WASHINGTON — “You're not going to die of prostate cancer.” That's the first thing Dr. Tanya B. Dorff, a specialist in genitourinary oncology, tells most of the patients with localized prostate cancer who are referred to her.
That simple sentence “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 the annual Community Oncology Conference.
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 center such as Johns 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 Monica, Calif.
Patients at low or 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.
Also, for an intermediate or 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.
When it comes to quality of life considerations, 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. “I tell patients that most of them will not end up with these consequences, and their risk is minimized 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). However, there's a bit more pressure for high-risk patients, who should be encouraged to decide within a few weeks.
One should also discuss 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.
FAMILY PRACTICE NEWS and Community Oncology are published by Elsevier.