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 Home: PCU 5|2003: Editor's Note
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Editor’s Note |
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| Acceptable Options |
Our continuing medical education group focuses on the clinical implications of emerging research results. One of the comments we frequently receive from listeners to this audio series is that they find it very reassuring to learn that prostate cancer research leaders often struggle with the same controversial decisions as community-based physicians.
When credible research evidence fails to clearly define a single standard of care, judgment and perspective represent the next best options. As an organization committed to education, it is essential for us to uncover these areas of uncertainty and understand the various perspectives on these difficult issues. In performing needs assessments for our educational endeavors, we regularly turn not only to research leaders, but also to community-based physicians. This spring, we convened two working groups to learn more about the most common challenging decisions in the management of prostate cancer.
In April, we gathered 15 research leaders for a "think tank" during the American Urological Association meeting in Chicago. Several weeks later, we met in New York with 23 community-based urologists and radiation and medical oncologists. Drs Mitchell Benson, Adam Dicker, Leonard Gomella and Michael Zelefsky joined us for a daylong, case-based brainstorming session. This edition of Prostate Cancer Update includes several audio excerpts from the New York working group. These two events were interesting and thought-provoking, and what was most striking was the diversity of perspectives that exist on many key management questions, including the following:
1. What is appropriate counseling for men presenting with localized disease?
We showed the participants in these meetings video clips from interviews with more than a dozen men recounting their experience when first diagnosed with prostate cancer. The messages these patients received were clearly very different depending on the specialty of their treating physician. Many of the physicians at the two meetings commented on the depth of anxiety and fear that the initial diagnosis of prostate cancer carried. One urologist who has been in practice for more than 30 years said, "Seeing these videos is a real eye-opener for me." Others commented that patients often put on a "brave front" for their doctor and want to be "good patients." The education message is that when considering the "favorable" prognosis of men with T1c Gleason 3+3 tumors, experienced physicians also keep in mind that many or most patients at initial diagnosis are terrified that they will succumb to the disease.
2. Should adjuvant endocrine therapy be offered to men presenting with localized high-risk disease?
An interesting dichotomy exists for the treatment of patients with high-risk tumors. Those treated with radiation therapy routinely receive adjuvant androgen deprivation, but those treated with radical prostatectomy generally are not offered immediate endocrine therapy. In this program, Dr Zelefsky notes that this difference in the utilization of adjuvant endocrine therapy is a direct result of the available research evidence. The radiation oncology community has more thoroughly investigated the use of adjuvant endocrine therapy than the urology researchers.
On the audio excerpt of the New York meeting found in this issue, Dr Benson labels the conservatism towards postprostatectomy adjuvant androgen deprivation as intellectual inconsistency. "I'm aggressive with these patients. If we say to a man that we are going to do a radical prostatectomy because we want to give him the best statistical chance of being disease-free for as long as possible, and there is an adverse pathology report, I believe it's unconscionable not to give the patient information about additional therapy." Other physicians are just as convinced that careful PSA monitoring and early treatment for biochemical recurrence are preferable. Dr Joseph Smith defends that approach in this program.
3. At what point should therapy be recommended for postsurgical or postradiation PSA relapse, and which therapy is optimal?
Researchers agree that there is a lack of definitive research evidence to define a treatment standard in this very common clinical scenario. In this audio program, Dr Michael Brawer presents a man with a PSA relapse whom he chose to treat with intermittent androgen suppression; however, the risks and benefits for this type of treatment strategy compared to observation, continuous androgen suppression or antiandrogen monotherapy are unknown. In both the New York working group and the Chicago "think tank" meetings, there was remarkable heterogeneity in the approach to androgen deprivation and in the utilization of postprostatectomy radiation therapy or postradiation salvage radical prostatectomy for PSA relapse.
The other perspectives that must be considered in making these difficult decisions are those of the patients. We previously reported on a "town meeting" of more than 300 prostate cancer survivors and their partners. Electronic keypad polling was utilized to solicit input about clinical scenarios that were very similar to the ones discussed by our physicians' groups, and there was as much heterogeneity among the prostate cancer survivors as the physicians.
At the epicenter of this maelstrom of viewpoints is the contemporary provider of CME with the imprimatur to not only update physicians on new research data but also to serve as a conduit between the key constituents. This is a very different role from the "see one, do one, teach one" approach we had in training house staff to do procedures. And while working group meetings like the one in this audio program help us understand the varied perspectives of the key constituents, they also increase our awareness that the evidence base for the management of patients with prostate cancer is far from ideal.
- Neil Love, MD
Participants at the research leader "Think Tank"
Chicago, Illinois - April 24-25, 2003
Faculty:
William Aronson, MD
University of California at Los Angeles |
Anna C Ferrari, MD
Mount Sinai Medical Center |
A Oliver Sartor, MD
Louisiana State University |
Arie S Belldegrun, MD
University of California at Los Angeles |
Leonard G Gomella, MD
Jefferson Medical College |
Paul F Schellhammer, MD,FACS
Eastern Virginia Medical School |
Michael K Brawer, MD
Northwest Hospital |
Judd W Moul, MD
Uniformed Services University of the Health Sciences; Walter Reed Army Medical Center |
Joseph A Smith Jr, MD
Vanderbilt University |
Gerald W Chodak, MD
University of Chicago |
Mack Roach III, MD
University of California at San Francisco |
Matthew R Smith, MD, PhD
Massachusetts General Hospital |
Nancy A Dawson, MD
Greenebaum Cancer Center |
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Mark S Soloway, MD
University of Miami School of Medicine |
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Howard R Soule, PhD
CaPCURE |
Participants at the Prostate Cancer Update Working Group Meeting
New York, New York - May 14, 2003
Faculty:
Mitchell C Benson, MD
Squier Urological Clinic, The Presbyterian Hospital |
Leonard G Gomella, MD
Jefferson Medical College |
Adam P Dicker, MD, PhD
Bodine Center for Cancer Treatment |
Michael J Zelefsky, MD
Memorial Sloan-Kettering Cancer Center |
Attendees:
Howard L Adler, MD
Stony Brook, NY
Donald A Bentravato, MD
Schenectady, NY
Dennis R Braun, MD
Norristown, PA
David T Chang, MD
Fair Lawn, NJ
Charles M Dalton, MD
State College, PA
Ronald D Ennis, MD
New York, NY
Leonard R Farber, MD
New Haven, CT
Fredrick Greenstein, MD
Brooklyn, NY
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Aftab Hussain, MD
Perth Amboy, NJ
Jack Jedwab, MD
Brooklyn, NY
Aaron E Katz, MD
New York, NY
Ronald P Kaufman Jr, MD
Albany, NY
George Klein, MD
New York, NY
Richard Kroll, MD, FACS
Pomona, NY
Irwin M Lieb, MD
Saranac Lake, NY
David B Lillie, MD, PC
Kenmore, NY |
Errol Mallett, MD
Brooklyn, NY
Glen McWilliams, MD
New York, NY
Sameer Rafla, MD, PHD
Brooklyn, NY
Gurmukh J Sadarangani, MD
New York, NY
Joseph G Trapasso, MD
Allentown, PA
Robert S Waldbaum, MD
Manhasset, NY
Gary H Weiss, MD
New Hyde Park, NY |
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