Clinical use of nomograms and other tools in prostate cancer counseling and prognosis

Clinical guidelines from such organizations as the American Urological Association (AUA) and the National Comprehensive Cancer Network (NCCN) call for measures designed to improve quality of care and facilitate better treatment decisions for men newly diagnosed with prostate cancer. The degree to which this really happens, however, is not well understood.

As an example, it is recommended that — in making decisions about the appropriate management of newly diagnosed prostate cancer patients — physicians and the patients themselves assess and incorporate risk stratification, functional outcomes, and life expectancy in selecting treatments appropriate and sensitive to each individual patient’s clinical characteristics and preferences. The types of tool that can be used to do this include things like the Partin tables, the Kattan nomograms, actuarial life expectancy charts, and a range of other quality of life (QoL) assessment methods and instruments.

A new paper by Kim et al., published on line this week in the Journal of Urology appears to be the first paper to really address the actual clinical use of such tools in day-to-day clinical practice.

In late 2011, Kim et al. queried a total of 1,422 prostate cancer specialists in the USA– including both urologists and radiation oncologists — through a mail survey, asking them for self-reported information on their clinical use of QoL instruments,  prostate cancer-specific nomograms, and life expectancy prediction tools in counseling patients diagnosed with localized prostate cancer.

Here is what they learned:

  • 641/1,422 physicians (45.1 percent) responded to the survey.
    • 313/641 were radiation oncologists.
    • 328/641 were urologists.
  • 55 percent of respondents reported using prostate cancer nomograms.
  • 27 percent of respondents reported using QoL instruments.
  • 23 percent reported using life expectancy prediction instruments.
  • On multivariable analysis,
    • Urologists were less likely to use QoL instruments than radiation oncologists (odds ratio [OR] = 0.40; p < 0.001).
    • Physicians were more likely to use QoL instruments (OR = 2.57; p < 0.001), prostate cancer nomograms (OR = 1.83; p = 0.009), and life expectancy prediction tools (OR = 1.85; p = 0.02) if they spent ≥ 30 minutes as opposed to < 15 minutes counseling their patients.

Kim et al conclude that, “Although [prostate cancer] nomograms have been implemented into clinical practice to some degree, utilization of QoL and life expectancy tools has been more limited.” They go on to note that, “Increased attention to implementing validated instruments into clinical practice may facilitate shared decision-making for [prostate cancer] patients.”

Now the key learnings that The “New” Prostate Cancer InfoLink takes away from this study are as follows:

  • If your physician spends < 15 minutes counseling you on your treatment options for localized prostate cancer, go and get another opinion from someone who is interested in trying to help you; any physician who is investing < 15 minutes in counseling a man with prostate cancer really does not appear to have the patient’s interests at heart.
  • Even if he or she is not using specific nomograms and related tools, any good physician should and will counsel patients about how age, comorbidities, and a range of other factors are likely to affect possible oncologic and overall outcomes after treatment for prostate cancer.
  • Any physician who has a patient’s best interests at heart, today, will mention multiple therapeutic options that are available for the management of localized prostate cancer and whether (and why) he thinks they are or are not potentially applicable forms of treatment for each specific patient; at the very least these should include open and robot-assisted forms of surgery, various marker-guided forms of external beam radiation therapy (there are a lot of these now), radioactive seed implantation (“brachytherapy”), and active monitoring of some type.

No physician is going to be able to tell a patient with absolute accuracy, up front, what his outcome will be after a specific treatment for localized prostate cancer. The best anyone can manage is a well-informed and well-educated estimate. Such estimates can be developed based on extensive experience and/or on the basis of systematically developed tools designed to help in prognosis. In the end, only the patient can decide what form of treatment is, for him, the one with the potentially greatest benefit and the lowest degree of risk … but to do this he needs to get good guidance and input from a knowledgeable and caring clinician.

4 Responses

  1. I would rather spend 45 minutes with a knowledgeable physician’s assistant without time pressure than an hour with a physician feeling time pressure. When the decision is made I would take the 15 minutes for the details of the procedure. There is just too much to absorb in those first days for a return on the physician’s time.

    Relaxed is more important to communication than facts. The facts are not hard facts, merely probabilities anyway.

    Wondering how many who have been through it feel the same.

  2. The pointers on what the physician should do are interesting … but there’s a catch. Many urology groups are now installing their own radiation facilities and contracting with radiation oncologists’s to come do that work. This is a point of contention in the radiation oncology community and the urology community that I have observed to be less than appreciated by the radiation oncologists. But your pointers do make a good case for patients to go to a more multidisciplinary facility so that they are not in need of pushing a specific treatment that the diagnosing doctor performs him- or herself. Anyway you slice it, however, whatever a doctor recommends will always have a flavor of conflict of interest.

    You also left out a very big piece. As a support group leader I do see some doctors sending their patients to a support group. But it’s not many. The fact is that if a doctor spent two hours with a patient going over all of the options, it would still not be enough time to develop what I would call a “well informed” or “educated” decision maker out of that patient. I think the only way that happens is in a support system, on line or live, that puts the patient in touch with his peers. I’ve been a part of that system now for 6 years and I know that most of the on-line patients I moderate are far better informed because questions can range from dumb to brilliant, in a store that’s open 24/7/365, and will get responses on any holiday. You can’t do that in a doctor’s office. So a patient that is willing to take the time to educate themselves can make a better decision when he has just that 15 minutes in the office.

    My goodness. Many patients I have met made their decisions at the mere suggestion of the only doctor they have ever seen for their cancer in a very short session. But I have observed these same patients spend months and endless timing searching out that perfect truck or car, that perfect camera or computer, or that perfect whatever with endless hours of research and yet 15 minutes was what they were willing to give before making a decision that will undoubtedly affect them for the rest of their lives.

  3. Tony:

    There are two quite different issues here in your comment:

    (1) The degree to which a patient can and should try to educate and inform himself using all available tools (including through good support groups and systems on or off line) … which we obviously encourage or we wouldn’t be doing what we do!

    (2) The attitude of a physician who would even consider that spending 15 minutes to “inform” a newly diagnosed patient was sufficient.

    We would never suggest that 30 minutes or even 2 hours with one physician was enough for a wise patient to become fully informed. Our point was that spending < 15 minutes with any newly diagnosed cancer patient shows a crass lack of emotional wisdom on the part of the diagnosing physician. It's barely enough time to explain one option, let alone the fact that there might be three or four.

  4. I guess my point is also that doctors cannot absorb all the blame for the 15 minute debacle. Many doctors have patients lined up out the door at HMOs or the VA or wherever. Yes they need to spend more time than that but adding five doctors to the second opinion list might still be deficient. My suggestion is better educating the doctors on the value of support groups, and to participate in them as well.

    I have heard, through the grapevine, of some doctors who would NEVER send patients to an Us TOO meeting because it’s not good for their business. “I’ve lost many patients when I send them there” was a specific comment I heard that I use to outline the general perception that many doctors have.

    The fact is we do not discourage that doctors offering of therapy, but we encourage the idea that the best decisions are educated decisions for individual patients, and we give those patients much food for thought. Sometimes that makes the patient move on to other options. This is a good way for patients to get educated and it’s also a good way for doctors to show good faith practice by adding a support mechanism to their recommendation list.

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