The More, The Merrier: Including a Medical Oncologist in Treatment Planning for Localized Prostate Cancer

Abstract

Most men newly diagnosed with localized prostate cancer in 2013 are noted to have low-risk disease.1 Although questions remain as to whether aggressive interventions, such as surgery or radiation, result in improved survival in these patients, there is little debate that these therapies are all associated with increased risk of sexual, urinary, and bowel dysfunction.2 As such, active surveillance has become an acceptable therapeutic approach in these low-risk patients.3 Unfortunately, active surveillance remains dramatically underused, with roughly 10% of men with low-risk disease electing this approach.4,5 To this end, it is critical that we identify ways to increase the uptake of active surveillance in appropriate patients. In this issue of the Journal of Oncology Practice, Aizer et al6 present the findings of a retrospective, cross-sectional study that showed an association between consultation with a medical oncologist and increased use of active surveillance in lowand very low-risk patients. The authors hypothesize that, because medical oncologists do not perform either surgery or radiation themselves, they are not biased toward a particular treatment modality and may be more inclined to recommend active surveillance as a treatment strategy than urologists or radiation oncologists. Although this hypothesis certainly has face validity, the results of this study do not prove this. This study must, therefore, be viewed with caution and should be considered preliminary at best for the following reasons. First, the study’s restrictive inclusion criteria limit the generalizability of the findings to the larger prostate cancer community. From an initially sizable cohort, the pool of subjects included in the study analysis was whittled down to just over 25% of its initial size. This occurred as a result of the exclusion of men who saw only one prostate cancer specialist, unmarried men, and men who were seen in multidisciplinary clinics initially. Second, and more important, it is impossible to determine causation in the setting of a cross-sectional study. In other words, it may be that men who were already strongly considering or had decided on active surveillance sought out consultation with a medical oncologist, as opposed to the consultation with the medical oncologist causing them to select active surveillance. Only a prospective study, and preferably a randomized clinical trial, could conclusively show whether consultation with a medical oncologist results in increased use of active surveillance. With these limitations acknowledged, involving medical oncologists as advisors to men with localized disease facing complex treatment decisions likely has value to patients and should be encouraged. Although medical oncologists can provide a unique perspective that urologists and radiation oncologists cannot, it is important to note these other specialists also bring something to the table that should not be ignored. This observation supports the role of multidisciplinary clinics in aiding patients newly diagnosed with prostate cancer to make the most informed decisions possible regarding treatment. As these authors have previously shown, the concept of the multidisciplinary prostate cancer clinic has been shown to be both feasible and effective in increasing the use of active surveillance in appropriate patients.7 Although finding a way to export this model from academic centers to community practice may be challenging, it is critical that this occur. Certainly, there will be opportunities in the Affordable Care Act to develop these innovative care delivery models, and we should seize on this to help our patients. As we move into an age of medical care that seeks to achieve a sensible balance between optimizing survival, limiting morbidity from treatment, and minimizing cost, ensuring that men who meet criteria to undergo active surveillance opt to do so will be an important part of prostate cancer care. Understanding factors that increase the uptake of active surveillance, such as involving medical oncologists in the initial management of these patients, is key. Time will tell if this strategy is ultimately favored by the prostate cancer community at large, or remains a missed opportunity to improve health.