PCa Guidance to Family Doctors

The August 15 issue of American Family Physician — supposedly one of the most widely read medical journals in America — carried an article by Mohan and Schellhammer entitled “Treatment options for localized prostate cancer.” Unfortunately the full text of this article is not available on line for the average reader.

In their article, Mohan (a family physician) and Schellhammer (a urologic oncologist who is himself a prostate cancer patient with progressive disease) offer family doctors rather more than a standard review of the diagnosis and treatment of prostate cancer, and it is the first review of prostate cancer to appear in American Family Physician since 2005. To that extent, it should be seen as a key overview on the subject of prostate cancer for the primary care community.

The article makes a number of evidence-based key points about the treatment of localized prostate cancer for the family practitioner, as follows:

Treatment of localized prostate cancer is unlikely to improve the survival of [most] men with low- and very low-risk disease and all such active interventions have potentially negative effects on health-related quality 0f life.
Despite this information, some 70 to 90 percent of men with localized prostate cancer choose an interventional treatment shortly after a positive biopsy.
More than 50 percent of such patients significantly over-estimate the survival benefit of treatment.
Treatment of localized prostate cancer should normally be recommended for higher-risk patients.
Risk level can be estimated based on cancer stage and grade, PSA level, and comorbidity-adjusted life expectancy (CALE).
Patients can be counseled that surgery and external beam radiation therapy are almost equal in efficacy for the treatment of localized prostate cancer.
Brachytherapy is an appropriate form of monotherapy in low-risk, localized prostate cancer.
Active surveillance is a reasonable management option for low- and very low-risk, localized prostate cancer.
The article also includes a series of tools that may be useful to primary care physicians and their patients in assessing risk and the appropriateness of differing forms of treatment, including:

A questionnaire to assess patient understanding of the benefits and risks of different treatment options.
A simplified algorithm (derived from the prostate cancer guidelines of the National Comprehensive Cancer Center Network) that can be used to aid selection of appropriate management of localized prostate cancer
A table to assist in assessment of a patient’s Charlson comorbidity index (CCI)
A table to assist in assessment of a patient’s comorbidity-adjusted life expectancy (CALE)
A table summarizing expected adverse effects at 2 years after treatment for localized prostate cancer
The Klotz (Canadian) protocol for active surveillance of men with localized prostate cancer (including indications for interventional treatment)
The article is supplemented by a handout for family physicians to use with their patients entitled “Prostate Cancer: Who Should Be Treated?” The full text of this brief handout is available on line.

Support group leaders and other prostate cancer educators are encouraged to ask the assistance of their family physicians or their local medical librarian in obtaining a copy of this article for their personal use.

It is inevitable that an article like this will not meet the approval of everyone in the prostate cancer community. It is an easy article to “pick holes in” if one is of a mind to do so. However, even with such limitations, what this article does do is to provide a series of tools and sound general information that will help the family practitioner to become more involved in the provision of appropriate guidance to patients diagnosed with prostate cancer — and particularly those patients of 60 to 80 years of age who comprise a significant majority of those being diagnosed with localized, low-risk prostate cancer today.