Smart mangement of localized prostate cancer begins with real communication

As we all start to think about becoming smarter about the real life use of the PSA test and applying greater thought in the use of various forms of monitoring rather than jumping straight to invasive treatment for what may well be relatively indolent forms of prostate cancer, some in the research and clinical communities have started to look hard at these issues too.

We would like to draw our readers attention to five articles that have appeared recently in the journal JAMA Internal Medicine — a journal primarily written for those in the primary care community. The first two of the five articles are:

Unfortunately, for these two articles, the complete texts of the articles are not available on line.

The other three articles are:

In the case of these three articles, the full texts of the articles are all available on line.

The fundamental topic being addressed by all five of these articles is how can we do a better job of not diagnosing prostate cancer when it doesn’t need to be diagnosed while effectively practicing patient-centric medicine, i.e., medicine that recognizes the rights of patients to be fully engaged in decisions that affect them clinically.

We are not going to try to get into the details of all five of these papers, but here are some of the things that appear to come across with great clarity:

  • The fact that the PSA frequently gives patients data that cannot tell them, definitively, that they don’t have prostate cancer is inherently a problem, and can lead, frequently, down the slippery slope to biopsies and treatment even when treatment is very hard to justify.
  • Once the decision to have treatment has been made, the treatment tends to be aggressive — even if aggressive treatment is actually difficult to justify because of the risk level of the cancer or the inevitability of side effects or the fact that the patient will almost certainly die of something other than prostate cancer even if he is just monitored.
  • How people think about prostate cancer risk (and therefore of the risks and benefits of the PSA test) and how their options are presented to them can profoundly influence their decision processes.

While it is difficult to see how to put much of the data discussed in great depth in these five articles into a real and practical context for a patient and his doctors, what we do know is that these five papers start to open new doors to the whole discussion about the diagnosis and treatment of prostate cancer because they all have one common key — that is that communication between patient and doctor is at the very heart of the decision process, and this is a fact that is still, all too often, overlooked as a critical factor in the management of many disorders (and prostate cancer in particular).

For the serious prostate cancer advocate, we recommend you read every one of these articles that you can get your hands on. Once you have done that, also have a look at the other article that we have already posted today (based on an interview with Dr. David Penson). Leaders in the urology and the primary care community are really working hard at what can be done to bring really sound knowledge and a patient-centric approach to this entire discussion, but it isn’t going to be easy until we have simple tests that will allow a physician to look at his 70-year-old patient and say, “There is only 1 chance in 100 that your prostate cancer will ever have any clinical impact in your life time.”

Even then, there will always be a subset of patients who react by saying, ” I don’t care if it’s 1 in a million. Get the cancer outta there!”

4 Responses

  1. Another great PCInfoLink article. The points made here are obvious to everyone except treating urologists and prostate cancer patients.

  2. Hmmm … They may also not be obvious to a significant number of treating radiation oncologists!

  3. Just in case no one has told you this in a while, thanks for all you do for us. I know this must take an incredible amount of your time.

  4. I recall coming across Tom Feeney’s site early in my personal journey. In the Watchful waiting section, he quotes from a study by Flood et al. on “The importance of patient preference in the decision to screen for prostate cancer.”

    This, so Tom said, was the result of two studies of men being screened.

    In the first study (of men responding to free screening offers), one group was shown a video that contained full disclosure of risks and benefits. The other was shown a video, designed by a pharmaceutical company, which made no mention of the existing controversy and only casually mentioned potential serious complications.

    In the second study (of men scheduled for a routine physical) one group was shown no video and the other was shown the full disclosure video.

    In the first study, among those who viewed the video that gave only partial disclosure, 26.4% said they would prefer watchful waiting over treatment if they were found to have cancer.

    In the second study, 85.9% of those who viewed the full disclosure video said they would prefer watchful waiting if they were found to have cancer.

    It was a little less than 20 years ago that the study was published (coincidentally in the year of my diagnosis — 1996), so it is good to see that there are some folk who now believe in full disclosure.

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