Some prostate cancer patients may never feel the need to see a medical oncologist; others may want an oncology consult soon after diagnosis; and a third group of patients may not see an oncologist until other forms of treatment have failed. Many men with prostate cancer are not even sure what role a medical oncologist has in their care. However you get there, when you decide you need to see a medical oncologist, you are going to want to find the right one for you. We asked Andrew Armstrong, MD, MSc to talk about how he would approach this need. Dr. Armstrong is a board-certified medical oncologist and an Assistant Professor of Medicine and Surgery specializing in management of prostate and other genitourinary cancers at the Duke Prostate Center, part of the Duke University Health System in Durham, North Carolina.
In an ideal world, if I was diagnosed with prostate cancer, I would try to make sure that I sought consultation at a center dedicated to multidisciplinary prostate cancer care. This includes expertise in surgery (surgical oncology), radiation (radiation oncology), and medicines (medical oncology) used to treat prostate cancer. Ideally this center would be one that not only has access to clinical trials, but is also leading the way to address some of the important questions in prevention, diagnosis, monitoring, and treatment of this disease. Such centers are usually part of an NCI-designated Comprehensive Cancer Center, and there are 20 of these comprehensive programs across the country. In addition, there are 10-12 institutions across the country with a particular expertise in prostate cancer clinical research. These institutions receive support from the US Department of Defense for this research as part of the Prostate Cancer Clinical Trials Consortium.
Why look at these institutions and why see several physicians? Two reasons.
Many of these institutions operate using multidisciplinary prostate cancer clinics, which means that you are seen by a team of physicians that can discuss the multiple options and complex decision-making processes involved for men with low, intermediate, and high risk prostate cancer. This care is quite individualized and there are often multiple options available, each with there own evidence base, outcomes, and safety concerns. After seeing one of these multi-D clinics, you will often leave with a much more nuanced but informed view of treatment options for your particular cancer so that you can make the right decision for you and your family.
Second, if you have more aggressive or advanced disease, these centers participate in a wide range of cutting edge clinical trials that will offer you the possibility of many of the most novel and innovative forms of treatment in development. Since prostate cancer can be very hard to treat successfully if it is no longer localized to the prostate, this gives the patient the widest possible choice regarding treatment options at a center that is entirely focused on prostate cancer therapy. These therapies could include immunologic (vaccine) strategies, novel targeted agents, chemotherapies, the use of hormonal therapies, active surveillance for low risk disease, and multi-modality therapy that combine surgery, radiation, and systemic therapy.
Having said that, I fully understand that it may be difficult or impossible for every patient to get to one of these specialty centers, and there are many, many community oncologists who provide excellent care for men with prostate cancer based on their years of experience and their dedication to their patients, so let me tell you what would be important for me in any oncologist I was going to select.
Experience is the first priority. I am going to look for someone who has a few years under his or her belt and who sees a lot of prostate cancer patients. If (s)he specializes exclusively in genitourinary cancers, so much the better, but that is less critical. (S)he would be board-certified in medical oncology, and would have had several years in practice. I would specifically ask for referrals to one or more oncologists who my other doctors knew had a deep understanding of the long-term management of prostate cancer. I would also be looking for someone who knew how to work well with other relevant specialists in areas such as radiation oncology and surgery.
My second priority is access to clinical trials. I am looking for someone who participates regularly in clinical trials of new therapeutics, particularly if I have recurrent or high risk disease. If a man has advanced stage, high Gleason score, or PSA-recurrent prostate cancer, or other features that indicate a high risk of recurrence after local definitive therapy, generally the mainstay of therapy has been androgen deprivation at some point to maintain control over his tumor growth. However, hormonal therapies have a number of toxicities, including cardiovascular, metabolic, and bone-related complications that make the investigation of less toxic and potentially more effective therapies appealing in this setting. Access to clinical trials does not always mean going to an academic medical center. Many medical oncologists have a significant clinical research component to their community practice because it is the best way to be able to offer patients access to development-stage drugs when they are appropriate while keeping patients in their own community for therapy. If possible I would be seeking someone who was still regularly involved in the clinical research process — but not someone who is a pure researcher. Remember that I said at the beginning that I am looking for someone who sees lots of patients on a regular basis. By participating in trials run by one of the major cooperative groups — e.g., the Southwest Oncology Group (SWOG), the Eastern Cooperative Oncology Group (ECOG), Cancer and Leukemia Group B (CALGB) or the Department of Defense Prostate Cancer Consortium — community oncologists can place patients on many of the major, ongoing trials of development-stage and new forms of treatment, and keep up to date with clinical research priorities at the same time.
My third priority is someone I can talk to. I am looking for a doctor who listens to me and my needs. I need an advisor and a guide, not a dictator! I want someone who can understand my (and my family’s) fears and concerns and who can empathize with what I am going through. I don’t need him or her to be my best friend because I want this doctor to be objective, but I also want to know that (s)he is willing to answer all my questions as best (s)he can. I should be able to talk to him or her about every possible need, from the risks and benefits of a specific type of chemotherapy or hormonal therapy or clinical trial to planning for hospice care and psychological counseling if these become necessary. The bottom line is that I want this physician to get to know and understand me and be straightforward with me. I am a human being, and I want her to be one to!
My fourth priority is a great support staff of nursing and administrative personnel. Even though I want to find a doctor who will give me as much time as (s)he possibly can, I am still going to be spending a good deal of time with the nursing and support staff. They will be the people who give me infusions if I need them and who will have to answer the questions that occur to me only after I’ve come out of the doctor’s office. They will be the people who I get on the phone when I call because I’m having some strange side effect that is making me feel really weird. I need them to be willing and eager to help me when the doctor isn’t immediately available. A center that offers the convenience of laboratory testing, radiology, nursing care, and doctor’s visits all in one location is ideal. All of these things make for a patient-friendly and empathetic environment.
So these are my four most important priorities, but other things need to be taken into account too:
- The doctor must be as willing to talk to my family as (s)he is to me. Every cancer affects not only the patient but also that patient’s close family. Patients and families need to make these decisions together, and the doctor’s role is to give the best guidance possible, not to tell everyone what is right and wrong, because we often don’t know what is right or wrong for any one individual patient.
- (S)he must have patience. I may need things to be explained to me more than once. Cancer is complicated, and so are many of the new treatments we use today, such as intensity modulated radiation therapy (IMRT), proton-beam radiation therapy, robotic surgery, intermittent hormonal therapy, when to start androgen deprivation, and the role of chemotherapy in prostate cancer management. It may take me time to understand the situation and come to a decision that feels right for me.
- (S)he must be willing to help me get highly specialized advice. Even if I can’t get to one of the major centers for regular treatment, it may be worth sending me there once and getting their guidance even though I am going to come back to a more local oncologist for my regular treatment.
- (S)he must have an open mind. If I turn up in her office with a protocol for a new drug (s)he has never heard of, I want to know that (s)he will help me to learn about it, not dismiss it out of hand. (But I also understand that if I turn up with a ream of new protocols at every visit, I may rapidly become a difficult patient to deal with!)
Last but by no means least, I am looking for someone who is responsive. If I phone the office with a question, I am looking for an answer as soon as reasonably possible. I don’t need someone who calls me back 3 days later and doesn’t even know why I called. This means that the practice must be efficient, with a well-organized process for ensuring that patients’ phone calls are handled quickly and effectively. You can usually work that one out after a couple of calls to any doctor’s office!