Prostate Cancer Specialists Research Articles

Perceptions of Active Surveillance and Treatment Recommendations for Low-risk Prostate Cancer

With the growing concerns about overtreatment in prostate cancer, the extent to which radiation oncologists and urologists perceive active surveillance (AS) as effective and recommend it to patients are unknown. To assess opinions of radiation oncologists and urologists about their perceptions of AS and treatment recommendations for low-risk prostate cancer. National survey of specialists. Radiation oncologists and urologists practicing in the United States. A total of 1366 respondents were asked whether AS was effective and whether it was underused nationally, whether their patients were interested in AS, and treatment recommendations for low-risk prostate cancer. Pearson's χ test and multivariate logistic regression were used to test for differences in physician perceptions on AS and treatment recommendations. Overall, 717 (52.5%) of physicians completed the survey with minimal differences between specialties (P=0.92). Although most physicians reported that AS is effective (71.9%) and underused in the United States (80.0%), 71.0% stated that their patients were not interested in AS. For low-risk prostate cancer, more physicians recommended radical prostatectomy (44.9%) or brachytherapy (35.4%); fewer endorsed AS (22.1%). On multivariable analysis, urologists were more likely to recommend surgery [odds ratio (OR): 4.19; P<0.001] and AS (OR: 2.55; P<0.001), but less likely to recommend brachytherapy (OR: 0.13; P<0.001) and external beam radiation therapy (OR: 0.11; P<0.001) compared with radiation oncologists. Most prostate cancer specialists in the United States believe AS effective and underused for low-risk prostate cancer, yet continue to recommend the primary treatments their specialties deliver.

Perceptions of radiation oncologists and urologists on the type of evidence that informs and changes the clinical practice of prostate cancer.

167 Background: Physicians have a variety of resources available about the treatment of localized prostate cancer. Yet, it is largely unknown what resources and evidence radiation oncologists and urologists commonly use to inform patients and possibly alter clinical practice. In this national survey study, we assessed the types of resources prostate cancer specialists’ use and the level of evidence needed to change treatment recommendations in localized prostate cancer. Methods: From a random sample, 1,422 physicians were sent a mail survey assessing what type of information was used to guide prostate cancer treatment. The survey also queried what level of evidence could alter recommendations. Multivariable logistic regression models were used to identify for differences in physician characteristics for each outcome. Results: Survey response rates were similar for radiation oncologists and urologists (44% vs. 46%; p=0.46). Specialty-specific journals represented the most commonly used resource to inform the clinical practice for radiation oncologists (65%) and urologists (70%). Relative to radiation oncologists, urologists were less likely to utilize medical journals (25% vs. 38.7%, OR: 0.50; p=0.01), cancer journals (21.7% vs. 50.8%, OR: 0.50; p&lt;0.001), but more likely to rely on clinical guidelines (46.3% vs. 37.7%,OR: 1.6; p=0.006). Radiation oncologists and urologists both viewed RCT’s as the most likely source of evidence needed to change treatment recommendations (85% vs. 77%). Conclusions: Both specialties most commonly rely on their specialty-specific journals to inform their clinical practice and view RCT’s as the level of evidence needed to change treatment recommendations for localized prostate cancer. Radiation oncologists embraced greater diversity in literature, while urologists were more likely to use clinical guidelines. Utilizing this information may overcome barriers to the dissemination and adoption of new treatment paradigms for localized prostate cancer.

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

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.

