Treatment ""Mismatches"" Common in Early Prostate Cancer

By Karla Gale

NEW YORK NOV 27, 2007 (Reuters Health) - More than one third of patients with early prostate cancer receive treatment that may not be appropriate based on pre-existing obstructive uropathy, bowel dysfunction or sexual dysfunction, the results of a prospective cohort study suggest.

"These "mismatched" treatments are relative contraindications -- they either disproportionately increase the likelihood of long-term symptomatic side effects or offer no benefit at an additional risk," lead author Dr. James A. Talcott told Reuters Health. "A patient may be willing to accept those risks because of a countervailing preference, such as a fear of surgery or the inconvenience of getting radiation treatments five times weekly for 8 or 9 weeks."

The study findings, slated for publication in the January 1st issue of Cancer and released online on November 26, showed that treatment mismatches produced worse patient outcomes.

Dr. Talcott, at Massachusetts General Hospital in Boston, and colleagues recruited 438 patients with untreated, clinically localized prostate cancer who sought treatment at multispecialty clinics in the Boston area between 1994 and 2000. Most of the men were in their 60s and ages ranged from 46 to 82 years old.

Prior to treatment and periodically over the ensuing 3 years the subjects completed questionnaires regarding problems with urinary, bowel or sexual function.

Only 11% were free of symptoms at baseline; 61% reported urinary obstruction, 64% reported sexual dysfunction, and 43% reported bowel dysfunction.

Contrary to the researchers" expectations, mismatches were common even among patients with severe baseline dysfunction in only one organ domain. Mismatches did not rise significantly with increasing clinical complexity and the rate of mismatches did not decrease over time.

For example, pretreatment urinary problems were exacerbated among patients who received brachytherapy, the authors report, and "external beam radiation therapy increased diarrhea, painful bowel movements, bowel urgency, and rectal bleeding in patients with baseline bowel dysfunction."

Similarly, patients with sexual dysfunction derived no additional benefit from nerve-sparing radical prostatectomy as opposed to traditional surgery.

Physician bias may partially explain treatment choices, Dr. Talcott said. "All things being equal, urologists recommend surgery for prostate cancer about 90% of the time, and radiation oncologists recommend radiation treatment 90% of the time."

However, poor communication may lie at the heart of the problem, the investigators suggest.

"Research from a variety of sources has shown that patients respond more frankly and freely to a questionnaire than to a person, and that treating physicians hear a censored version of events from patients, compared to what their family members or nursing staff hear," Dr. Talcott explained. "It seems patients sometimes tailor their comments to physicians according to what they believe he or she wants to hear."

Using questionnaires could help, he added. However, "there is a lot of paperwork and little time in medicine, and physicians, like most people, are reluctant to exchange any of the latter in favor of the former, particularly if they think it is unnecessary."

"We would need to prove to them that they get better information as rapidly with a questionnaire for them to adapt to using them."

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