Men with early stage, low-risk prostate cancer, who could have opted for active surveillance or “watchful waiting,” appear to be satisfied with the more-aggressive treatments they’ve chosen, according to patient questionnaires. Yet, privately, many men complain to their doctors of persistent side effects such as urinary incontinence and erectile dysfunction following surgery or radiation.
[See: 10 Things Younger Men Should Know About Prostate Cancer.]
It’s doubtful that men are as overwhelmingly happy with their treatment decisions as surveys generated by medical practices suggest, says Dr. Claus Roehrborn, a professor and chairman of the department of urology at UT Southwestern Medical Center in Dallas. It’s important for men making these choices to truly understand what to expect.
For men who want aggressive treatment, one choice is whether to undergo surgery or radiation. The most common operations to remove the prostate gland are radical open prostatectomy — the older, traditional method that uses a larger incision — and laparoscopic radical prostatectomy, which uses smaller incisions and special tools. Robotic-assisted laparoscopic prostatectomy, also known as robotic prostatectomy, allows the surgeon to move robotic arms inside the patient’s body via a control panel.
About 90 percent of prostate surgery performed in the U.S. now is robotic rather than open surgery, says Dr. Michael Leapman, an assistant professor of urology at Yale School of Medicine in New Haven, Connecticut. Immediate surgical outcomes — less blood loss and shorter hospital stays — appear to be better for robotic-surgery patients. However, he says, the data don’t really show improved long-term results in cancer outcomes or sexual function.
[See: Which Medical Screenings Should You Have in 2017?]
Radiation therapy includes 3-D conformal radiation, which allows radiation beams to conform to the shape of a tumor. Stereotactic body radiation, done with devices such as a Gamma Knife or CyberKnife, is a noninvasive, precision form of radiation that allows shorter treatment and recovery time. However, “the side effects are not better,” according to the American Cancer Society’s website. “In fact, some research has shown that some side effects might actually be worse with [stereotactic radiation than 3-D radiation].”
Proton beam therapy involves radiation with protons instead of X-rays to target the cancer. Although it’s offered by some centers to treat prostate cancer, proton beam therapy is best supported by evidence for treating children with brain cancer. Not much data are available for patient satisfaction among prostate cancer patients, Leapman says. However, he notes, strong marketing pushes for new technologies can raise patients’ expectations unrealistically high.
Survey Says …
Urologists and other specialists shouldn’t rely too heavily on superficial survey results from patient questionnaires, Roehrborn says. Digging a little deeper might reveal a more conflicted response, he says. A patient who’s emotionally and otherwise invested in his treatment decision might find it difficult to admit he’s unhappy with it afterward.
For example, a patient who chooses proton beam radiation at a distant center has likely talked over the choice with his family, friends and neighbors. In some cases, the patient may have paid for the treatment out of pocket. Even when outcomes aren’t that good — PSA blood-test levels (a measure of a cancer-related protein) haven’t dropped or side effects occur — men tend to defend their decision to others and themselves, Roehrborn says.
Some patients are more likely to express dissatisfaction. Decision regret is higher in African-American men after robotic surgery for prostate cancer, according to a May 2014 study in the journal Urologic Oncology. “What we showed was the overall rate of satisfaction was quite high,” says study co-author Leapman. However, the study found a difference between African-American and white men.
A new study in the July issue of the Journal of Clinical Oncology tracked long-term survivors of localized prostate cancer for up to 15 years. Men who were monitored but didn’t undergo radiation or surgery were less likely to report regret than those who underwent active treatment.
Better-Prepared Patients
Making sure patients understand treatment advantages and possible complications could reduce the disconnect between what they say and how they really feel post-treatment. Some patients who are good candidates for watchful waiting might be more likely to consider that option.
In some cases, disappointment is due to the disease itself. “With some patients, when you do the surgery you find higher-grade disease [than expected],” Leapman says. “Maybe surgeons have not counseled adequately that patients might need ablative radiation afterward or hormonal therapy if we detect higher-grade disease or distant spread.”
By working together, doctors and patients can achieve more realistic expectations, improve the decision-making process and minimize certain complications.
— Talk frankly about side effects. Urinary incontinence or dribbling after prostate cancer treatment troubles some men more than others. “Some patients cannot stand the fact there is even one drop of urine leaking at any time of the day or night,” Roehrborn says. “Some patients wear one or two pads and are perfectly happy.” People need to consider how treatment could affect their lifestyle. One daily pad or less is tolerable for most patients, he says. “But two or three pads? It’s the moment they can’t play golf or travel, or the moment they can’t go line dancing — whatever they do. It’s a big problem.”
— Be proactive with sexual rehab. Sexual rehab starts right away, Roehrborn says. “The best thing you can do between now and your surgery is: You can have a lot of sex,” he tells patients. “You can masturbate a lot. The more [sexual activity] you do, the better it will be for your recovery.” He suggests medication for men who are having erection problems even before treatment. “The more active you are before surgery, the more [comfortable] and confident you are, the better your recovery would be,” he says. Men’s partners can also participate in pre-treatment counseling, he says, and if difficulties persist afterward, seeing a sex therapist could help.
— Educate to boost understanding. “It ultimately comes down to patient education,” Leapman says. Standard written materials and drawings might not really do the job. “One of the things we’re trying to employ is very well-choreographed and explicit images,” he says. For instance, a graphic or photo of the bladder catheter that patients will need for one or two weeks after surgery gives them a better idea of what’s entailed. Visual tools and better verbal explanations can help bridge the communication gap, he says.
— Seek insight from former patients. Talking to other men who’ve undergone treatment for prostate cancer can give new patients a better sense of what to expect. Peer counseling and discussion helps, Leapman says. Many medical practices and hospitals offer support groups for men to share their experiences.
[See: 10 Ways to Prepare for Surgery.]
“The best way to avoid buyer’s remorse and decisional regret is not to treat patients who don’t need to be treated,” Leapman says. There are “highly accurate” ways to predict who needs to be treated and who is at appropriately low risk to offer active surveillance.
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Why Many Men Experience ‘Buyer’s Remorse’ After Prostate Cancer Treatment originally appeared on usnews.com