547 A NATIONAL SURVEY OF RADIATION ONCOLOGISTS AND UROLOGISTS ON ACTIVE SURVEILLANCE FOR LOW-RISK PROSTATE CANCER

INTRODUCTION AND OBJECTIVES: While active surveillance (AS) is well recognized as an acceptable treatment strategy for low-risk prostate cancer (PC), the extent to which radiation oncologists and urologists perceive AS as effective and routinely recommend it to patients is unknown. Therefore, we sought to assess the attitudes and treatment recommendations for low-risk PC from a national survey of PC specialists. METHODS: A mail survey was sent to a population-based sample of 1,439 physicians in the U.S. from late 2011 and early 2012. Physicians were queried about their attitudes regarding AS and treatment recommendations for patients diagnosed with low-risk PC (PSA 10 ng/dl; T1c; and Gleason 6). Pearson Chi-square and multivariate logistic regression were used to test for differences in attitudes and treatment recommendations by physician demographics, compensation structure, primary place of employment, and specialty. RESULTS: Overall, 362 radiation oncologists and 360 urologists completed the survey for a 52% response rate. Most physicians reported that AS is effective for low-risk PC (72%) and stated that they were comfortable routinely recommending AS (69%). Urologists were more likely to agree that AS is effective (78% vs. 65%; p 0.001) and were comfortable recommending AS (75% vs. 62%; p 0.001) compared with radiation oncologists. Most physicians recommended radical prostatectomy (44%) or radiation therapy (32%), but fewer endorsed AS (22%) for low-risk disease. After adjusting for physician covariates, radiation oncologists were more likely to recommend radiation therapy (OR: 10.68; p 0.001), while urologists were more likely to recommend surgery (OR: 4.03; p 0.001) and AS (OR: 2.49; p 0.001) for low-risk PC. CONCLUSIONS: Although AS is widely viewed as effective by both radiation oncologists and urologists, most urologists continue to recommend surgery, while most radiation oncologists recommend radiation therapy. Our results may explain in part the relatively low contemporary use of AS in the U.S.

Clinical Implementation of Quality of Life Instruments and Prediction Tools for Localized Prostate Cancer: Results from a National Survey of Radiation Oncologists and Urologists

Although clinical guidelines recommend assessing quality of life, cancer aggressiveness and life expectancy for making localized prostate cancer treatment decisions, it is unknown whether instruments that objectively measure such outcomes have disseminated into clinical practice. In this context we determined whether quality of life and prediction instruments for prostate cancer have been adopted by radiation oncologists and urologists in the United States. Using a nationally representative mail survey of 1,422 prostate cancer specialists in the United States, we queried about self-reported clinical implementation of quality of life instruments, prostate cancer nomograms and life expectancy prediction tools in late 2011. The Pearson chi-square test and multivariate logistic regression were used to determine differences in the use of each instrument by physician characteristics. A total of 313 radiation oncologists and 328 urologists completed the survey for a 45% response rate. Although 55% of respondents reported using prostate cancer nomograms, only 27% and 23% reported using quality of life and life expectancy prediction instruments, respectively. On multivariate analysis urologists were less likely to use quality of life instruments than radiation oncologists (OR 0.40, p <0.001). Physicians who spent 30 minutes or more counseling patients were consistently more likely to use quality of life instruments (OR 2.57, p <0.001), prostate cancer nomograms (OR 1.83, p = 0.009) and life expectancy prediction tools (OR 1.85, p = 0.02) than those who spent less than 15 minutes. Although prostate cancer nomograms have been implemented into clinical practice to some degree, the use of quality of life and life expectancy tools has been more limited. Increased attention to implementing validated instruments into clinical practice may facilitate shared decision making for patients with prostate cancer.

A national survey of radiation oncologists and urologists on active surveillance for low-risk prostate cancer.

4657 Background: While active surveillance (AS) is well recognized as an acceptable treatment strategy for low-risk prostate cancer (PC), the extent to which radiation oncologists and urologists perceive AS as effective and routinely recommend it to patients is unknown. Therefore, we sought to assess the attitudes and treatment recommendations for low-risk PC from a national survey of PC specialists. Methods: A mail survey was sent to a population-based sample of 1,439 physicians in the U.S. from late 2011 and early 2012. Physicians were queried about their attitudes regarding AS and treatment recommendations for patients diagnosed with low-risk PC (PSA&lt;10 ng/dl; T1c; Gleason 6 in one of twelve cores). Pearson Chi-square and multivariate logistic regression were used to test for differences in attitudes and treatment recommendations by physician demographics, compensation structure, primary place of employment, and specialty. Results: Overall, 321 radiation oncologists and 322 urologists completed the survey for a 45% response rate. Most physicians reported that AS is effective for low-risk PC (71%) and stated that they were comfortable routinely recommending AS (67%). Urologists were more likely to agree that AS is effective (77% vs. 67%; p=0.005) and were comfortable recommending AS (74% vs. 61%; p=0.001) compared with radiation oncologists. Most physicians recommended radical prostatectomy (47%) or radiation therapy (32%), but fewer endorsed AS (21%) for low-risk disease. After adjusting for physician covariates, radiation oncologists were more likely to recommend radiation therapy (OR: 10.97; p&lt;0.001), while urologists were more likely to recommend surgery (OR: 4.69; p&lt;0.001) and AS (OR: 2.18; p=0.001) for low-risk PC. Conclusions: Although AS is widely viewed as effective by both radiation oncologists and urologists, most urologists continue to recommend surgery, while most radiation oncologists recommend radiation therapy. Our results may explain in part the relatively low contemporary use of AS in the U.S.

