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THE CONUNDRUM
Prostate cancer reflects a broad range of biology and clinical risk and its management needs to be tailored to balance the risk of disease progression with the risks of the side effects of treatment. The million-dollar question for men with localized prostate cancer: Do you want to be treated for prostate cancer and reap the benefits of increased survival and longevity, but also possibly incur the risks and compromises that may interfere with your quality of life, often sexual and urinary side effects?
This is the conundrum that many men with localized prostate cancer face. How does one weigh the trade-offs and arrive at a rational decision about the best course to pursue, whether it is active surveillance, surgery, radiation, or focal ablative therapies? “Shared decision making” is the term applied to the collaborative process of arriving at decision, a choice that is ultimately made by the patient with the physician providing guidance and direction.
TRIAGE AND RISK CATEGORIZATION
Years ago, virtually everybody with newly diagnosed prostate cancer underwent surgery. Urology has evolved tremendously and urologists are now much more nuanced and sophisticated in terms of ability to discern who needs treatment and who does not based upon a number of factors.
Triage prioritizes treatment by the severity of the disease and likelihood of recovery with and without treatment. Newly diagnosed prostate cancer is categorized by disease severity into the following risk categories:
Very low risk
Low risk
Favorable intermediate risk
Unfavorable intermediate risk
High risk
Very high risk
Very low risk and low risk prostate cancer can be readily and safely managed with active surveillance. Unfavorable intermediate risk, high risk, very high prostate cancer risk merit active treatment. The “grayest” area is the favorable intermediate risk category.
WEIGHING SURVIVAL VERSUS TREATMENT-RELATED SIDE EFFECTS
Navigating the trade-offs between the pluses and minuses of prostate cancer treatment options is challenging for urologists and patients alike. This is particularly difficult with localized prostate cancer since the outcomes among the various options are often similar, although the side effect profile is more variable. Patients with localized prostate cancer have a choice between active surveillance and active treatments (surgery, radiation, androgen deprivation, focal therapies). Active treatments increase survival and longevity, but also escalate possible intimate issue side effects including urinary control and erectile/ejaculatory function. How does one prioritize the strengths and weaknesses of any particular treatment and make treatment choices?
A recent article in the Journal of Urology by Watson et al addressed this issue (Vol 204, Aug. 2020, 273-280), evaluating and quantifying the trade-offs between active surveillance and active treatments in more than 600 men with newly diagnosed localized prostate cancer. They used “discrete choice experiments” (originating in mathematical psychology and economics) to predict individual choices and found that men with favorable intermediate risk prostate cancer are willing to accept up to a 10% or so survival disadvantage over 10-15 years in order to preserve urinary and sexual function. The study showed that even patients with high risk prostate cancer are willing to accept a decrease in survival for faster recovery and functional improvements.
Patients desire to be cured of prostate cancer, but they also want to retain their urinary control and sexual function. Not everybody after radical prostatectomy achieves “trifecta” status: undetectable PSA, good urinary control, satisfactory erections. Side effects and complications are important to patients and need to be carefully weighed into the treatment decision making process.
“Complications are the patient’s perceptions, and for the patient, perception is reality.“
–Dr. Richard Williams
Bottom Line: Typically, the discussion with the newly diagnosed patient explains the various treatment options that offer a survival benefit (quantity of life) and their potential urinary and sexual functional side effects (quality of life). Urologists rarely discuss this from the reverse perspective—asking patients what survival benefits might be traded off to preserve function. Patients with favorable intermediate risk disease are the particular category of patients that may prefer active surveillance to active treatment and may be willing to assume the possible risk of a survival disadvantage.
