A duty of care in the management of prostate cancer

A new article in the journal Nature Reviews: Urology is entitled, “The implications of ageing and life expectancy in prostate cancer treatment.” It’s an important issue. The key focus of this article (by Kalra et al.) is on the increasing need to be able to accurately assess life expectancy for individual patients with prostate cancer so that we can then ensure that treatment is implemented (when necessary) with appropriate expectations about outcomes — and take account of the potentially differing needs of men with different life expectancies and with different priorities.

As Kalra et al. are clear to point out (as a subhead in their article):

Age is in the eye of the beholder.

We have all come across 75-year-olds who act and behave as though they are much younger, just as we have all come across 55-year-olds who act and behave as though they are much older. However, being able to predict, accurately, the life expectancies of two such individuals, just diagnosed with (say) “favorable” intermediate-risk prostate cancer, cannot be based on how they look and behave alone. A variety of other issues are also going to be critical, starting with any co-morbid conditions and the levels of the co-morbidities. The tools currently available to make such an assessment are not great. And where such tools exist, the correlation between the application of those tools and the accuracy of those tools in predicting life expectancy in men with prostate cancer is not good.

There are quite certainly other common, rare, and serious clinical disorders in which the patient’s individual physical and mental health status is fundamental to how the clinical team should be managing the condition. However, prostate cancer offers a perfect paradigm for such disorders because:

  • There may be very real questions about whether any type of treatment is necessary, let alone advisable, on an individual basis.
  • How treatment may affect very specific aspects of the quality of life of an individual patient may be crucial to that patient’s self-perception, self-esteem, and social functioning.
  • Some forms of treatment may have deleterious affects on the aging process (e.g., long-term hormonal therapy and its effects on mental functioning and cardiovascular health).
  • An older patient (and his spouse/partner) who still have a very intimate and active sex life could find their relationship to be utterly disrupted by the loss of that form of intimacy.

And that’s just for starters. Feel free to add to the list!

Furthermore, this is all true regardless of the patient’s age. The priorities will change among individuals as patients get older, but the concept of optimizing the patient’s overall outcome (as opposed to just his oncologic outcome) should surely, always, be a priority.

In talking with prostate cancer patients and spouses and partners, we hear regularly from at least some that they don’t feel that their doctors are actually listening to what they are saying. And of course we know that we are much less likely to hear from patients and spouses and partners who do feel that their doctors are listening. Those patients and their spouses and partners don’t feel the need to complain to anyone!

We are also well aware that many patients don’t really “hear” what the doctors tell them — for all sorts of reasons, ranging from insufficient education to understand what they are being told to blinding shock at the diagnosis of “CANCER!“. And then of course there are always the patients who just aren’t listening either!

Regardless, it would seem to us to be at best unethical for clinicians today to neglect to take serious and careful account of the many factors that can affect a prostate cancer patient’s overall outcomes in considering the management of his prostate cancer. The biological age, life expectancy, physical and mental health, and reasonable quality of life expectations of each individual patient would appear (at least to us) to be critical factors related to the care that any clinician is able to offer that patient. That’s true whether the patient is 40 or 85! What patients want from their doctors more than anything else is that sense of “care.”

It is therefore interesting to us that Kalra et al. seem to make almost exactly the same point when they raise a key element in a report issued some time ago by the Institute of Medicine. That report was based around the idea that patient-centered care and shared decision-making are and should be key factors in improving the quality of cancer care.

Kalra et al. use that concept in stating the following:

Prostate cancer management could be greatly enhanced for clinicians and patients if comorbid conditions and other biological determinants were used in the determination of life expectancy.

and that is on top of such other factors as the patient’s functional status, psychological state, social support network, cognitive function and capabilities, nutritional status, and the risks presented by polypharmacy (i.e., when patients are already on several other drugs for the management of other conditions).

If we are ever going to be able to implement truly individualized care for men with prostate cancer, we need to understand that “individualized”or “personalized” care is not just about whether patients have certain genetic or other biological markers that may be of interest to scientists. It is even more about the multiple factors that affect how a patient is likely to respond to particular types of care given his personal situation and circumstances — and his reasonable life expectancy as at the heart of that discussion.

As Kalra et al. also point out, the US has an aging population. By  2040 it is expected that there will be about 80 million Americans of age 65 years or more. About half of them will be men, and a lot of those men will be at risk for prostate cancer. Aging and life expectancy are already at the heart of high-quality management of prostate cancer, and the need to be able to integrate this issue into prostate cancer disease management protocols over the next 20 years should be a priority. We have a ways to go!

Editorial comment: The “New” Prostate Cancer InfoLink thanks Dr. Jeri Kim of the University of Texas M. D. Anderson Cancer Center for kindly providing us with a full-text copy of this article.



One Response

  1. Great post. I look forward to reading more from you.

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