Most prostate cancer nomograms were developed and validated for prediction of biochemical tumor recurrence (time to biochemical failure), an endpoint that is not understood by many patients.4,8,9 But recent studies suggest that these tools also predict outcomes that are more meaningful to patients, such as prostate cancer-specific mortality.4,8 Indeed, one such study, conducted in North Carolina, found that prostate cancer nomograms more accurately predict prostate cancer-specific mortality than biochemical recurrence.4
As survival rates improve, quality of life assessments are becoming increasingly important factors in clinical decision making. Because treatment with curative intent for slow-growing prostate tumors may impact quality of life and life satisfaction without improving survival, some authors have argued that watchful waiting is more appropriate for many elderly patients.1 Quality of life measures are objective but frequently self-reported instruments that capture sexual, bladder, and bowel function, whereas life satisfaction reflects subjective evaluations of symptoms, happiness, and a patient’s ability to achieve life goals.1
AN OPPORTUNITY TO DECREASE TREATMENT REGRET
A recent national survey of 313 radiation oncologists and 328 urologists suggests that prostate cancer nomograms are used by 55% of clinicians, and far fewer utilize quality of life or life expectancy prediction tools (27% and 23%, respectively).2 Radiation oncologists are significantly more likely than urologists to use quality of life instruments (P<0.001), perhaps reflecting a greater awareness or appreciation of toxicities associated with radiotherapy than with other treatment modalities.2 The survey also revealed that clinicians who spend more time counseling patients with a new diagnosis are more likely to employ predictive tools.2
“Our finding that approximately 75% of clinicians do not use QOL or life expectancy tools is concerning, given the increased attention placed on overtreatment of localized PC, and the complications and morbidity in functional outcomes related to radiation therapy and surgery,” concluded senior author Jon C. Tilburt, MD, of the Mayo Clinic in Rochester, Minnesota.2
Objective assessments of quality of life are particularly important because previous research has shown that agreement on treatment-related QOL issues between physicians and patients is poor after primary treatment.2 “With health-related QOL representing a key patient-centered outcome measure, efforts to improve standardized assessments using validated measures may be an opportunity to better educate and inform patients about treatment-related QOL issues, decrease treatment regret, and improve patient satisfaction,” reported the authors.
Predictive tools empower patients and ultimately, might well reduce medically-unjustified treatment, the researchers noted.2 “Shared decision-making through the integration of decision aids and evidence-based tools has the capacity to improve quality of care and reduce the overtreatment of low-risk disease,” they wrote.2
Bryant Furlow is a medical journalist based in Albuquerque, New Mexico.
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2. Kim SP, Karnes RJ, Nguyen PL, et al. Clinical implementation of quality of life instruments and prediction tools for localized prostate cancer: results from a national survey of radiation oncologists and urologists. J Urol. 2013;189(6):2092-2098.
3. Prostate cancer treatment (PDQ). National Cancer Institute Web site. http://www.cancer.gov/cancertopics/pdq/treatment/prostate/HealthProfessional. Accessed September 13, 2013.
4. Teeter AE, Presti JC Jr, Aronson WJ, et al. Do nomograms designed to predict biochemical recurrence (BCR) do a better job of predicting more clinically relevant prostate cancer outcomes than BCR? A report from the SEARCH database group. Urology. 2013;82(1):53-58.
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7. Shariat SF, Walz J, Roehrborn CG, et al. External validation of a biomarker-based preoperative nomogram predicts biochemical recurrence after radical prostatectomy. J Clin Oncol. 2008;26(9):1526-1531.
8. Shilkrut M, McLaughlin PW, Merrick GS, et al. Interval to biochemical failure predicts clinical outcome in patients with high-risk prostate cancer treated by combined-modality radiation therapy. Int J Radiat Oncol Biol Phys. 2013;86(4):721-728.
9. Teeter AE, Freedland SJ. Reply [Editorial Comment on Urology. 2013;82(1):53-58]. Urology. 2013;82(1):59.
10. Schroeck FR, Sun L, Freedland SJ, et al. Race and prostate weight as independent predictors for biochemical recurrence after radical prostatectomy. Prostate Cancer Prostatic Dis. 2008;11(4):371-376.
11. Stephenson AJ, Scardino PT, Eastham JA, et al. Postoperative nomogram predicting the 10-year probability of prostate cancer recurrence after radical prostatectomy. J Clin Oncol. 2005;23(28):7005-7012.
12. Roberts WW, Bergstralh EJ, Blute ML, et al. Contemporary identification of patients at high risk of early prostate cancer recurrence after radical retropubic prostatectomy. Urology. 2001;57(6):1033-1037.
13. Moul JW, Connelly RR, Lubeck DP, et al. Predicting risk of prostate specific antigen recurrence after radical prostatectomy with the Center for Prostate Disease Research and Cancer of the Prostate Strategic Urologic Research Endeavor databases. J Urol. 2001;166(4):1322-1327.