life and can even lead to death in some patients (neutropenia, thrombocytopenia, peripheral neuropathy, etc.). On the other hand, chemotherapy with mitoxantrone (the first form of chemotherapy ever approved for the treatment of advanced prostate cancer) is palliative. It has no impact on survival, but it did help to lower patients’ PSA levels and it had some impact on bone pain.

The management of progressive forms of prostate cancer is a balancing act — and this is the idea at the core of the new ASCO opinion. On the one hand one is constantly trying to prevent the progression of the disease so that the patient lives for as long as possible. On the other hand one is trying to optimize the quality of every day or every patient’s remaining life.

The drive for this new ASCO provision clinical opinion actually came from a study published in the New England Journal of Medicine back in 2010. In that study, Temel et al. were able to show that, at the end of life, patients with late stage, non-small-cell lung cancer who were randomized to receive high quality palliative care as well as standard oncologic care actually lived longer than patients who were given standard oncologic care alone. But this principle applies long before the end of life.

The care of all patients with cancer should be based on the idea that one is trying to maximize the extent of life and the quality of that life — and given the long extent of the life of most men with progressive forms of prostate cancer, understanding and applying this principle to the care of these men should be a fundamental premise underlying all aspects of their medical management.

Filed under: Living with Prostate Cancer, Management, Treatment Tagged: | care, curative, oncologic, palliative