BERKELEY, CA (UroToday.com) - Current prostate cancer (PCa) management is not one-dimensional but includes many aspects that may surpass the competence of individual PCa specialists.
Quite important is the view that we are not just dealing with PCa, but treating and managing patients. Several studies have explored patient-specific expectations of PCa management, while others have investigated physician’s perceptions. However, direct comparisons have seldom been made. The study presented in the abstract ‘PCA: Prostate Cancer, Patient-Centred Approach or both?’ and published in BJU International[1] tried to fill this gap in knowledge by comparing the opinions of both groups via questionnaires on patient-physician communication and patients’ expectations of PCa management.
The data generated by this study may complement our current knowledge of best practice and optimal patient care. Based on the survey outcomes, it is clear that there is room for improvement in fulfilling the expectations of PCa patients. Not only the amount of time spent during a consultation (either for delivering the diagnosis or prognosis of PCa or for discussing treatment options) which was deemed insufficient by a large proportion of patients, but also the information given by the treating physician was considered too limited. The physicians claimed to have provided information to their patients to a much greater extent than that the patients reported to have received it. This discrepancy may point to some aspects in patient management that need focused attention in future care, i.e. providing information to the patient in a gradual way, tailored to the patient’s level of understanding. Alternatively, this observed discrepancy could be related to limitations of the study, namely that most patients were diagnosed more than 5 years prior to their questionnaire completion, which could have influenced the accuracy of their memory and related data reporting in this survey. In addition, the physicians who completed the survey were not the physicians who had actually treated the patient respondents, i.e. the surveys among patients and physicians were not matched with respect to practice setting and country (e.g. 67% of patient respondents were Belgian, versus <10% of physician respondents). As patients’ attitudes towards physicians’ treatment recommendations and towards decision making have been shown to vary across European countries,[2] this may partially explain the gap between physicians’ and patients’ opinions about the type of provided information. As such, it would be interesting to confirm survey data in a matched patient-physician setting, with patients who had been diagnosed with PCa less than 2 years before the survey.
Another limitation of the survey is the fact that the disease stage of the patient respondents was not known. However, the disease stage might be estimated based on the patients’ treatment: 26.2% of patients indicated that they had received hormone therapy, while only 7.1% of patients had received chemotherapy.[3] Based on these figures, the percentage of patients with metastatic or CRPC included in the current survey is likely to be rather low, reflecting the real-life situation. Indeed, in real life, about 30% of patients are estimated to be on hormone therapy for high-risk non-metastatic PCa, and about 8% of patients are thought to be metastatic or castration-resistant.[4]
As patients with metastatic or castration-resistant PCa (CRPC) probably represent only a minority of all patient respondents, it is difficult to verify whether the survey results also apply to this specific patient group, which is known to have a worse health-related QoL than the group of patients with localised or locally advanced PCa. This was shown in a European survey on the management of PCa:[5] median EQ-5D and median FACT-P scores were lower in patients with metastatic and castration-resistant PCa, than scores in patients with localised or locally advanced PCa. Consequently, we could speculate that these patients have different needs and treatment objectives than patients with localised or locally advanced PCa. Indeed, metastatic and CRPC patients have already been shown to be more bothered by hospital / clinic visits compared to patients with lower disease states.[5] Similarly, information-seeking behaviour regarding PCa also differed among patients in different disease stages and among different European countries.[5] The majority of patients look to their PCP and/or prostate cancer specialist for more information about their condition, although with advancing stage, there is also a reliance on family and friends. As such, it is possible that the balance of treatment objectives −as indicated by both patients and physicians in the current survey− with high treatment efficacy prevailing over good tolerability and low burden of medical care, might tilt over in the other direction in patients with metastatic or CRPC. Thus, QoL preservation and pain reduction might be much more important treatment outcomes for these patients. However, more recently, various new therapies have been introduced, which give CRPC patients and their treating physicians the possibility of prolonging survival and the hope of turning the disease into a chronic condition. The treatment paradigm for CRPC patients is rapidly evolving, and future studies are needed to define the optimal sequencing and potential combinations of these new agents. [6]
Regardless of the above-mentioned methodological limitations, the results of the current surveys pinpoint some important ways for physicians to further improve quality of care, i.e.,
- by taking adequate time for their patients and by providing information during several subsequent consultations,
- by using appropriate and understandable terminology,
- by giving relevant and up-to-date prognostic and therapeutic information,
- by encouraging shared decision-making between patients and physicians and between patients and their relatives, and
- by building the multidisciplinary team (MDT) around the patient, with his individual needs and preferences as the centre or care and by providing a permanent contact person within the MDT.
In this way, a patient-centred approach will really become synonymous with optimal PCa management.
References:
- PCA: Prostate Cancer, Patient-Centred Approach or both? Denis L et al. BJU Int 2012;doi:10.1111/j.1464-410X.2011.10859.x
- Assessing the attitudes to prostate cancer treatment among European male patients. Schulman C. BJU Int 2007;100(Suppl 1):6-11
- PCA: Prostate Cancer, Patient-Centred Approach or both? Denis L et al. BJU Int 2012;doi:10.1111/j.1464-410X.2011.10859.x. Additional data on file.
- Prevalence of prostate cancer (PC) clinical states (CS) in the United States: Estimates using a dynamic progression model. Solo K et al. J Clin Oncol (Suppl 15):322s(abs.4637).
- Current treatment patterns and characteristics of castration resistant prostate cancer (CRPC) patients; a European survey. Baskin-Bey E et al. Unpublished data.
- Optimizing Outcomes of Advanced Prostate Cancer: Drug Sequencing and Novel Therapeutic Approaches. Crawford D, Flaig W. Oncology Vol. 26 No. 1
Written by:
Louis Denis, Steven Joniau,* Alberto Bossi,† Edwina Baskin-Bey,‡ and John M. Fitzpatrick§ as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Europa Uomo, Antwerp, Belgium, *Department of Urology, University Hospitals Leuven, Leuven, Belgium, †Department of Radiotherapy, Institut Gustave Roussy, Villejuif, France, ‡Astellas Pharma Europe Ltd, Staines, Middlesex, UK , and §Surgical Professorial Unit, Mater Misericordiae Hospital and University College Dublin, Dublin, Ireland
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