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Leah
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I must say I found the following article in USA Today ( 4/1/09, by Liz Szabo) , bonechilling. A British study confirms what I’ve said many times: that when it comes to performing minimally-invasive radical prostatectomy or laparoscopy (which includes robotically assisted surgery, *although that was not the subject of this study*), NO amount of experience on the part of the surgeon is enough.
And there is another very important point being made which I have NOT heard before: That “open” surgeons (those who perform the traditional radical retropubic prostatectomy) who later switch to laparascopic surgery produce (much) worse results than doctors who initially specialize in this area.
Here are some excerpts from the USA Today article (more comments at end):
“Prostate cancer patients whose surgeons have anything less than the highest degree of experience with a popular new procedure may be at greater risk of relapse, according to a study in The Lancet Oncology April 1 edition.
<snip> “While it takes at least 250 surgeries for a doctor to become proficient at the traditional surgery — allowing patients to feel confident that doctors removed all of the cancerous tissue — surgeons need to do at least 750 keyhole procedures to become proficient. Doctors who are used to performing traditional surgery actually have a harder time learning keyhole techniques than novice surgeons who are learning to perform the procedure for the first time, the study shows.
“That suggests that doctors shouldn’t try to switch back and forth between techniques, but instead focus on perfecting their skills on just one type of prostate removal and patients who opt for keyhole surgery should go to cancer centers where doctors specialize in the procedure, authors say.”
The take-home message for men who have decided on laparascopic prostatectomy but do not live near a top-rated urologic oncology facility (“Center of Excellence) is that they should consider traveling to one or finding a “high-volume” surgeon in private practice. (For some guidance about top hospitals, look at usnews.com, “Rankings”, keyword “Cancer”, not Urology”. Also, at castleconnolly.com, “America’s Top Doctors for Cancer”.) A lot of people are unaware that there are charities which make arrangements for patients and their families to stay close to the hospital for the duration of treatment. I know because I was on the receiving end of such a favor. Ask the hospital social worker or chaplain about this.
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Leah
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I wholeheartedly agree with the sentiments expressed in the article Prostate Cancer: Men Deserve Better, European Association of Urology, March 17, 2009 (exerpts below). http://www.alphagalileo.org/ViewItem.aspx?ItemId=56307&CultureCode=en. But talk is cheap. The question is, how do we bring about real change (change we can believe in!)? That’s a lot to ask — but heck, we are worth it. We also need a system in which newly diagnosed PC patients are seen by a multidisciplinary team of doctors, consisting perhaps of a urologist, radiation oncologist and medical oncologist. Fortunately, we have such a model now. I received this article a few weeks ago about a new, “patient-centered” unit at UCLA: “Urologic Oncology Institute Launched To Offer Multi-Disciplinary Care, Personalized Treatments To Patients” (March 04, 2009). https://mail.google.com/mail/?source=navclient#search/multi/11fdd1625aa370e2
In this case, a group of urologists (and patients) are pointing out some shortcomings of current PC management, such as a lack of communication between doctor and patient. In order to truly give consent to a treatment such as surgery or radiotherapy, I believe a patient must have been informed of the risks and benefits of all the reasonably accepted treatments available.
The burden is on the urologist to do this, because these doctors are almost always the “first stop” (and usually only stop) for newly diagnosed PC patients. There is an issue of time here, as the doctor can’t spend the whole day discussing PC with the patient, but one advocate has suggested that urologists provide patients with written materials about PC that they then could use for discussion. I think this is a good idea.
Also, the authors lament the poor quality of life that can ensue after prostate cancer treatment. But the comparison with breast cancer treatment is not a good one. Women who are treated for BC may have a better quality of life than men treated for PC for an obvious reason — their urinary and sexual functions have not been interfered with.
What we need is new treatments, applied sparingly, with fewer side effects.
Finally, I want to add a word about two neglected areas in PC treatment. We need to do more to diagnose and treat mood disorders and other psychological issues which may occur in PC patients. Second, we need to draw in a spouse or significant other (if there is one) into the discussion of PC options, and also monitor the partner’s well-being over time.
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“Prostate Cancer: Men Deserve Better”
“Vast improvements in prostate cancer recognition, management and treatment are needed, according to major prostate cancer groups speaking at the European Association of Urology’s 24th Annual Congress today.
“… The group’s overarching concern is a lack of clear and consistent information, particularly in areas that affect a man’s quality of life and that of his family. Prostate cancer and its treatments impact on all elements of a man’s life and not just his physical being. Many men experience urinary incontinence and impotence which can severely compromise their sense of masculinity and day-to-day quality of life, affecting their work, social activity and love life. The charter asks for practices to be put into place to better inform and educate men, their families and all those involved in prostate cancer care of the far-reaching effects of the disease and to encourage a more open, communicative and holistic approach to its treatment and management.
