A couple of years ago I participated in a small group discussion as part of a larger conference on the problems of getting more people to take cancer screening seriously.
During the course of that discussion the topic turned to prostate cancer early detection, a topic that I have covered previously.
I distinctly remember the comment of one of the members of the group, who happened to be the director of a large national employer based group interested in health care issues. This representative, who happened to be very knowledgeable and very influential, was also very direct.
Her comment was to the effect that when it came to prostate cancer screening there were so many different recommendations and so much “noise” that it was confusing to her constituents, not to mention their employees as to what the right thing was to do with respect to prostate cancer screening.
Get your messages straight, she said, and then we (the employer community) will know what to do. In the meantime, don’t blame us if we don’t seem too enthralled with encouraging prostate cancer screening.
You may or may not agree with such a blunt assessment, but it is an honest one.
Over the past several years, there has been a sea-change developing in medicine demanding that we develop evidence based information to guide the care decisions that we make for our patients. We want to be able to provide clear, evidence-based information to our patients about what the best treatment is for their particular condition.
That’s not to say there isn’t a lot of art in the practice of medicine. There is still much we don’t know, and there are many treatments offered to patients that have't been confirmed in well done, rigorously designed clinical trials.
Which brings me to my topic today regarding the treatment of prostate cancer.
The sad fact is that the same confusion that exists for the screening of prostate cancer applies to the treatment of prostate cancer as well. We don't have the evidence we need to provide the clarity of message that our patients expect and want in their time of need.
There are many different ways to approach the treatment of a man who has been diagnosed with prostate cancer. A number of variables are factored into the equation, including the man’s age, his overall health and life expectancy, and the grade, size and extent of his cancer, for example.
Then there comes the question of what type of treatment should be used. Should it be radical surgery? With or without robotic assistance? How about external beam radiation therapy? Or should you have radioactive seeds implanted into the prostate? How about a combination of both radiation types? And what about IMRT (intensity modulated radiation therapy), which concentrates the radiation beam, allows higher doses to be administered with fewer side effects? Or should you travel to a center that uses proton therapy which is even more focused and intense radiation? And don’t forget the newest wrinkle, which is using CT scans on a regular basis to reposition the radiation beam.
And after you, the patient and your family, digest all of that information, there is the real decision: should you receive treatment at all? If you are older, infirm, or have a small, low grade prostate cancer there is a reasonable probability that your prostate cancer may never bother you again. So no treatment or “watchful waiting” may be right for you.
If you decide to receive surgery or radiation, the reality is that the treatment may in fact be worse than the disease in your particular case.
This can all be very, very confusing to someone who has just been diagnosed with prostate cancer.
There are these days no shortages of professional, knowledgeable medical opinions available. Unfortunately, from my experience, you usually get one recommendation from a surgeon, another from a radiation oncologist, and your family doctor probably doesn’t have the knowledge basis on which to make an absolute firm decision.
There are also databases available which may help you decide what to do. Fortunately, some doctors are collecting the results of thousands of cases and keeping track of treatments and results. That may give some idea of what the best treatment may be for you.
The problem is that treatment at times can be a moving target. For example, take robotic surgery. There is a long history of surgery in the treatment of prostate cancer, so the doctors have a pretty good idea of what the outcomes are going to be percentage wise. But along comes robotic surgery, and now more doctors are doing radical prostate cancer surgery. We won’t know for many years whether or not this new technique is going to significantly impact the results in prostate cancer surgery—for better or worse.
And the radiation techniques keep changing, so we don’t have a decades long experience with any radiation treatment approach to know, again, what the long term results are going to be.
This past weekend, at a prostate conference sponsored by the American Society of Clinical Oncology in San Francisco, a new bit of information was added.
A researcher from Philadelphia examined data from a nationwide, government sponsored cancer registry called SEER which they merged with Medicare data to determine the answer to a simple question: does treatment make a difference? Do men who receive radiation or surgery live longer having undergone some form of therapy?
Sounds somewhat elementary and simple, but recall my earlier comment that “watchful waiting” was appropriate for some men depending on their disease status and other considerations.
In this study, which examined the medical records of nearly 50,000 men, they found that treatment (either with radiation or surgery) did in fact make a difference and that the men who were treated—even older men over 75 years of age—did better if they received some treatment. The researchers said in their abstract that they considered whether or not there were any differences in the medical conditions of the men that might account for the difference they observed, and could find none.
The study wasn’t designed to find out whether one form of treatment was better than another. But the data was sufficient for them to conclude, “In the absence of randomized studies comparing radical prostatectomy and radiation therapy, eligible men should be considered for (treatment).”
I don’t know that this study is going to change anything that doctors do or that I would recommend to a patient. But it is going to increase the debate, especially about men ages 75-80 at the time of diagnosis.
There have been other studies reported recently that came to different or opposing conclusions.
One study in the Journal of the American Medical Association reported in 2004 concluded that their findings supported treatment of men with early stage prostate cancer early in the disease, especially if the man had a life expectancy over 15 years.
Another study, reported in the same journal in 2005, said that is not the case because they could in fact not find evidence that men with low grade prostate cancers showed a benefit from early treatment. These men did not have an increased rate of death from prostate cancer if they lived more than 15 years.
So who is correct in this debate?
The reality is there is no right and wrong here.
Clearly we need to keep studying the issue and develop better information. And we need to see the abstract presentation come out in a peer reviewed medical journal so we have more information to look at and help us understand better how well the study was done and whether it should have a significant impact on how we treat our patients.
In the meantime, being informed is your best friend. Learn what you can from your doctors, and get information from reputable web sources hosted by organizations such as the American Cancer Society, the National Cancer Institute, and the National Comprehensive Cancer Network, where you can find both professional and patient-friendly information discussing your treatment options.
Don’t ignore the fact that your personal physician—the person that knows you best—may be able to walk you through some of the decisions. They may be able to help you sort out your options and what is best for you.
Ultimately, I hope that we eventually get to the point when we can find our way through the noise and the clutter. We have done a lot of excellent work in prostate cancer over the past couple of decades. We can find the disease earlier, and we have more men surviving prostate cancer than ever before.
But our journey is not going to be over until we are able to tell which men really need treatment, and which treatment is best for them.
We still have a long way to go.
