Why is this debate still going on at all?


The question between different types of physician as to whether radiation therapy or surgery is “better” for the first-line, curative treatment of localized prostate cancer has now been debated (over and over) for more than 40 years.

In truth, however, it is high time that all participants in this debate need to look at this question from the perspective of the patient and not from the perspective of the medical practitioner. And, in any case, the vast majority of men diagnosed with very low- and low-risk forms of prostate cancer should now be advised that active surveillance is or at least may be the appropriate form of initial care in their cases. That fact has radically changed the nature of the debate.

Given that perspective, many may be interested in two recent articles on the CancerNetwork.com web site. They are:

(The “New” Prostate Cancer InfoLink should be clear up front that Dr. Moul has, for several years, been the chairman of the Scientific Advisory Board of this service of Prostate Cancer International.)

The problem with this type of “point”/”counterpoint” discussion is that has become outdated. It is based on a set of 20th (as opposed to 21st) Century perceptions about the “curative” nature of treatment for supposedly localized prostate cancer.

In today’s world, in determining what to do with a patient who is newly diagnosed with prostate cancer, there are a whole bunch of questions that need to be addressed before we even get to the question of how to treat him. Those questions include:

  • Does this patient actually need immediate treatment at all?
  • If this patient doesn’t need immediate treatment,
    • Is he willing to accept and “live with” active surveillance, at least for a while?
    • Is he still insisting that he wants to have immediate treatment because he just wants the cancer eliminated?
    • Does he have a full appreciation of the risks and benefits of monitoring as opposed to treatment under his individual circumstances?
  • If this patient does need immediate treatment, because he has a higher-risk form of prostate cancer,
    • What is the chance that his prostate cancer will recur after first-line treatment?
    • Is he absolutely averse to any particular forms of treatment?
    • Does he have priorities with regard to (for example) maintenance of erectile/sexual function?
    • What does “quality of life” mean for him as an individual?
  • What are all of the available forms of first-line treatment for localized prostate cancer, along with their risks and benefits?

It is the very humble postulate of The “New” Prostate Cancer InfoLink that there is no longer (if there ever was) a “right” or “better” form of first-line treatment for localized, potentially curative prostate cancer in general. The question of what is the “best” form of therapy for an individual patient is very highly dependent on numerous factors that are going to be important to that particular patient. Those factors need to be teased out and discussed.

What is more, there are patients who, in the opinions of their doctors, may really need treatment, but who would prefer to have active monitoring of some type.

And then there is the question that is commonly avoided by the radiation oncology community in discussions with patients. Even if radiation therapy is the most appropriate form of treatment for an individual patient, which is the most appropriate form of radiation therapy for this particular patient?

The question of how a specific patient should be treated for localized prostate cancer today is best determined by placing the patient himself at the center of the discussion and then ensuring that he is being carefully listened to, educated, and informed by physicians who may have different perspectives — and someone in the room (a real “patient advisor”) should be a neutral third party whose only interest is in helping that patient to come to a decision that works for the patient himself!

It is not, in our opinion, the responsibility of the medical profession, to set out to “cure” every case of prostate cancer. Rather, the responsibility of the medical profession to help each, individual patient to understand his individual situation and the risks and benefits of treatment — if it is needed or insisted upon. The patient then needs to make the final decision.

Of course the patient also always has the option to say,  “I dunno doctor, what would you do?” Any such patient should be referred, without fail, to a physician who is not going to treat him but who has the knowledge and the experience to help make the best possible decision for that patient and refer him to the best possible provider of the relevant form of care.

6 Responses

  1. Why is this debate still going on at all?

    The answer has been patently obvious for a long time:

    Given the overwhelming evidence that financial conflicts taint practitioners, it seems reasonable to ask those same practitioners for some basic standards of evidence.

    It is shameful of you that you ignore this fact.

  2. Dear Mr. O’Neill:

    Conflict of interest is just one of several of the reasons, and we have never ignored it. It is a fact of life across the entire US healthcare system because of the way that system is designed and functions.

  3. Very well said, thank you! This type of position paper is good for all of us to read!

    As a Gleason 9 patient, T1cN0M0, I would be very interested to see your “op-ed” on options for that condition as well. Current thinking is that radiation is “better” than surgery. Your thoughts could be as helpful with forms of advanced cancer as you provide here with forms of low- and intermediate-risk cancers. IJS. :-)

    Thank you again!

    Steven

  4. Mike:

    Thanks for simply saying this, “it is high time that all participants in this debate need to look at this question from the perspective of the patient, and not from the perspective of the medical practitioner.”

    I like to point out that the 2017 AUA/ASTRO/SUO Guidelines (for medical practitioners) say the same thing in several ways — first and foremost by putting a prostate cancer patient on the panel this time.

    But also this — from the Shared Decision Making Section:

    “1. Counseling of patients to select a management strategy for localized prostate cancer should incorporate shared decision making and explicitly consider cancer severity (risk category), patient values and preferences, life expectancy, pre-treatment general functional and genitourinary symptoms, expected post-treatment functional status, and potential for salvage treatment. (Strong Recommendation; Evidence Level: Grade A) …

    “3. Clinicians should encourage patients to meet with different prostate cancer care specialists (e.g., urology and either radiation oncology or medical oncology or both), when possible to promote informed decision making. (Moderate Recommendation; Evidence Level: Grade B)

    “4. Effective shared decision making in prostate cancer care requires clinicians to inform patients about immediate and long-term morbidity or side effects of proposed treatment or care options. (Clinical Principle)”

  5. Good post. The questions and discussion about “surgery v. radiation” should include the financial toxicity to the patient.

    Not all carriers pay the same depending on treatment and that too is a challenge that patients must face before diving into a decision. Insurance has been shrinking coverage in the last 6 years, making the patient burden much higher than in the past. Knowing that your carrier will pay most of the treatment (typically 80% but not always) leaves a financial decision for the patient that the medical practitioners know far too little about. This is very important to stress to high-risk patients who may end up with follow-up care for years to come. If money is no object then great but that does not represent the typical patient at diagnosis and this should be considered.

    Lastly, the old argument that you can do radiation after surgery but not vice versa is still in play and will affect decisions. That argument has not changed. Additionally, having the whole prostate for analysis after surgery still gives a best picture of the state of the disease. That will potentially be more valuable as we continue to progress with molecular biomarkers.

    Just a note: SWOG’s soon to be released trial S1802 will test radiation vs. surgery in mHSPC at presentation. But that still leaves a huge gap between those that do not need treatment and the men in this trial, where a trial won’t answer this article’s topic.

  6. Thank you Jan for adding the SDM statements. And you know I was on that panel writing these guidelines and it was a very interesting section from a patient advocate’s perspective. We had to wordsmith it a bit but we were all in agreement with these statements.

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