Educating the family doctor about prostate cancer management


The August 15 issue of American Family Physician — supposedly one of the most widely read medical journals in America — carried an article by Mohan and Schellhammer entitled “Treatment options for localized prostate cancer.” Unfortunately the full text of this article is not available on line for the average reader.

In their article, Mohan (a family physician) and Schellhammer (a urologic oncologist who is himself a prostate cancer patient with progressive disease) offer family doctors rather more than a standard review of the diagnosis and treatment of prostate cancer, and it is the first review of prostate cancer to appear in American Family Physician since 2005. To that extent, it should be seen as a key overview on the subject of prostate cancer for the primary care community.

The article makes a number of evidence-based key points about the treatment of localized prostate cancer for the family practitioner, as follows:

  • Treatment of localized prostate cancer is unlikely to improve the survival of [most] men with low- and very low-risk disease and all such active interventions have potentially negative effects on health-related quality 0f life.
  • Despite this information, some 70 to 90 percent of men with localized prostate cancer choose an interventional treatment shortly after a positive biopsy.
  • More than 50 percent of such patients significantly over-estimate the survival benefit of treatment.
  • Treatment of localized prostate cancer should normally be recommended for higher-risk patients.
  • Risk level can be estimated based on cancer stage and grade, PSA level, and comorbidity-adjusted life expectancy (CALE).
  • Patients can be counseled that surgery and external beam radiation therapy are almost equal in efficacy for the treatment of localized prostate cancer.
  • Brachytherapy is an appropriate form of monotherapy in low-risk, localized prostate cancer.
  • Active surveillance is a reasonable management option for low- and very low-risk, localized prostate cancer.

The article also includes a series of tools that may be useful to primary care physicians and their patients in assessing risk and the appropriateness of differing forms of treatment, including:

  • A questionnaire to assess  patient understanding of the benefits and risks of different treatment options.
  • A simplified algorithm (derived from the prostate cancer guidelines of the National Comprehensive Cancer Center Network) that can be used to aid selection of appropriate management of localized prostate cancer
  • A table to assist in assessment of a patient’s Charlson comorbidity index (CCI)
  • A table to assist in assessment of a patient’s comorbidity-adjusted life expectancy (CALE)
  • A table summarizing expected adverse effects at 2 years after treatment for localized prostate cancer
  • The Klotz (Canadian) protocol for active surveillance of men with localized prostate cancer (including indications for interventional treatment)

The article is supplemented by a handout for family physicians to use with their patients entitled “Prostate Cancer: Who Should Be Treated?” The full text of this brief handout is available on line.

Support group leaders and other prostate cancer educators are encouraged to ask the assistance of their family physicians or their local medical librarian in obtaining a copy of this article for their personal use.

It is inevitable that an article like this will not meet the approval of everyone in the prostate cancer community. It is an easy article to “pick holes in” if one is of a mind to do so. However, even with such limitations, what this article does do is to provide a series of tools and sound general information that will help the family practitioner to become more involved in the provision of appropriate guidance to patients diagnosed with prostate cancer — and particularly those patients of 60 to 80 years of age who comprise a significant majority of those being diagnosed with localized, low-risk prostate cancer today.

4 Responses

  1. As a support group leader I believe that we run the risk of “losing” doctor support in our groups when we educate new group members about AS and about going slow in their decision process. In fact I have heard that a few urologists and a radiation oncologist here locally in Las Vegas will not send their patients to see us. As one put it, “If I send a patient to Us TOO I will likely lose that patient.”

    Trying to rally the support of doctors with this “careful management” philosophy is a real challenge that must also come with influence from the doctors’ peers. These doctors need to understand that the support group isn’t there to discourage patients from their care ~ but rather we are there to enlighten those patients and help them make educated decisions. If an educated patient is not good for business, then that isn’t the support groups fault.

    But from a group leader’s point of view it also gets frustrating to hear that some doctors are not current with understanding disease management trends.

    We try to inform all patients about these points:

    (1) When it comes to doctor’s skills, 50% of doctors are below the median average.

    (2) A recent study showed that 43% of doctors will not change their approach to disease management even after being presented with compelling evidence that a better approach is available.

    (3) When it comes to prostate cancer, there is no specialized continuing education necessary after a doctor originally has his license issued. In fact, state requirements for continuing education for doctors are typically less hours than what is required for real estate agents and some state-certified construction contractors. The biggest difference is that the real estate agent and the contractor are required to show that they completed continuing education before a license is reissued.

    It’s actually way too easy to find a doctor that is below the median average, or who won’t change his ways, or has not even reviewed the latest information available about treating or monitoring prostate cancer … And I seriously doubt that most doctors who fit in any one of those categories will want to work with a support group that raises these concerns. … Especially when they see that we hand out that piece of paper.

  2. It’s reasonably shocking that it’s taken them 6 years to come up with this “review.” How many tens of thousands of men could have been offered the idea of alternatives to “interventional” treatment after biopsy by their family physicians?

    There’s free student membership on offer, and a $40 annual subscription to their journal, but if that’s the current standard of article, it’s not encouraging.

  3. This is to me good. If we can increase the discussion of differential diagnosis and appropriate treatment we may be able to take some of the pressure about over-treatment.

  4. Tony,

    Has the support group attempted to talk privately to the doctors? You may want to discuss this article with them, invite them to speak to the group and suggest that they look at this CME program. They may learn that you are not the enemy but rather just wanting the best for men. They probably have similar objectives. At least I hope so. It has sometimes worked with doctors in Virginia.

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