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PCU2|2002: Editor
“The Talk”
“I usually have ‘the talk’ with men
when their PSA goes above 0.2 ng/mL after radical prostatectomy.
We discuss the fact that we probably have not completely cured
the cancer, may need secondary treatment and should start
thinking about our options. I dread this as a clinician. We
go into the surgery expecting a cure and usually the PSA is
undetectable after surgery. The moment the PSA rises represents
a point of major frustration for both the patient and the
doctor.”
— Judd W Moul, MD |
Nothing in medical school adequately prepares us for
the daunting task of informing a patient that a therapy with significant
morbidity has been unsuccessful, and that the disease is now life-threatening.
Like all oncologists, I have had these “talks” many
more times than I care to remember.
Because of our ability to monitor PSA, prostate cancer is very
unusual and these “talks” often occur years before the
disease becomes clinically symptomatic. However, the emotional toll
of this situation can be enormous. While the biologic and clinical
implications of this relatively new phenomenon are still being defined,
patients and doctors — already faced with morbidity from the
local therapy — struggle with decisions about embarking on
additional treatments with their own toxicities.
In the enclosed program, Dr Moul sorts through his approach to
patients with a PSA-only relapse. I noticed with great interest
how often he uses the word “we” in describing his shared
decision-making with the patient. Prostate cancer management has
always involved difficult treatment choices, particularly with respect
to optimal local therapy. Dr Moul outlines a logical, patient-centered,
decision-making approach to the more recent phenomenon of PSA-only
relapse.
The dilemma of PSA-only relapse has become so important in clinical
practice that the topic also surfaced in the other three interviews
in this issue of Prostate Cancer Update. Dr Craig Zippe notes that
PSA screening has resulted in the earlier diagnosis of prostate
cancer, which allows more frequent preservation of potency after
radical prostatectomy. Therefore, the impact of castration on quality
of life for a patient with a PSA relapse is a major issue. Dr Zippe
remarks that potency-sparing alternatives, such as antiandrogen
monotherapy, may be important options for these patients.
Dr Anthony D’Amico comments on the rapid evolution of clinical
research in men with PSA-only relapse, and he reviews the use of
factors, such as PSA doubling time, to identify men at an increased
risk of death from prostate cancer. Dr D’Amico points out
that the ability to identify patients with a poor prognosis is not
only important for current patient care but also for clinical research.
Surrogate endpoints, like PSA doubling time, may allow investigators
to answer key clinical questions more quickly in randomized clinical
trials.
Dr Anna Ferrari provides an interesting biologic perspective relevant
to how PSA-only relapse fits into the continuum of metastatic prostate
cancer. Dr Ferrari’s research suggests that approximately
30% of prostate cancer patients with pathologically negative lymph
nodes have evidence of micrometastatic disease, detected by RT-PCR,
in their lymph nodes.
She notes that clinical research in breast cancer has clearly
demonstrated that systemic therapy is more effective for micrometastatic
disease than for clinically evident metastases. While a comparable
database does not exist in prostate cancer, available evidence suggests
that early endocrine intervention may improve long-term outcome.
The first issue of Prostate Cancer Update included an interview
with urologist and prostate cancer research leader, Dr Paul Schellhammer,
whose own recent struggle with the disease includes a PSA-only relapse.
Dr Schellhammer related how his perspective on the risks and benefits
of intervention has changed as a result of living personally with
prostate cancer.
Similarly, after his interview, Dr Moul shared with me his experience
with his father-in-law who died from prostate cancer some years
ago. When I asked Dr Moul how this experience affected his approach
to patient care, he said, “In addition to being as empathetic
as I can with the patient, I try to be as compassionate as possible
with families. I try to get as many family members involved who
want to be involved or whom the patient will allow to be involved.”
Management of the patient with PSA-only relapse is a complex biopsychosocial
challenge. As noted by Dr Ferrari, the potentially long natural
history of prostate cancer suggests that a chronic disease management
model is appropriate, like diabetes. From that perspective, “the
talk” must be viewed as the beginning of a long and often
complex series of clinical interventions with the ultimate goal
of maximizing quantity as well as quality of life.
— Neil Love, MD
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