The benefits of multidisciplinary prostate cancer care

The essential element of a multidisciplinary approach to patient care brings together prostate cancer specialists to educate patients and involve them in their medical decisions, which brings with it many benefits. Now, there is evidence that this approach also improves clinical outcomes in prostate cancer.

PCA: Prostate Cancer, Patient‐Centred Approach or both?

What's known on the subject? and What does the study add? Several studies have explored patient-specific expectations of prostate cancer management, while others have investigated physicians' perceptions. However, the opinions of both groups have seldom been compared in one study. Therefore, the present study compares the results of two surveys, one among physicians and one among patients, on patient-physician communication and patients' expectations of prostate cancer management. The present review aims to highlight the differences and similarities in opinion on prostate cancer management between physicians and patients. It reflects the most important results of two surveys on patient-specific expectations in prostate cancer management, done among European prostate cancer specialists and patients with prostate cancer. These results are compared with published data. In addition, the authors' opinion on the survey results and on optimal prostate cancer management is included. To evaluate differences and similarities in opinions on and expectations of prostate cancer management between physicians and patients. Two surveys on patient-specific opinions and expectations in prostate cancer management were done in 2011 among European prostate cancer specialists and patients with prostate cancer. Survey results were complemented with existing published data and with the authors' opinion. Most specialists spent 15-29 min on delivering the diagnosis, and about the same amount of time on explaining treatment options. This time was considered insufficient by 35% and 48% of patients, respectively. There was a large discrepancy between physicians' and patients' opinions about the type of provided prognostic and therapeutic information, indicating that patients may not have completely understood this information. Shared decision-making was preferred by both patients and specialists. Treatment efficacy was the most important factor determining treatment choice for both groups, while the physician's opinion or experience also had a great impact on patients' treatment choice. Patient-support groups have an important role in providing relevant information and in exchanging experiences between patients. The supportive role of partners/relatives was more appreciated when discussing treatment options than during diagnosis. Although patients' expectations are generally matched by their caring physician(s), physicians can still improve quality of care by taking adequate time for their patients, by using terminology that is easily understood by patients and by encouraging shared decision-making. A multidisciplinary team may be an important part of the treatment paradigm, with the individual patient's needs and preferences as the centre of care.

Future directions for the Prostate Cancer Specialist Nurse in Australia

Prostate cancer is the most commonly diagnosed cancer in Australian men. A cancer diagnosis causes physical, social and psychological morbidity. The role of the specialist nurse in chronic illness care is well recognized both nationally and internationally; however, the role of the Prostate Cancer Specialist Nurse is not as developed or formalized in Australian health care delivery. Prostate Cancer Foundation of Australia (PCFA) aims to bridge this gap and has developed a model to pilot a number of Prostate Cancer Specialist Nurses in various locations throughout both metropolitan and regional Australia.This paper reports on the findings of a project commissioned by PCFA to define a model for a national Prostate Cancer Specialist Nursing service. The service model was developed following an extensive consultation process at a national level. A framework for practice and professional development for the Prostate Cancer Specialist Nurse has been developed which utilizes both the Australian Nursing and Midwifery Council Registered Nurse Competency Frameworks and the National Cancer Nursing Education Project Professional Development Framework. The pilot program will involve PCFA working in partnership with host health regions by providing funding for the recruitment of the nurses on a 3‐year trial basis. The nurses will be employed directly by the host health regions and will be professionally supported by PCFA. The program will also be formally evaluated.

Assessing Older Prostate Cancer Patients for Chemotherapy: Recommendations from the International Society of Geriatric Oncology

Prostate cancer in elderly patients is a major health concern. A panel of prostate cancer specialists and geriatric oncologists has developed specific treatment guidelines for this population. These guidelines are valid, internationally accepted and compulsory. However, they must be adapted during the decision-making process as a function of the patient’s health status. Health status screening is based on dependence, nutrition and evaluation of comorbidities. Patients are divided into four health status-based groups that allow adaptations of cancer treatment with androgen deprivation, chemotherapy and palliative treatment.

