At the risk of foolishly rushing into topics about which angels commonly fear discourse, we need to continue our journey this year through the clinical management of clinically localized prostate cancer. We – and I am including myself in this – should make a new year’s resolution to be self-reflective, explore our biases and preconceived notions, and observe and chart new and emerging data. Several trials are ongoing which may more brightly illuminate our path.
Dr. Jenny L. Donovan of the University of Bristol (England) recently published an article in the Journal of the National Cancer Institute Mongraphs brilliantly summarizing the current state of the debate (2012;45:191-6). She describes the maturation of our "group think" as we evolved from a strategy of watchful waiting only for those men with limited life expectancy to a deeper realization and appreciation for the downsides of radical intervention for nonaggressive disease.
Clinicians hold an enormous amount of sway in the decisions that patients make about clinical care, and personal and professional biases commonly take the helm. When it comes to complex clinical issues, most of us have neither a firm grasp on the data nor the time to explain it.
Decision aids are an effective clinical tool that can improve the quality of the decisions about screening and treatment. For prostate cancer screening, decision aids enhance patient knowledge, reduce decisional conflict, and reduce interest in prostate-specific antigen screening. Relatively less is known about how treatment should be presented to enhance decision making.
Dr. Donovan describes Prostate Testing for Cancer and Treatment (ProtecT), which has enrolled more than 3,000 men with clinically localized prostate cancer, and compares radical prostatectomy, radiotherapy, and active monitoring.
In the process of recruiting for the study, investigators learned that "watchful waiting" was frequently interpreted as "no treatment." As a result, the term was changed to "active monitoring." Decisions, in clinical medicine, as in business, are contingent upon the salesperson, and word choice is crucial. Data from this trial are expected in 2016.
In the meantime, we can facilitate our decision with the use of an amazingly helpful online decision aid produced by the federal Agency for Healthcare Research and Quality. This tool is designed for patients with clinically localized prostate cancer. This may serve as a useful homework assignment for our Internet-savvy patients.
Providing our patients with this degree of information will empower them and advance our clinical discussions about prostate cancer treatment.
This column, "What Matters," regularly appears in Internal Medicine News, a publication of Frontline Medical Communications. Dr. Ebbert is professor of medicine and primary care clinician at the Mayo Clinic in Rochester, Minn. He reports having no conflicts of interest. The opinions expressed are those of the author. Reply via e-mail at firstname.lastname@example.org.