Australian men with a recent diagnosis of prostate cancer that require active treatment, as opposed to careful monitoring, are often not given all the options available to them.
This means not all men are getting the necessary information and support to make a decision on what treatment is best. A growing body of evidence and treatment guidelines support the fact that less invasive radiation therapy is equally effective in curing or controlling cancer as surgical removal of the prostate, known as radical prostatectomy.
While all patients see a urologist - the specialist surgeon who does the biopsies and gives the diagnosis - they only see a radiation oncologist if the urologist or GP refers the man on. In this way, the urologist is the gatekeeper to men receiving optimal (or sub-optimal) care. The fear of cancer and a natural emotional response to get it out may lead to a less than fully-informed decision for surgery, and to possible regret of this decision later on.
Bias in medicine is a reality, and it is not surprising doctors favour familiar treatments. But it is problematic when bias creates a hurdle to men getting accurate, balanced information. There is plenty of evidence men aren’t getting the chance to hear about their radiation therapy options. A recent US study found that men seeing both a radiation oncologist and urologist were six times more likely to choose radiation therapy compared with men seeing only a urologist.
In Australia, the proportion of men receiving radiation is much lower than research on effectiveness of radiation therapy would predict if men with prostate cancer were exhibiting truly informed choice. Meanwhile, prostate surgery rates are higher and continue to rise, especially in the case of robotic surgery.
The gold standard of care
The gold standard of care for prostate cancer begins with the patient and his support person talking with the experts – the surgeon (urologist), a radiation oncologist and a specialist nurse. In doing so, the man is provided with the relevant information and impartial advice he needs to make an informed decision about his preferred treatment.
Virtually all specialist doctors who treat cancer profess to be part of a multi-disciplinary team, that includes surgeons, medical and radiation oncologists and other experts, and attend meetings where the relevant health professionals discuss patient “cases” to decide on management. These team meetings are valuable, but they are only one aspect of a high quality service. Meetings do not include the patient, the man with prostate cancer, who is integral to the decision-making process.
The multi-disciplinary team model has been successful in the treatment of breast cancer. There is nearly always more than one good treatment option available for men with prostate cancer, sometimes several. For men with low risk cancers, many may not require active treatment up front (or ever) and are appropriately managed by active surveillance or careful monitoring.
But other men with prostate cancer require active treatment to reduce the chance of dying, or suffering symptoms, from cancer. Alternative treatment pathways are very different for the individuals involved, in terms of patient experience, potential side-effects, the need for additional treatments, and potential out-of-pockets costs. This is why the man with prostate cancer has to be the most important member of the team who decides on the treatment.
Putting the patient at the centre
Only the patient can weigh up the trade-off between the risk of bowel problems (with radiation therapy) and the risk of urinary incontinence (with surgery). Likewise, the choice between attending the cancer centre for radiation treatment every weekday over several weeks versus hospitalisation and time off work for recovery after surgery. There are many other pros and cons that may sway a man to prefer one approach over another.
As already mentioned, the ideal model for decision-making for prostate cancer treatment is that the man has a consultation with a urologist and a radiation oncologist. As the two types of prostate cancer specialists have distinct expertise in different areas, seeing both is the only way men can get complete, up-to-date information.
The man can then consider his options and discuss these with his family and GP if he wishes. The good news is that men can take time to do this, as most prostate cancers are relatively slow-growing.
In the United Kingdom, Canada, and select centres including some in Australia, prostate cancer teams do place the man at the centre of decision-making. But this must become the rule rather than the exception and Australian men should be strongly encouraged and assisted to see all experts.
Ultimately, men need to be empowered in their decision-making through being part of a process that enables and supports them in making fully informed choices. Until then, men who require active prostate cancer treatment need to insist on seeing all the specialists in the area, including a radiation oncologist.
Authors: Sandra Turner, Associate Professor, University of Sydney