“Tom Hudson, Chairman of Europa Uomo, explains, ‘Our charter highlights the shortcomings in the current management of men with this condition but from a very practical viewpoint. For example, maintaining key relationships, love life and intimacy throughout prostate cancer is incredibly important but can often be overlooked. Many men feel uncomfortable discussing these issues and avoid them altogether. It is an area which is absolutely key to men’s quality of life and there needs to be a cultural shift in the way it is approached and managed’.
“Louis Denis, Secretary of Europa Uomo, adds “There is still much room for improvement in the management of prostate cancer and the fight against the disease is far from over. Prostate cancer does not receive anywhere near the level of interest and funding it warrants and this must be addressed. With the right holistic approach, men diagnosed with prostate cancer can live long and fulfilled lives. This approach has been taken very successfully to women with breast cancer and we believe that men deserve to be treated in the same way. At the moment, quality of life for men with prostate cancer can be very low, and steps must be taken to recognise and treat the whole person behind the disease, not just the disease itself.”
http://www.europa-uomo.org/
http://www.eaustockholm2009.org
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Leah
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I have long said that prostate cancer surgery is a PROCESS, not a one-time event. RP doesn’t end when the anesthesia wears off. You are likely to have problems that need further attention, such as impotence or incontinence, even if it’s temporary. And of course you will need a doctor who will follow you for signs of recurrence. Careful monitoring of PSA and periodic DREs are a must.
Keep this in mind when interviewing potential surgeons. Ask about their accessibility after surgery. Unfortunately, there are some “cut and run” types who will leave you on your own to cope with nasty side-effects.
I believe the medical profession has not addressed the issue of follow-up care for RP patients adequately. So I was pleased as punch to receive in my daily mail an abstract of a study done at the Yale University School of Nursing called:“Follow Up of Men Post-Prostatectomy: Who is Responsible?” (Yale Univ. School of Nursing, November 13, 2008.)http://www.urotoday.com/index.php?option=com_content&task=view_ua&id=2218600
Finally, they’re asking the right question
Here is how the researchers framed the problem:
“Men living with prostate cancer represent a large, at-risk population deserving access to comprehensive follow-up services stemming from chronic aspects of living with the disease. Current research about the quality and accessibility of prostate cancer follow-up services is limited.”
The purpose of the Yale study was to “describe the patient, provider, and health plan characteristics speculated to influence prostate cancer follow-up care.”
The researchers found a lot of deficiencies in the follow-up care of post-RP patients, among them a lack of coordination among doctors and duplication (of PSA tests, for example), even though all of the men were seen by urologist. And there were many chronic, untreated side effects:
“All of the men participated in follow-up visits to a cancer care provider (urologist) and were monitored for recurrence by prostate-specific antigen (PSA) testing. Fewer men had rectal examinations performed. For nearly half of the men, the general medical provider duplicated the PSA test, indicating a lack of coordination among providers. Persistent late effects included urinary incontinence (60%) and erectile dysfunction (71.9%). No significant associations were found among patient, provider, and health plan characteristics to their utilization.”
I have to say the “persistent late effects” of incontinence and ED in this population were unusually high. But it confirms that prostatectomy patients need ongoing care and support. (For example, I always recommend that any RP patient who has not recovered erectile function after two months see an ED specialist. At least give “penile rehabilitation” a try).
A major finding of the Yale study was that “nurses can play a major role in providing good follow-up health care for RP patients”:
“Nurses are uniquely positioned to assume a central role in promoting access to comprehensive, non- duplicative post-prostatectomy follow-up care. Additionally, nurses can provide effective counseling, advocacy, and education for men living with prostate cancer.”
Nurses are underestimated and underutilized but they’re part of the solution. So bring on the sisters (and brothers)!
Reference:
Urol Nurs. 2008 Oct;28(5):370-80.
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Leah
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My fellow blogger, Kathy Meade, alerted me to the following. It’s about time we developed holistic approaches to treating cancer patients!
“University of Edinburgh researchers have reported success with an interdisciplinary intervention for treating major depressive disorder in people living with cancer. The intervention is delivered by specially trained oncology nurses, is designed to work alongside a patient’s usual cancer care, and emphasizes screening for depression, antidepressant medication, and teaching patients problem-solving skills. Results from a randomized clinical trial of the program, called’Depression Care for People with Cancer’, were reported in the July 5 issue of Lancet. (2008;372:40-48).”
To read the entire article, go to:
http://caonline.amcancersoc.org/cgi/content/full/58/6/319