“How to select the optimal therapy for early-stage prostate cancer”

The title of this commentary is also the title of a review article just published in Critical Reviews in Oncology/Hematology. While this is hardly a “first tier” journal for the average urologist or radiation oncologist, it is still gratifying to see an increase in this type of article in the peer-reviewed literature.

Kollmeier and Zelefsky make a series of critical points in this review:

  • Many patients will have a range of appropriate therapeutic options.
  • It is very important to consider whether, in fact, any therapy is necessary at all (particularly for men presenting with early-stage, low-grade, low-volume disease).
  • It is important to consider the side-effect profiles for all potentially appropriate treatment modalities.
  • Other factors also need to be considered, including
    • The medical condition of the patient
    • Emotional and psychological factors
    • Family/peer viewpoints
    • The patient’s perceptions about specific treatment options.

Doesn’t this sound much more like what an educated patient or support group leader might have been telling a newly diagnosed patient and his family than the sort of thing we have read in the scientific literature in the past? And ain ‘t that just great?

2 Responses

  1. Yes, Sitemaster, sounds like what many of us have been saying for years. But importantly, we now have the support of a recognized medical body. It does come about, however, at a time when active surveillance (AS) is being promoted for, as the paper says, “It is very important to consider whether, in fact, any therapy is necessary at all (particularly for men presenting with early-stage, low-grade, low-volume disease)” and then following with mention of the side effects that are well known to accompany other treatment options to somewhat “push” the active surveillance option.

  2. Honest, explicit, detailed descriptions of the risk of disease outcomes directly integrated into an honest, explicit, detailed description of the side effects of treatment including honest, explicit, detailed descriptions of the risk of side effects is the only ethical way to support diagnosed men in making decisions about prostate cancer treatment.

    Until a diagnostic process exists to distinguish what’s actually prostate “cancer” and what’s not, but is now being treated as such (loved Dr. Oppenheimer’s recent comments about the power of language in perceptions of risk of disease), this type of explicit conversation is the primary tool for protecting both men at risk of over-treatment and men at risk of dying from prostate cancer.

    Any clinician or advocate who has convinced him/herself that minimizing or trivializing likely impacts of the disease or the treatment of the disease (which includes the hateful, dismissive language of the AUA regarding radical treatment in any and all situations for younger men, and the recently updated NCCN patient guidelines) has crossed an ethical boundary, is engaging in paternalism, and needs to reexamine his/her moral compass. Upon examination of our attitudes and actions, most of us understand we’re in the wrong if we have to obfuscate, use euphemism, engage in lies of omission, and use other forms of fallacious reasoning and arguments to manipulate folks into doing what we think they should be doing whether we’re “saving their lives” or selling them a used car.

    The basic rules of human decency and respectfulness should apply to the economics of medical practice, including the treatment of cancer. I suspect history will remember this as a very dark period where many of the people treating prostate and other forms of cancer knew from the science that they were, in fact, “over-treating” many human beings, saddling them with the consequences of treatment for the rest of their lives, making a buck on it, and rationalizing their behavior by maximizing in their own minds the significance of remaining ambiguity in the science (e.g., FDA refusing to acknowledge preventive power of dutasteride) and minimizing and trivializing the impact of their treatments on people’s “quality of life” (a flip of the coin for irreversible impotence and other sexual dysfunction, urinary and fecal incontinence for prostate cancer, the disfigurement of mastectomy, the chronic pain and disability caused by lymphedema, etc.).

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