Tips Offered for Talking to Patients About Prostate Cancer

[Guest guest]

If only this was the way all urologists talked to their newly

diagnosed patients, but this doctor is an oncologist. A horse of a

different color.

Laurel

Tips Offered for Talking to Patients About Prostate Cancer

Elsevier Global Medical News. 2008 Feb 6, M. E. Tucker

WASHINGTON (EGMN) - " You're not going to die of prostate cancer. "

That's the first thing Dr. B. Dorff, a specialist in

genitourinary

oncology, tells most of the patients with localised prostate cancer

who are

referred to her. Data bear out that simple sentence, which she

finds " opens the

mind to receive all the other information and process it to make an

informed

analytical decision . . . I tell them we're not talking about death,

but their

chances of surviving free of PSA, " she said at a conference sponsored

by

Elsevier Oncology.

Another clinical pearl: Many patients have had a biopsy done at a

community

hospital that lacks specialists in prostate pathology. Whenever there

is a

question or inconsistency, Dr. Dorff sends the specimen for a second

opinion

pathology review to a centre such as s Hopkins or Bostwick

Laboratories that

has expertise in this area, " because so much of what we're telling our

patients is based on the Gleason score, " said Dr. Dorff of the

Angeles Clinic and

Research Institute, Santa , California.

Patients at low/intermediate risk for disease progression will often

wonder

why they're not receiving all the imaging tests that other family

members with

cancer underwent for disease staging. Simple reassurance will usually

suffice here, although there are a couple of situations in which Dr.

Dorff does

consider imaging in patients who are not at high risk for

progression. For

example, obtaining a baseline colour Doppler ultrasound or

endorectal magnetic

resonance imaging in a low-risk patient allows the physician to

delineate the

tumour area before embarking on active surveillance. That way,

subsequent

imaging used during active surveillance can determine how the nodule

changes over

time.

Also, for an intermediate/high-risk patient who is undecided about

whether

to choose surgery or radiation, an MRI can identify whether there is

extracapsular extension or seminal vesicle involvement. Such a

finding would point to

the need for adjuvant radiation along with surgery, in which case he

might

choose primary radiation with hormone therapy instead.

Indeed, dynamic contrast-enhanced magnetic resonance imaging(DCE-MRI)

and

magnetic resonance spectroscopy (MRS) are emerging technologies that

hold

promise for improving prognostic and treatment capabilities in the

future. They

are currently being evaluated in numerous clinical trials at

specialised centres

in the United States.

" Of course imaging isn't perfect, but it is another tool to help men

who are

on the fence to better understand their treatment options, " Dr. Dorff

said.

When it comes to quality of life considerations, here's another

clinical

pearl: Simplify the side effects discussion by telling the patient it

really

comes down to a tradeoff between bowel toxicity - slightly more

prevalent with

radiation - and urinary toxicity, somewhat more likely with surgery.

Impotence

isn't part of the equation because that risk isn't decisively

different

between modalities. And of course, " I tell patients that most of

them will not end

up with these consequences, and their risk is minimised by going to a

high-volume urologist and radiation oncologist. "

Low-risk patients can also be given the luxury of time. Data from at

least

one study suggest that delaying treatment for up to 12 months did not

compromise curability compared with immediate surgery (J. Natl.

Cancer Inst.

2006;98:355-7). " I tell men it's okay to take time to make a

decision. They can

interview physicians in different specialties - or take a month's

vacation - if

they need that in order to be comfortable with their decision. " On

the other

hand, there's a bit more pressure for high-risk patients, who should

be

encouraged to decide within a few weeks, Dr. Dorff recommended.

Additional important issues to discuss with the patient include plans

for

surveillance after treatment, the need for bone mineral density and

cardiac

evaluation for patients on androgen deprivation therapy, screening

recommendations for family members, and a review of the patient's

lifestyle and dietary

habits, which is as important for heart health as it is for the

prostate. " For

many of these men this is a wake-up call. Their No. 1 cause of

morbidity and

mortality is cardiovascular. If their prostate cancer diagnosis is a

way for

me to get them to eat a heart-healthy diet and get back into the gym

exercising, then I've probably accomplished more for them than I have

by dealing with

their prostate cancer. "