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'Mismatched' prostate cancer treatment
more common than expected
Study suggests quality of
life factors may not receive adequate consideration
BOSTON - November 26, 2007 - More than a third of men with
early prostate cancer who participated in a study analyzing treatment
choice received therapies that might not be appropriate, based on
pre-existing problems with urinary, bowel or sexual function. The
prevalence of these treatment "mismatches" could reflect
patient' unwillingness to discuss such problems with their physicians.
The study will appear in the January 1, 2008 issue of the journal
Cancer and is being released online.
"Prostate cancer patients experience the same fears and hard
decisions as all cancer patients do, but prostate cancer treatment
directly affects very personal things that most people aren't comfortable
talking about - urinary, bowel and sexual function," says James
Talcott, MD, SM, of the Center
for Outcomes Research at Massachusetts
General Hospital (MGH) Cancer Center, who led the study. "In
this case, however, having that information matters because the
three major treatments available to patients have different patterns
of potential side effects. Knowing if patients already have problems
in these areas should help guide treatment decisions."
The standard treatment options for early prostate cancer are external
radiation therapy; brachytherapy, in which tiny radioactive particles
are implanted into the prostate gland; and prostatectomy, surgical
removal of the prostate gland. These approaches have similar levels
of effectiveness, but each presents a different risk of side effects
- external radiation can lead to bowel dysfunction, brachytherapy
may cause urinary problems, and surgery can damage nerves involved
in sexual function. For patients who already have problems in these
areas, therapies that could worsen their symptoms are usually not
recommended. In addition, approaches designed to preserve normal
functions, such as nerve-sparing prostate-removal surgery, would
not be appropriate for patients for whom those functions have already
been lost.
To investigate the frequency of treatment mismatches, the research
team enrolled patients treated for early prostate cancer at four
Boston centers over a six-year period. Study participants completed
a questionnaire before beginning treatment and subsequent questionnaires
at intervals of 3, 12, 24 and 36 months after they entered the study.
They also gave the researchers - who were not involved in their
clinical care - permission to review their medical records. The
questionnaires were designed to assess urinary incontinence and
other urinary problems, along with bowel and sexual dysfunction.
Participants were also asked to assess their level of distress with
any symptoms they experienced.
Of the almost 440 patients who completed the entire study, 389 or
89 percent reported having some level of urinary, bowel or sexual
problem before beginning treatment. Those participants were classified
into four groups. Group 1 was patients with serious symptoms in
a single area, for whom decisions would be expected to be the most
straightforward. Group 2 had less serious symptoms that would count
against a single treatment option. Group 3 had problems in several
areas but still had one potentially appropriate treatment. Group
4 included those patients with significant dysfunction in all three
areas, for whom none of the treatment options would be recommended.
The study results showed similar levels of treatment mismatches
in all groups - 34 percent in Group 1, 37 percent in Group 2, and
40 percent in Group 3. Among Group 4 patients - those with dysfunction
in all three areas - only 5 percent chose watchful waiting, a strategy
in which they receive no treatment but are followed closely by their
medical team. Since patients take many considerations into account
when choosing therapies, the surveys asked about several factors
that might affect those decisions, none of which could account for
the mismatched choices. As expected, patients reporting pre-existing
conditions were more likely to have problems after treatment if
they had received a mismatched treatment.
"It could be that treatment choices are determined by factors
other than those we asked about, or patients may decide to go ahead
with mismatched treatments for their own reasons, knowing the risks,"
Talcott says. "But it also could be that the open, frank conversations
patients should have with their doctors aren't taking place or that
doctors aren't making it clear to patients why they should be forthright
about urinary, bowel or sexual problems they are having." He
and his colleagues theorize that patients may be more open about
addressing sensitive topics on a questionnaire than they are in
conversation and suggest that factoring such a questionnaire into
treatment decisions could reduce mismatches, a strategy they hope
to study in the future.
First author of the Cancer study is Ronald Chen, MD, of the
MGH Cancer Center; the other co-authors are Jack Clark, MD, Boston
University School of Public Health, and Judith Manola, MS, Dana-Farber
Cancer Institute. The study was supported by a grant from the Agency
for Healthcare Research and Quality.
Massachusetts General Hospital, established in 1811, is the original
and largest teaching hospital of Harvard Medical School. The MGH
conducts the largest hospital-based research program in the United
States, with an annual research budget of more than $500 million
and major research centers in AIDS, cardiovascular research, cancer,
computational and integrative biology, cutaneous biology, human
genetics, medical imaging, neurodegenerative disorders, regenerative
medicine, systems biology, transplantation biology and photomedicine.
Media Contacts: Sue
McGreevey, MGH Public Affairs
Physician Referral Service: 1-800-388-4644
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