Finding common ground on how “best” to treat localized prostate cancer, and what to tell the patients

One of the hardest issues for newly diagnosed prostate cancer patients to deal with has long been the differences in opinion between physicians about appropriate first-line treatment (and the relevant information they are offered) — most especially for patients with localized disease.

The advent of multidisciplinary prostate cancer clinics (which dates back to the mid-1990s, when one of the very first such clinics was set up at Thomas Jefferson University Hospital in Philadelphia) has helped to address this issue, but a more recent initiative in the Toronto region of Ontario, Canada, seems to have taken this to a whole new level, which is inclusive of community-based (as opposed to academic) multidisciplinary prostate cancer clinics.

The initiative is described in a paper by Loblaw et al. in the February issue of the Canadian Journal of Urology. The full text of this paper is accessible for free on line. The basic intent was that a multidisciplinary group of urologists and radiation oncologists should try to reach consensus on a bunch of things like these:

  • Which patients should be offered active surveillance (and which shouldn’t)?
  • What forms of treatment should be discussed with which patients, based on their risk category at diagnosis (i.e., low-risk, favorable intermediate-risk, unfavorable intermediate-risk, high-risk, very high-risk, node-positive, metastatic)
  • Which patients should not be offered which types of treatment, and based on what reasons?
  • If a patient is appropriate for several types of treatment, what outcomes information should they be given, and based on what data?
  • Are there subgroups of patients (beyond their risk level) who may have different types of outcome associated with different types of treatment (with respect, for example, to erectile function post-treatment)?
  • When should patients be offered adjuvant or salvage external beam radiation therapy after first-line surgery?
  • What are the appropriate options for treatment of patients progressing after first-line radiation therapy?
  • What are the appropriate options for treatment of patients progressing after first-line high-intensity focused ultrasound?

The full list of initial issues is listed in Table 1 of the paper by Loblaw et al. (see above). This list of issues was then  “blown out” into a total of 86 questions that a group of 32 urologists and 8 radiation oncologists set out to answer together, as a group.

Approval for the answers to each question required 75 percent of the respondents to agree to the answer. When there was no consensus to the right answer for a specific question, the answer was re-phrased and re-submitted to the respondents for their approval. And (perhaps astonishingly), after just three rounds of submission and re-submission, at least 75 percent of the respondents agreed to all proposed answers to all 86 questions with an average approval rating of 89 percent (range, 75 to 100 percent).

Now the paper does not list out all of the questions and all of the approved answers developed through this process, so quite how good the answers are to each of the questions is not immediately transparent. However, what is important here is the idea that an entire group of 40 physicians who treat prostate cancer at several different centers could and should come to a consensus about the information being provided to all of their patients based on their risk level and other factors.

Loblaw et al. write that:

Our hope is that this document will become a regional “de facto” standard and since September 2015 we have already seen the positive effects of this process on the patients whose care we share.

Now we do have one criticism of the way that the group went about this process, and that is the apparent absence of any knowledgeable patients or patient advocates in the process. We are not suggesting that the patient or the patient advocates should have been voting on the answers to the questions raised, but … It does seem to us that there was the opportunity for knowledgeable patients or their advocates to be helping to ensure that (a) the right issues and questions were all being raised and that (b) they could subsequently have been invited to comment (politely) on the quality of the answers that had been approved by the group.

With this proviso, we wish to clearly commend Dr. Loblaw and his colleagues for seeking this type of consensus on the quality and consistency of the information being provided to newly diagnosed patients by their group in the Toronto area, and we very much hope that similar initiatives can be implemented in other areas across North America and elsewhere around the world.

2 Responses

  1. This is very good stuff, all around:

    – The initiative itself, to create a productive symposium under a big tent;
    – The process by which a good consensus was achieved;
    – The willingness to engage in the process to completion without any apparent signs of internal politicking;
    – The sitemaster’s straightforward reporting and excellent small points of critique.

  2. The Toronto group has kindly shared with me a copy of the booklet that is distributed to all patients about the key therapeutic options that they recommend to patients in association with this initiative. It includes information about active surveillance, open and robot-assisted forms of surgery, low- and high-dose rate brachytherapy, and standard and hyperfractionated forms of external beam radiation therapy. It also mentions the role of androgen deprivation therapy — but it is not a booklet primarily for men with metastatic forms of prostate cancer.

    The booklet is simple, thorough, straightforward, but not exhaustive. It is one of the few patient booklets prepared by physicians that I have seen which appears to be completely honest about the risks for erectile dysfunction post-treatment. However, …

    (presumably because the group is still testing this multi-center informational process) I have been asked not to share this booklet on the Internet at this time, and I shall be complying with that request.

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