November 26, 2007
American Cancer Society

Many Prostate Cancer Patients Receive Improper or "Mismatched" Therapies

Prostate cancer patients often receive treatment that is contraindicated by pre-existing conditions, like urinary or bowel dysfunction, according to a new study. Dr. James Talcott of the Massachusetts General Hospital in Boston and co-investigators found that patients with certain pretreatment dysfunctions often receive contraindicated or "mismatched" therapies, which can lead to worse outcomes. The study is published in the January 1, 2008 issue of CANCER, a peer-reviewed journal of the American Cancer Society.
The American Cancer Society estimates that more than 218,000 American men are diagnosed with prostate cancer and more than 27,000 die from the disease each year. The three most common treatments for the disease are external beam radiation, brachytherapy, and radical prostatectomy.

Clinical studies have found no differences in efficacy among the three major therapies for the treatment of prostate cancer, but each brings with it certain risks, such as urinary incontinence or sexual dysfunction. Therefore, the best therapy for a particular patient will depend on the individual’s pre-treatment status. For example, patients with pre-existing bowel dysfunction should not receive external beam radiation as a first line of therapy because the treatment inevitably irradiates the adjacent rectum in addition to the prostate and causes acute and long-term bowel dysfunction. Similarly, patients with problematic urinary obstructive symptoms should not receive brachytherapy, which delivers radiation to the prostate and can cause complete obstruction in patients with pre-existing obstructive symptoms.

Dr. Talcott and his colleagues surveyed 438 patients who sought therapy for untreated, localized prostate cancer from several hospitals in the Boston area between June 1, 1994 and August 31, 2000. Several additional questionnaires were mailed to patients until 36 months after treatment, and medical records were reviewed.

The study shows that 389 patients reported pre-existing dysfunction, and more than one-third received mismatched treatments. Increasing clinical complexity of a patient's condition had little effect on the likelihood of mismatched treatments. Patients who had a single baseline dysfunction that contraindicated one treatment were just as likely to be given a mismatched treatment as patients with weaker contraindications or patients for whom multiple treatments were contraindicated. As expected, mismatched brachytherapy and external beam radiation therapy led to worsened urinary and bowel symptoms, respectively.

The investigators plan to test whether incorporating prostate cancer–specific survey instruments into clinical practice may increase awareness of patient baseline dysfunction, reduce treatment mismatches, and improve outcomes.

The authors conclude that their observations "raise concerns about physician-patient communication." Similar situations may also exist for other types of cancer, "producing unsuspecting barriers to patient-centered choices of treatment, palliative care and hospice," say the authors.