Dr. Fred Saad is professor and chair of urology at the University of Montreal Hospital Centre, and he holds the University of Montreal endowed chair in prostate cancer research.
One in 8 Canadian men will be diagnosed with prostate cancer in their lifetime. What’s stood out for you in terms of the data being reported on in the System Performance spotlight report?
This report puts the importance of prostate cancer as a societal problem into perspective. It also highlights the challenges that we face in decision-making at every step of the disease, and the need for research, again, at every stage of the disease.
There are a number of management approaches for low-risk prostate cancer, how do you help a patient navigate through the treatment options?
The physicians who make these diagnoses have a responsibility to put things into perspective. Otherwise, patients get very confused. Some have catastrophic reactions when they hear the word “cancer.” But we have to explain what we found at the biopsy, and explain PSA levels. If they fit the criteria for low risk disease, we can safely reassure the patient that they don’t need to be treated up front, that they can be watched. Patients need to know that the way cancers evolve can be very different from one patient to the other.
Patients are very interested in learning more about their disease, and there are a lot of tools out there that I encourage them to use and read. This helps them be part of the decision-making process.
Use of active surveillance seems to range across Canada despite the fact that it is a valid treatment option for low-risk prostate cancer. What do clinicians need to know to have a conversation about active surveillance with their patients?
The question of active surveillance is not a simple one. It is now a recognized option, and what physicians need to know is that not all patients diagnosed with prostate cancer are destined to suffer or die of the disease. So they need to have a frank discussion of the pros and cons of treatment in low risk prostate cancer, and patients have to be part of that discussion.
The challenge is that we’re not always 100% sure that what looks like low risk actually is low risk. That’s where we need research, so we can more reliably tell a patient that they can be watched safely. We’re doing that as part of a large initiative in Canada that’s funded by the Terry Fox Foundation. I’m leading a cross-Canada biomarker network to identify biomarkers that can help us make decisions about who can be safely watched. Some people might seem like candidates for active surveillance with low-risk disease, but they could actually be harbouring high-risk cancers. In these people, the challenge is to not miss the window of opportunity for curing somebody who has a disease that might lead to mortality.
Having said that, the vast majority of patients are very safely watched in active surveillance, and risk for them is minor as long as health-care professionals are using the criteria for active surveillance correctly, and then ensuring proper follow-up. Active surveillance implies that the patient will be treated if the cancer shows signs of progressing to a more aggressive form. Fortunately, more than half the patients we start on active surveillance will never require treatment, and, on average, we postpone treatment for several years for patients who will require treatment.
How do you involve your patients in the treatment decision-making process?
It’s about taking the time to make sure the patient understands, and having a frank discussion with him. You explain what their disease is, you explain what a Gleason Score is. You explain that PSA is not something toxic in their system. It’s a reflection of the burden of the disease.
I get them involved by giving them information, making them more knowledgeable about their disease, and that makes the whole situation less stressful. They feel more like partners in the treatment of their disease. It even starts before diagnosis, when they first show up with an elevated PSA. At that point, they need to understand what that means, why we need to go to do an ultrasound and biopsy. That way, they’re already getting a head’s up of the different scenarios that might play out depending on the results of the tests.
How do you help a patient who has been identified for active surveillance cope with living with prostate cancer?
It’s a team effort. We need to explain to the patient that low risk prostate cancer evolves slowly, and that with follow-up we’ll be able to intervene if the disease becomes more aggressive. I often insist that family members be there for the discussion because it’s something that patients shouldn’t live alone. I also think what empowers patients is information. It helps them a lot.
Our report found that there was a wide range across Canada in terms of referrals for emotional support. What do you think the challenges are for clinicians in helping their patients find this support?
It’s still not as widespread as we’d like, and I think we have a lot to learn from the breast cancer model. They have decades of experience ahead of prostate. But for now, there are support groups across Canada. There are organizations like Movember and Prostate Cancer Canada that cover all of Canada, and PROCURE in Quebec. We have more and more resources to help patients find information, but where we really have work to do is actually having human resources available for support. This type of support is very variable depending where you are in Canada and that’s the next step for us. Support groups are great, but in some cases we need even more expertise for patients in distress.
The bottom line is that support is still not easily accessible, and it needs to be.
The report found that there was a low rate of use of palliative radiation despite its effectiveness. Why do you think this is not being used more often?
It might be like morphine where people resist it because they think it means it’s the end of their lives. Maybe it’s a negative connotation around palliative radiation therapy.
To be honest, I was a little bit disappointed that it’s not used as much as it should because there’s absolutely no reason for patients to suffer. We have to use everything we have. If it’s radiation therapy that’s needed, that has to be used. And we need to demystify with patients that seeing a palliative care specialist doesn’t mean they’re in the last month of life. It’s really a team effort to make sure that patients don’t suffer when solutions are available, and there are almost always solutions available. We just need to better organize the system.