Prostate Cancer Survivors Need Well-Rounded Care


I'm Dr. Gerald Chodak, for Medscape. This week I want to talk about a prostate cancer survivorship guide recently issued by the American Cancer Society (ACS) to help primary care physicians in their management of men with this disease.

Estimates are that there are 3 million men surviving after a diagnosis of prostate cancer, and although the treating physician is most likely managing the cancer itself, there may be unmet needs that can be addressed by the primary care physician.

The ACS convened a panel of experts in a variety of specialties and they also conducted a literature review. They reviewed 222 papers that are part of this report. The guidelines can be broken up into several areas.

First is general health and promotion of well-being. Of interest, many men have focused to a great extent on their concerns about prostate cancer while omitting other health concerns that are far more likely to result in their death. One of the guidelines has to do with general health issues such as stopping smoking, watching their weight, reducing obesity, improving nutrition, and taking regular exercise. Sadly, too many men with prostate cancer don't engage in these healthier activities, and although the studies are not clear on their overall impact on prostate cancer survivorship, indirect studies suggest a general benefit whereby health and survival can be improved. That is something that needs to be addressed more.

Other issues relate to quality of life as a consequence of the treatment for prostate cancer. Urologists, oncologists, and radiation therapists are aware of the need to monitor patients who have treatments and experience side effects, and make efforts to address them. But over time there may be unmet needs, and the primary care physician can address these. There are validated surveys, such as the Expanded Prostate Cancer Index Composite (EPIC) and the International Index of Erectile Function (IIEF) sexual questionnaire, that should be considered for periodic use to determine whether there are unmet needs. Over time, many patients may stop talking to their treating physician about those problems even though they are bothersome, and so the primary care physician has an opportunity to identify the problems and then try to intervene in some way.

Psychological issues are often underaddressed. Many men become depressed as a consequence of their diagnosis or of the side effects that they are having to endure. There is a simple distress thermometer tool that has been developed by the National Comprehensive Cancer Network. It allows doctors to identify the psychosocial well-being of a patient. That should be used on a regular basis.

Another problem is the medical consequences of the treatments for prostate cancer -- in particular, androgen deprivation therapy (ADT). Many urologists do not adequately address the problems that can occur. Patients may develop problems with diabetes, hypertension, or metabolic syndrome. They can develop anemia, cognitive changes, impotence, and psychological problems. The primary care physician should be on the lookout for such problems. In fact, any doctor who puts a patient on ADT should make sure to converse with the primary care physician so that these problems can be adequately addressed.

Another consequence of ADT that must be addressed is bone mineral density changes. Many doctors are monitoring for this problem, and patients have unmet needs in this area.

Last, there may be problems with secondary cancers that could cause symptoms. No one is recommending routine screening for them, but both bladder and bowel cancer can occur as a consequence of radiation therapy. The incidence is low, but if patients develop problems with blood in their stool or urine, this certainly needs to be carefully addressed.

In the end, we have guidance to help the primary care physician in the management of men with prostate cancer. A lot more work needs to be done in terms of identifying opportunities to improve survival, but the primary care physician has this tool to do a better job of managing men who are living with a diagnosis of prostate cancer. I look forward to your comments. Thank you.