Visits to urologists and radiation oncologists prior to treatment decision making for clinically localized prostate cancer (LCaP)

6506 Background: The two primary therapies for LCaP are delivered by different types of physicians, urologists and radiation oncologists. We evaluated how visits to various specialists relate to treatment choice. Methods: Using data from the Surveillance, Epidemiology and End Results (SEER)-Medicare linked program, we evaluated 85,088 men with LCaP aged 65 and older diagnosed between 1994 and 2002 who received either radical prostatectomy (n=18,201), radiotherapy (n=35,925), primary androgen deprivation therapy (n=14,021), or expectant management (n=16,941) within 9 months of diagnosis. Prostate cancer specialists were identified by Medicare claims or data from the AMA Physician Masterfile. Results: Table 1 shows a strong association between the different specialists consulted and primary therapy received. When men aged 65 to 69 saw only a urologist, 70% had a radical prostatectomy; when also seen by a radiation oncologist, 15% had a radical prostatectomy. We found greater than expected variation in the propensity of a particular urologist’s patients to undergo radiotherapy evaluation, suggesting that some men are seen by a radiation oncologist less frequently (and others more frequently) than would be explained by chance. Conclusions: Recognizing that prostate cancer specialists have different viewpoints on the most appropriate management strategy, it is imperative to ensure that all men have access to balanced information prior to definitive therapy. No significant financial relationships to disclose. [Table: see text]

Men, Masculinities, and Prostate Cancer: Australian and Canadian Patient Perspectives of Communication With Male Physicians

Patient-physician communication is vital in cancer care, and aspects of the patients' experiences provide insight into what constitutes effective cancer communication. Complexities inherent in prostate cancer regarding screening, treatment(s) efficacy, and side effects commonly form the basis of patient-physician discussions. However, the specificities of patient-physician communications, particularly in the male dyad, and the connections to masculinity are poorly understood. The authors used secondary analysis of data from two interview studies of 19 Canadian and 33 Australian prostate cancer survivors who were treated by male general practitioners and prostate cancer specialists. Participants acknowledged that physician expertise and compassion underpinned the development of trust, and both reassurance and humor were effective communication strategies. Participants were often self-directed in researching prostate cancer, consistently using biomedical language and numerical markers when discussing their disease. Analysis of findings enabled interpretations regarding what might be considered prostate cancer communication competencies in the male patient-physician dyad.

Medical specialists’ accounts of the impact of the Internet on the doctor/patient relationship

In the context of health service delivery, deprofessionalization denotes a trend towards a demystification of medical expertise and increasing lay scepticism about health professionals, suggesting a decline in the power and status of the medical profession. This process has been linked to increasing consumerism, the rise of complementary medicine and the emergence of the Internet. Drawing on data from in-depth interviews with prostate cancer specialists, this article explores their experiences of the Internet user within the context of the medical consultation. Results suggest that the deprofessionalization thesis is inadequate for capturing the complex and varying ways in which specialists view, and respond to, the Internet-informed patient. It is argued that the ways in which these specialists are adapting to the Internet and the Internet user should be viewed as strategic responses, rather than reflecting a breakdown in their authority or status. 'Enlistment' and 'translation' are presented as useful conceptual tools for understanding specialists' experiences of the Internet.

Hormone-refractory prostate cancer: Issues, approaches, and recommendations

This supplement to Urology offers urologists, medical oncologists, and other healthcare professionals a concise update on current and investigational therapies for asymptomatic (ie, biochemical progression only) as well as symptomatic hormone-refractory prostate cancer (HRPC). It is the product of a roundtable meeting held in Chicago, Illinois, on September 18, 2004, which was attended by a small invited group of internationally recognized prostate cancer specialists from the fields of medical oncology, urology, and endocrinology. The purpose of the roundtable discussion, and of the resulting monograph, was to review and analyze the most recent clinical trial findings and to examine their implications for the current management of and for future research in HRPC.

ASCO Inaugurates Meeting for Prostate Cancer Specialists

ASCO Inaugurates Meeting for Prostate Cancer Specialists

The eMale

This article argues that experiences of, and attitudes towards, online communities are deeply embedded in understandings of masculinity, the perceived character of the Internet, and changes in the roles of the patient and the expert within decision-making processes. Drawing on the accounts of a group of Australian men with prostate cancer and prostate cancer specialists, this qualitative study explores experiences of online support groups. Results point to three unexplored and important factors influencing how both patients and clinicians perceive and experience online support. First, online support groups provide some men with a method of managing constraints posed by dominant constructions of masculinity within their experiences of prostate cancer, allowing for increased sharing and intimacy by limiting inhibitions associated with face-to-face encounters. However, other men view online support groups as havens for deception and misinformation, and computer-mediated communication as a highly problematic form of social interaction. Finally, this article shows how some medical specialists experience online support groups as a threat to their expert status and control over decision-making processes, outlining the nature and possible implications of their responses to this threat.

