More than a third of men with early prostate cancer who participated in a study analyzing treatment choice received therapies that might not be appropriate, based on pre-existing problems with urinary, bowel or sexual function. The prevalence of these treatment “mismatches” could reflect patient’ unwillingness to discuss such problems with their physicians. The study will appear in the January 1, 2008 issue of the journal Cancer and is being released online.
“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 about – urinary, bowel and sexual function,” says James Talcott, MD, SM, of the Center for Outcomes Research at Massachusetts General Hospital (MGH) Cancer Center, who led the study. “In this case, however, having that information matters because the three 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 decisions.”
The standard treatment options for early prostate cancer are external radiation therapy; brachytherapy, in which tiny radioactive particles are implanted into the prostate gland; and prostatectomy, surgical removal of the prostate gland. These approaches have similar levels of effectiveness, but each presents a different risk of side effects – external radiation can lead to bowel dysfunction, brachytherapy may cause urinary problems, and surgery can damage nerves involved in sexual function. For patients who already have problems in these areas, therapies that could worsen their symptoms are usually not recommended. In addition, approaches designed to preserve normal functions, such as nerve-sparing prostate-removal surgery, would not be appropriate for patients for whom those functions have already been lost.
To investigate the frequency of treatment mismatches, the research team enrolled patients treated for early prostate cancer at four Boston centers over a six-year period. Study participants completed a questionnaire before beginning treatment and subsequent questionnaires at intervals of 3, 12, 24 and 36 months after they entered the study. They also gave the researchers – who were not involved in their clinical care – permission to review their medical records. The questionnaires were designed to assess urinary incontinence and other urinary problems, along with bowel and sexual dysfunction. Participants were also asked to assess their level of distress with any symptoms they experienced.
Of the almost 440 patients who completed the entire study, 389 or 89 percent reported having some level of urinary, bowel or sexual problem before beginning treatment. Those participants were classified into four groups. Group 1 was patients with serious symptoms in a single area, for whom decisions would be expected to be the most straightforward. Group 2 had less serious symptoms that would count against a single treatment option. Group 3 had problems in several areas but still had one potentially appropriate treatment. Group 4 included those patients with significant dysfunction in all three areas, for whom none of the treatment options would be recommended.
The study results showed similar levels of treatment mismatches in all groups – 34 percent in Group 1, 37 percent in Group 2, and 40 percent in Group 3. Among Group 4 patients – those with dysfunction in all three areas – only 5 percent chose watchful waiting, a strategy in which they receive no treatment but are followed closely by their medical team. Since patients take many considerations into account when choosing therapies, the surveys asked about several factors that might affect those decisions, none of which could account for the mismatched choices. As expected, patients reporting pre-existing conditions were more likely to have problems after treatment if they had received a mismatched treatment.
“It could be that treatment choices are determined by factors other than those we asked about, or patients may decide to go ahead with mismatched treatments for their own reasons, knowing the risks,” Talcott says. “But it also could be that the open, frank conversations patients should have with their doctors aren’t taking place or that doctors aren’t making it clear to patients why they should be forthright about urinary, bowel or sexual problems they are having.” He and his colleagues theorize that patients may be more open about addressing sensitive topics on a questionnaire than they are in conversation and suggest that factoring such a questionnaire into treatment decisions could reduce mismatches, a strategy they hope to study in the future.
First author of the Cancer study is Ronald Chen, MD, of the MGH Cancer Center; the other co-authors are Jack Clark, MD, Boston University School of Public Health, and Judith Manola, MS, Dana-Farber Cancer Institute. The study was supported by a grant from the Agency for Healthcare Research and Quality.
Massachusetts General Hospital, established in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH conducts the largest hospital-based research program in the United States, with an annual research budget of more than $500 million and major research centers in AIDS, cardiovascular research, cancer, computational and integrative biology, cutaneous biology, human genetics, medical imaging, neurodegenerative disorders, regenerative medicine, systems biology, transplantation biology and photomedicine.