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PROSTATE cancer, as the most common cancer (aside from non-melanoma skin cancer) diagnosed in men and the second commonest cause of cancer-related death in men, represents a significant and growing health problem.
The fact that prostate cancer (PC) is more frequent with increasing age, and can have a slow natural history, presents unique challenges in its diagnosis and management. The risks and side effects of treatments have to be carefully weighed against the probability of the cancer progressing, causing symptoms or leading to death. Advances in diagnostic tests, selection algorithms, surgical approaches, radiation therapy techniques and medical therapies have led to progressively improved outcomes for PC patients over time.
A recent article in MJA InSight by Professor Ian Haines cites anecdotes from the author’s self-selecting patient cohort and proffers the opinion that urologists are telling patients that “they need immediate treatment or they will die” and “invariably, this is robotic surgery”.
The reality, however, is very different.
In selecting between various management options for PC, an individualised and informed choice needs to be made, taking into account the particular benefits and side effects of each treatment option, as well as the features of the cancer and patient preferences. Men and their families are provided information on treatment options from a variety of sources and they are supported in their decision making.
In this process, the Prostate Cancer Specialist Nurses program, run by the Prostate Cancer Foundation of Australia (PCFA), has been a huge step forward, but more patients need access to such support.
As clinical practice evolves with accumulating scientific evidence, an increasing proportion of men with low-risk cancer are now managed by active surveillance. Many men are also referred for and undergo primary radiation therapy. In fact, data from the Prostate Cancer Outcomes Registry show that over the years 2013 to 2015, 40–50% of men in Victoria with newly diagnosed prostate cancer underwent treatments other than surgery.
While decision regret can be an unfortunate outcome of any PC treatment, the rates remain low and comparable between treatments.
The study quoted in Professor Haines’ article as showing a major difference between surgery and radiation therapy addressed a somewhat different question in a selected sample of men who had not been cured by surgery.
In addition, multidisciplinary collaboration is a key factor in implementing better management of PC, particularly in Australia, where this is practiced better than in many settings around the world. The recently released clinical practice guidelines on prostate specific antigen (PSA) testing and management of early stage prostate cancer, developed by a broad multidisciplinary group brought together by Cancer Council Australia and the PCFA, exemplifies this approach. The achievement of such a consensus is unique internationally, and for the first time, it provides a rational basis for using the PSA blood test for early detection to maximise benefits while minimising potential harm.
Moreover, in line with Cancer Australia recommendations, much of PC management is now undertaken in a multidisciplinary clinical setting. A study in 2012 reported that about a third of newly diagnosed prostate cancer patients were discussed at an institutional multidisciplinary meeting (MDM). As the number of MDMs has increased, and particularly with their implementation in many private practices and institutions, the proportion of patients’ cases being discussed has increased significantly. Ideally, all men being treated for prostate cancer should have access to an MDM review or be seen by both a radiation oncologist and a urologist prior to finalising their decision.
Finally, through the Australian and New Zealand Urogenital and Prostate Cancer Trials Group, cooperative trials have been developed and implemented, often in collaboration with other groups such as the Trans Tasman Radiation Oncology Group and the Urological Society of Australia and New Zealand, to examine many aspects of PC management.
Notable interdisciplinary trials have included the RAVES trial of adjuvant versus early salvage radiation therapy after surgery, and the ENZARAD study of novel hormonal therapy with radiation. Results from these studies will help further improve the care of prostate cancer patients, and men who are eligible should be informed and provided an opportunity to enrol.
Although much has been achieved to date, more remains to be done, and will need ongoing coordinated multidisciplinary effort. Individual outliers who practice outside of these principles, or vocal critics who seek to undermine them, should not distract from our focus on improving the management of patients with PC.
Associate Professor Shomik Sengupta is a urologist at Austin Health and the University of Melbourne, and Genito-urinary Oncology Advisory Group leader with the Urological Society of Australia and New Zealand.
On behalf of:
- Professor Ian Davis, medical oncologist at Eastern Health and Monash University, and chair of the Australian and New Zealand Urogenital and Prostate Cancer Trials Group;
- Professor Mark Frydenberg, urologist at Monash Health and Monash University, and president of the Urological Society of Australia and New Zealand;
- Associate Professor Chris Karapetis, medical oncologist at Flinders Medical Centre and Flinders University, and chair of the Medical Oncology Group of Australia, Inc;
- Associate Professor Andrew Kneebone, radiation oncologist at Royal North Shore Hospital and University of Sydney, and co-chair at the Faculty of Radiation Oncology Genito-Urinary Group; and
- Associate Professor Anthony Lowe, CEO of the Prostate Cancer Foundation of Australia.
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I have had RRP and left 100% ED and incontinent so far, being a professional from a different discipline I have some empathy with the Urologists situation I elected to go with a top surgeon even though it was all out of pocket.
He was so busy it was like a production line, first reality is this guy has to be fully focused on his part of the process for my best outcome and in that he was.
There where other resources to follow up any issues and I am expected to access these as required.
The problem I see is we the patient need to understand the workload these guys have and be resourceful in following up resources available, there is a whole continence clinic in the hospital where I was operated that if there is not a satisfactory recovery I will access.
Be proactive he has done his job we have the condition there are resources but we need to go back to our GP and find what is now relevant.
