Employment After Therapy for Localized Prostate Cancer: Widening the Perspective

Abstract

From the traditional biological perspective, medical therapy is judged by its effects on survival or other indicators related to pathophysiology, such as growth or shrinkage of cancer masses. More recently, investigators have broadened their assessments of medical interventions (and conditions). So-called outcomes research explicitly recognizes that chronic diseases and their treatments may affect patients’ lives in ways other than causing symptoms, organ dysfunction, and death. They may also impair patients’ ability to perform activities of daily living, continue their usual social roles and interactions, and preserve their economic condition — each a plausible aspect of health-related quality of life. A rapidly progressing cancer’s ability to wreak havoc on virtually all aspects of patients’ lives is widely appreciated. However, although measuring these consequences might infl uence public policy choices, the results would rarely affect clinical decisions. Patients with advanced, aggressive cancers have two basic choices: either pursue the treatment their oncologists identify as most likely to postpone death from cancer or — if deterred by brief anticipated survival, frail health, or the expected toxicity of treatment — submit to their cancer, focusing on symptom palliation. However, for cancer patients who can anticipate prolonged survival and have two or more treatment alternatives, neither of which is decisively more effi cacious or less toxic, a fuller appreciation of the manifold consequences of each treatment may help them identify the better choice, given their own circumstances, goals, and preferences. Clinically localized prostate cancer meets these conditions. Nearly all patients survive a decade or more; competing treatments do not differ demonstrably in effi cacy but produce various combinations of permanent urinary, bowel, or sexual dysfunction in most men; and observation alone would not affect most men’s life expectancy [although evidence that a small group of men live longer after active therapy is now appearing ( 1 , 2 ) ] but would produce anxiety in many men and their families. Although we have at best a rough idea how men choose between alternatives with consequences that diverge in so many ways, a reasonable model is that they compare treatments by what matters most to them fi rst, proceeding through progressively less important characteristics until they reach a crucial, “ deal-breaker ” difference ( 3 ) . In the past decade, outcomes researchers have documented the phys