'Mismatched' prostate cancer treatment more common than expected

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.