Men with early-stage prostate
cancer frequently choose
treatments that worsen problems they already have, according to a new
study published in Cancer.
Researchers from Boston University School of Public Health,
Dana-Farber Cancer Institute, Harvard Medical School, Harvard Radiation
Oncology Program, and Massachusetts General Hospital found that of 438
men who completed the study, 389 (89%) reported pre-existing urinary,
bowel, or sexual problems, yet more than one-third opted for treatments
that made them more vulnerable in those areas.
“Prostate cancer patients experience the same fears and hard
decisions as all cancer patients do, but prostate cancer treatment
directly affects very personal things that most people aren’t
comfortable talking abouturinary, bowel, and sexual function,” lead
researcher James Talcott, MD, SM, of the Center for Outcomes Research
at Massachusetts General Hospital (MGH) Cancer Center, said in a
statement. “In this case, however, having that information matters
because the 3 major treatments available to patients have different
patterns of potential side effects. Knowing if patients already have
problems in these areas should help guide treatment options.”
A High Degree of Mismatch
The 3 most common active treatments for prostate cancer –
brachytherapy,
external
beam radiation therapy, and radical
prostatectomy — have been shown to be about equally effective in
clinical trials. But each has its own unique set of urinary, bowel, and
sexual side effects that need to be taken into consideration when
choosing a treatment.
A man with urinary irritation or difficulty passing urine, for
example, might be advised against brachytherapy because it can make
these symptoms worse. Likewise, men with bowel problems would likely be
discouraged from external beam radiation therapy because it can affect
the rectum as well as the prostate. Depression impotence radical prostatectomy
is typically done in an effort to preserve sexual function. In some
cases, though, this approach might reduce the chance that a surgeon can
remove the entire tumor, so for men who already have erectile
dysfunction, the risks of this procedure might outweigh any
erectile dysfunction vacuum pump
benefits.
The men in the study were recruited from Boston-area
multi-specialty treatment centers. They answered questions about their
urinary, bowel, and sexual function before they underwent treatment.
The researchers then classified the men into 4 groups. The
first 2 groups had a urinary, bowel, or sexual problem that would
likely make 1 of the 3 most common prostate cancer treatments
inappropriate. The inappropriate treatment was more clear-cut for men
in Group I than those in Group II. Patients in Group III had problems
in several areas, but were felt to have at least one “appropriate”
treatment option. Men who had problems that would be further aggravated
by all of the treatments fell into Group IV.
The researchers found a surprising number of mismatched
treatments among the study participants, regardless of the clinical
complexity of their cases. About 34% of Group I patients received a
treatment that might have worsened a pre-existing problem, compared to
37% in Group II and 40% in Group III.
Not surprisingly, choosing a mismatched treatment had negative
effects. More men who had bowel problems prior to external beam
radiation therapy reported diarrhea, pain with bowel movements, bowel
urgency, and rectal bleeding. Patients who had urinary problems prior
to brachytherapy were more likely to report painful urination. They
also reported more need to urinate at night, though the difference did
not reach statistical significance. Nearly all men with sexual
dysfunction continued to have trouble in that regard after radical
prostatectomy, regardless of whether a drug for treatment of erectile dysfunction procedure was
used.
Emphasizing Everything impotence know leading need overcoming tells urologist
Concerns
The authors offer several hypotheses to explain why many men
didn’t seem to take these problems into account as part of their
treatment decision-making. Some men may make decisions hurriedly and
base their decisions on anecdotes and impotence zinc (see “Fear,
Anecdotes Often Trump Facts When Men Make Prostate Treatment
Decisions.”)
Another explanation is that men might have a hard time talking
to their doctors about sensitive issues, making it harder for
physicians to determine the extent of any dysfunction. Talcott and his
co-authors suggest physicians consider using questionnaires to get more
candid responses to sensitive quality-of-life questions.
The authors also note that there are other factors that might
legitimately enter into treatment decisions. For example, some men
might not consider external beam radiotherapy if radiotherapy centers
are not close enough for daily treatments to be practical.
Mark S. Litwin, MD, professor of urology at the David Geffen
School of Medicine at the University of California, Los Angeles (UCLA),
and the UCLA School of Public Health and a researcher at UCLA’s Jonsson
Comprehensive Cancer Center, calls this a “great study that provides
real opportunities for quality improvement.” He agrees that there’s a
real need for a standardized pre-consultation questionnaire. “We should
use any tool we can to better understand and better inform our
patients,” says Litwin, who was not involved in the research.
But Litwin sees the problem in a slightly different light:
“It’s not that men don’t tell their doctors about their pre-existing
problems, but that they have a skewed perspective of them, and as a
result, of their treatment outcomes. We in medicine need to do a better
job of sitting down with our patients and explaining how these
treatments are going to affect quality of life.”
Only around 5% of the men in each group chose “watchful
waiting,” or “active surveillance,” a percentage Litwin and the
researchers suggest reflects the tendency in the United States to
over-treat prostate cancer in some cases. “We need to lay out the
quality-of-life compromises associated with active treatment and help
guide patients who should embrace active surveillance,” Litwin said.
Citation: “Treatment
‘Mismatch’ in Early Prostate Cancer.” Published online Nov.
26, 2007, and in the Jan 2008 issue of Cancer (Vol.
112, No.1). First author: James Talcott, MD, SM, Center for Outcomes
Research at Massachusetts General Hospital (MGH) Cancer Center.
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