Brachytherapy for recurrent prostate cancer after radiation therapy

Prostate cancer specialists routinely see patients with recurrent disease after external beam irradiation. Traditionally, only palliative treatments have been offered with hormonal intervention or simple observation. A significant, although as yet uncertain, percentage of these patients will have only locally recurrent cancer and thus are potentially candidates for curative salvage therapy. Permanent brachytherapy with (125)I or (103)Pd has been used in an attempt to eradicate the remaining prostate cancer and prevent the need for additional intervention. It is particularly critical in this population to identify those patients most likely to have distant metastases or who are unlikely to suffer death or morbidity from their local recurrence to avoid potential treatment morbidity in patients unlikely to benefit from any intervention. Review of the literature shows 5-year freedom from second relapse after salvage brachytherapy in approximately 50% of patients, although with careful case selection second relapse free survival rates of up to 83% may be achieved. A schema is presented, based on the available data, suggesting that it may be possible to identify those patients who are most likely to benefit from salvage treatment. These include men with the following: (1) histologically confirmed local recurrence, (2) no clinical or radiologic evidence of distant disease, (3) adequate urinary function (IPSS < 20), (4) age and overall health indicative of >5- to 10-year life expectancy, (5) prolonged disease-free interval (>2 years) from primary radiation therapy, (6) long prostate-specific antigen (PSA) doubling time (>6-9 months), (7) Gleason sum </=6, and (7) PSA <10 ng/mL at the time of recurrence.

Brachytherapy for recurrent prostate cancer after radiation therapy

Prostate cancer specialists routinely see patients with recurrent disease after external beam irradiation. Traditionally, only palliative treatments have been offered with hormonal intervention or simple observation. A significant, although as yet uncertain, percentage of these patients will have only locally recurrent cancer and thus are potentially candidates for curative salvage therapy. Permanent brachytherapy with 125I or 103Pd has been used in an attempt to eradicate the remaining prostate cancer and prevent the need for additional intervention. It is particularly critical in this population to identify those patients most likely to have distant metastases or who are unlikely to suffer death or morbidity from their local recurrence to avoid potential treatment morbidity in patients unlikely to benefit from any intervention. Review of the literature shows 5-year freedom from second relapse after salvage brachytherapy in approximately 50% of patients, although with careful case selection second relapse free survival rates of up to 83% may be achieved. A schema is presented, based on the available data, suggesting that it may be possible to identify those patients who are most likely to benefit from salvage treatment. These include men with the following: (1) histologically confirmed local recurrence, (2) no clinical or radiologic evidence of distant disease, (3) adequate urinary function (IPSS < 20), (4) age and overall health indicative of >5- to 10-year life expectancy, (5) prolonged disease-free interval (>2 years) from primary radiation therapy, (6) long prostate-specific antigen (PSA) doubling time (>6-9 months), (7) Gleason sum ≤6, and (7) PSA <10 ng/mL at the time of recurrence. © 2003 Elsevier Inc. All rights reserved.

Finding help for sexual problems after prostate cancer treatment: a phone survey of men's and women's perspectives.

As part of a larger postal survey, 320 survivors of prostate cancer who reported they were likely to seek help in the next year for a sexual problem were interviewed by phone about their strategies for finding help and the types of treatment that would help resolve post-cancer sexual problems. In addition, 164 sexual partners (including 160 wives, three female partners in committed relationships, and one gay male partner) were interviewed. Educational materials were used by patients and partners to answer questions about sexual dysfunction but were less useful in helping to find professional referrals or in actually resolving sexual problems, particularly for African-American couples. Men's preferred method of finding help was to consult a urologist or prostate cancer specialist to find a medical treatment for erectile dysfunction. Ninety-one percent of men had already tried to find medical help for erectile dysfunction, but previous attempts remained unsuccessful. Men wanted an oral medication that would resolve their sexual problem naturally, without major side effects. Only 43% of men said their partners had encouraged them to find help, and indeed a large minority of women had resigned themselves to having unsatisfying sex lives. These data suggest that including the partner in counseling about medical treatments for sexual function, and giving both men and partners realistic expectations about the limitations of existing treatments could boost the success of sexual rehabilitation after prostate cancer.