Cancer management guidelines are exactly that — guidelines!

A new article in BJU International provides patients with some insight into just how closely members of the urology community tend to follow some of the guidelines issued by their professional organizations with regard to the management of prostate cancer.

The study was carried out (in late 2007) to investigate just how closely urologists in Spain followed some of the relatively “controversial” guidelines issued by the European Association of Urology (EAU). However, our suspicion is that urologists in the USA may also follow available guidelines with a comparable degree of rigor.

Of course what is or should be “controversial” in the management of prostate cancer is in itself a matter of opinion, so it is hard to know how to interpret some of these data, but “they are what they are.”

Based on a careful review of responses from 242 Spanish urologists, the following are examples, reported by Alcaraz et al., of the degree to which these specialists adhered to the professional guidelines about topics deemed to be “controversial” by an expert panel:

  • Average (mean) adherence to the guidelines was 52.1 percent overall (which would certainly seem to confirm that Spanish urologists were indeed split about the appropriateness of the EAU guidelines on some controversial issues).
  • For patients with or suspected of having localized/locally advanced prostate cancer
    • 30.3 ± 14.4 percent of urologists adhered to guidance about the type of anesthesia to be used during biopsy.
    • 17.3 ± 10.4 percent of urologists adhered to guidance about staging of localized disease.
    • 32.9 ± 27.6 percent of urologists adhered to new criteria for biochemical relapse after radiotherapy.
    • 34.4  ± 20.1 percent of urologists adhered to recommendations regarding interpretation of a raised PSA after radical prostatectomy.
  • For patients with metastatic prostate cancer
    • 34.5 ± 24.9 percent of urologists adhered to guidance regarding the use of androgen blockade
    • 21.8 ± 13.5 percent of urologists adhered to guidance regarding the reintroduction of hormone therapy (presumably after the failure of radiation therapy with hormone therapy as an earlier management strategy).
  • With respect to ongoing patient monitoring in men with metastatic disease
    • 83.9 percent of urologists measured serum testosterone levels at some point in time.
    • Only 17.4 percent of urologists used the conventional threshold level of 50 ng/dl as a guidance for an adequately low level of serum testosterone.

There are two very different ways to look at this degree of variation among the Spanish urology community about the appropriate management of prostate cancer:

  • Urologists just don’t conform to the guidelines issued by their professional societies.
  • There is such variation in professional opinion about the management of some aspects of prostate cancer that guidelines are, to all intents and purposes, of minimal value.

The truth is probably somewhere in between.

One clear example relates to the regular measurement of serum testosterone levels in men receiving androgen deprivation therapy. Classically, the level of serum T that physicians consider to indicate a “castrate” level is, indeed, 50 ng/dl. However, many physicians consider a more appropriate castrate level to be 20 ng/dl, and there is no consensus at all about how often serum T levels should be assayed (e.g., one a year, every 6 months, every time PSA is assayed). And then there are those physicians who (rightly or wrongly) just don’t think measuring serum T is even a worthwhile exercise.

For the patient who wishes to participate significantly in decisions about his health care, the important thing is to understand which guidelines your physician does and doesn’t follow and why. Just because he/she doesn’t agree with certain guidelines doesn’t make him/her wrong. Indeed, he/she may be on the cutting edge of opinions that have yet to be incorporated into standard guidelines. But if — as an example — you really want to know your serum T levels, despite the fact that your doctor doesn’t, then you need to be very clear about your need, even if you and your doctor agree to disagree abot their importance.

5 Responses

  1. Yesterday I switched from an oncologist who I felt was adhering to guidelines too closely to one who at least initially appears to pay attention to patients’ medical history and requests. One good thing switching did was force me to finally put down on paper what my wishes are with respect to my medical care: how I rank quality of life issues in order of importance; the fact that I never want to be hospitalized; the fact that I hate pain, and of the two, I prefer drugs (he laughed), etc.

    I commend this exercise to every prostate cancer patient, whether you change doctors or not. It is the only way I know of to make sure you and your doctor are on the same page and have the same agenda. Otherwise they can only guess what you want … what your priorities are … what you are and are not willing to endure, etc.

  2. @ John — Had I listened to a urologist who followed the prostate cancer guideline which he helped write, I might well not be writing this now. The guideline was written in 2007. I realized I was ill towards the end of 2008. The doctor relied strictly on the old guideline (and told me so, not understanding that a PhD could think). This resulted in his attempt to exclude me from the most modern, aggressive, treatment for my aggressive prostate cancer. I saw the trick and left the country, which was Holland. People are humane where I am now, and set-up the proper combination treatment. If I survive it is thanks to these people. As for the doctor, I outed him in print and online in several countries. It took me 1.5 years, but it is possible that I uncovered a scam. I was told later that I had helped many people.

  3. I am interested in the “controversial” nature of the EAU guideline. I have that guideline but have not yet studied it. Knowledge of controversies might well affect future decisions of mine, so I do need some data about this. I am trained in the sciences and in aspects of prostate cancer, so the use of technical terminology is no problem. Please go into as much detail as you deem necessary. The more comprehensive and deep, the better. Thanks.

  4. Dear George:

    I think you would need to get and read the full paper yourself to do this. That is a major project that I do not have the time to undertake. Sorry.

  5. @Sitemaster. Right. I have it and shall read it asap.

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