I knew that after ADT I would be impotent, but nothing more. I was not told, certainly not prepared for the nervous breakdown, suicidal thoughts, loss of friends. I was not told that there was a prostate cancer foundation, nor any support groups. I was left to fend for myself.
Being well informed is NOT the same as being well prepared. You could be informed that a bushfire is approaching, but that is not the same as being prepared to stay and defend your property. Men who are diagnosed with PCa will probably be informed of the quality of life risks associated with treatment, but they are not prepared for the consequences. Men are not told of the likelihood of a particular outcome, especially when it comes to ED, and they are certainly not prepared for the severity of the consequences. Urologists give their patients very unrealistic expectations. Informed; yes. Prepared; no. If urologists don’t believe this, then they have not spent enough time talking to patients a year or two after treatment.
My husband’s PSA level was quite low but doubled in 7 months. Three months later he had a biopsy with a resultant Gleason score of 7, being a 4 plus 3. We listened to his urologist and looked at the options using the Prostate Cancer Foundation booklet and decided upon a radical prostatectomy a further 3 months later. Thank goodness we did as his prostate itself enlarged dramatically In that time and attached itself to the bowel and bladder, meaning that his surgery was huge and there were severe post surgical complications. In spite of this, he was back at work 6 months later.
We chose radiation therapy 3 months post op as his margins were not clear and all went smoothly for 2 years afterwards, with zero readings on his PSA tests. Unfortunately, he debeloped bladder neck contractures and strictures which placed his life in extreme danger. The emergency doctor tried to clear these in outpatients for 5 hours with no pain relief before he was rushed for emergency surgery but long term irreparable damage was done to his nerves and muscles. Shortly afterwards, he became utterly and completely incontinent and was in constant agonising pain but our original urologist (who’d been wonderful pre and post op) declared that he’d have to live with it. We felt alone and very unsupported as he could not even go to a supermarket or anywhere without a huge puddle just rushing down his legs and he could not get away from this pain.
We spent many hours on the internet looking for support and alternatives, contacted the Prostate Cancer Foundation, and tried many other avenues but no one was interested.
Eventually I found a urologist in Sydney who specialised in this type of complication and he underwent surgery to have an Artifical Urinary Sphincter inserted. This has been life changing and whilst, not the outcome we expected, has meant that he can return to an almost normal level of life. 4 years later his PSA is still zero.
There needs to be more research and support for the men who suffer this debilitating condition post op and post radiation as the lack of support, interest and assistance was appalling.
In my experience, if I may change the quote slightly, “The amount of information, and the degree of support given by a urologist can vary enormously from patient to patient”.
If I had not the will, or the means to find out for myself, I don’t know where I would be today.
” urologists are telling patients that “they need immediate treatment or they will die” and “invariably, this is robotic surgery”. The reality, however, is very different.”
As a man who has recently been treated for prostate cancer, my personal experience is completely opposite to this comment from the author. The amount of information, and the degree of support given to a patient varies enormously between doctors. There are still plenty of urologists who believe all they need to do is remove the cancer and that the quality of life issues after surgery is nothing to do with them. The urologist who performed my biopsy did nothing but advertise his own surgical expertise and did nothing to help after surgery when I had a string of ongoing complications. Not good enough!
I make two points.
First, I have further interesting anecdotes which are that a number of radiation therapists and other experts in this field have communicated with me since my article on ‘The scandal of prostate cancer management in Australia’ to congratulate me and say they fully agreed. The radiotherapists said they cannot comment publicly because it will affect their professional relationships with urologists they work with.
Second, this is not personal and I have very good relationships with many of my urology colleagues. This is a contest of ideas using landmark data about a major major public health issue/scandal for AUSTRALIAN men. The current ad-hoc management of this ‘disease’ must continue to be addressed properly by the NHMRC and by multidisciplinary teams of experts largely free of financial conflicts of interest. The physical, psychological and financial costs for AUSTRALIAN men and our health system are too great to do otherwise….. and to do it soon before too much more unnecessary harm is done.
I suspect that the Poll question 1 should be in two parts, (a) referring to overtreatment and (b) referring to underinformed. The more I have to do with PCa patients, the more I hear of lack of information.
TURP early ’09 age 66. PSA about yearly in the 4s until mid ’14 when 8.0.
MRI showed tumour through posterior capsule heading for the rectum
Bx Gleason 8! One urologist called it inoperable. I had radical surgery, fortunately the rectum was well clear.
Now healthy without DXRT
I had a very enlarged Prostate (80ml) which in theory should be benign, but had it biopsied because of a recent rapid rise in my PSA – though not very high in absolute terms. Low grade CA was found in two adjacent locations out of nine samples.
My Urologist told me first that my low grade CA would be likely to cause me no problem for about 10 years if we did nothing and that with a TUR for the enlargement and obstruction, and some radiotherapy I could be confident of no problem inside about 15 years.
I was 66 at the time. My answer was that on general family form I could expect otherwise to live into my late 90s or beyond. So, I’d sooner not gamble and was inclined to proceed to radical prostatectomy. I have no regret about that choice despite some sexual dysfunction. Who wants to live with uncertainty?
I know two other members of my graduating year in medicine who have made the same decision. Both are Urologists.