Many low-risk patients are not hearing about active surveillance as an appropriate management option

Current guidelines from the American Urological Association (AUA), the American Society for Radiation Oncology (ASTRO), and the National Comprehensive Cancer Network (NCCN) all clearly state that, for men diagnosed with low-risk prostate cancer, active surveillance is an appropriate form of first-line management. However, …

A recent paper by Broughman et al. in the Journal of the National Cancer Institute has shown that, among the men in this study who had both normal sexual function and a strong preference for maintenance of their sexual function, only 39.2 percent were actually receiving active surveillance as their initial form of management. Quite why this is the case is not entirely clear from the available data. After all, no one else was in the room listening to the conversations between the patients and their doctors. But it does make one wonder whether (a) some physicians are still not routinely advising all men with low risk prostate cancer about all of their options in a sufficiently “neutral” manner and (b) whether patients are asking their doctors the right questions and being sufficiently clear about their preferences.

The database on which this study has been based is the North Carolina Prostate Cancer Comparative Effectiveness and Survivorship Study of 1,194 patients. In this study:

  • 628/1,194 patients (52.6 percent) expressed a strong preference for preservation of their sexual function.
  • 566/1,194 patients (47.4 percent) had a lower level of preference about preservation of their sexual function.
  • Unsurprisingly, older men  were less likely to have a strong preference about preservation of their sexual function.
  • Also unsurprisingly, men with normal sexual function at diagnosis were more likely to to have a string preference about preservation of their sexual function than men with poor sexual function at diagnosis.
  • 568/1,194 patients (47.6 percent) hadboth low-risk prostate cancer and a strong preference about preservation of their sexual function, but …
  • In this group of 568 men, there was no indication of an association between baseline sexual function or strong preference to preserve sexual function and receipt of initial management on active surveillance.

One possible reason for this is a continuing belief among some physicians that their skill and their individual ability to treat their low-risk patients (surgically or in other ways) is such that the patients will retain their normal sexual function post-treatment. Quite why any physician  would believe this today — given all of the evidence to the contrary — is hard to imagine. But beliefs can be difficult to change.

Broughman et al. conclude that:

Treatment choice may not always align with patients’ preferences. These findings demonstrate opportunities to improve delivery of patient-centered care in early prostate cancer.

Some might have liked to see a rather blunter conclusion! And in another commentary on this paper, on the OncLive web site, it is worth noting some comments made by the senior author of the paper (Dr. Ronald C. Chen of the Department of Radiation Oncology at the University of North Carolina School of Medicine):

Unfortunately, we found that men who had low-risk prostate cancer and wanted to preserve sexual function did not necessarily choose active surveillance. … This indicates that many patients may not have known about active surveillance as an option.

The takeaway for prostate cancer patients is that they should always ask two important questions. One, how aggressive is my cancer? Two, what are my options? After understanding this, it is important they communicate with their doctor what their priorities are in making a decision among the available options.

Active surveillance is widely recognized to be an excellent option for patients diagnosed with low-risk prostate cancer, because it is the best option to preserve the patient’s quality of life, including sexual function.  Some patients with prostate cancer may initially want aggressive treatment, and it is important for the physician, urologist, and radiation oncologist to fully counsel patients about the slow-growing nature of low-risk prostate cancer and that active surveillance is a safe option.

The bottom line is that high-quality, shared decision-making is dependent on a full and careful discussion of the risks and benefits of all of the possible clinical options. Preservation of good sexual function is not going to be possible as a priority for men with high-risk prostate cancer if they want to have treatment. By contrast, preservation of the current level of sexual function is easily achievable for most men with low-risk forms of prostate cancer … if they are appropriately informed about the way active surveillance works and the high quality of the outcomes over time.

4 Responses

  1. This is criminal!

  2. Walt:

    I think it’s a little more complex than that. Many patients will simultaneously tell their doctors that their sex life is a big imperative and that “just getting rid of the cancer” is equally or even more important!

  3. So it would be a major big Washington government overreach for an insurance company (Medicare) or hospital to require an active surveillance waive before surgery?

    Or just a money grubbing lawyer to file a class action law suit for the benefit of those not informed?

  4. Men who are newly diagnosed with prostate cancer need to be told that … Every Prostate Cancer is Different … which leaves them with — What’s Mine? The answers are in their own medical records.

    There are currently five risk categories for newly diagnosed prostate cancer patients:

    * Very low risk
    * Low risk
    * Favorable intermediate risk
    * Unfavorable intermediate risk
    * High risk

    The first three of the above categories all have some component of an active surveillance option or recommendation; the last two categories have no real recommendation for active surveillance.

    Patients and caregivers can look up these five risk categories if they click here.

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