Dr. Peter Chung is a radiation oncologist at the Princess Margaret Cancer Centre who treats patients with prostate cancer.
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 in the System Performance spotlight report?
The fact that there was so much variation across Canada. Also, that mortality over the years has fallen, while incidence has gone up and down a bit over the years, but is overall fairly stable.
There are a number of management approaches for low-risk prostate cancer, how do you help a patient navigate through the treatment options?
Many of these options are relatively equivalent in terms of survival, so to choose between radiation or surgery or surveillance, you need to look at factors such as the patient’s age and co-morbidities. You also need to think about finding something that is palatable to the patient, because some patients have very specific ideas about what they do and don’t want, both in terms of treatments and side effects. Ultimately, the evidence suggests that long-term survival is excellent regardless of the management approach.
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?
These conversations are always difficult because prostate cancer outcomes are not measured in the usual five-year timeline of most other cancers. Instead, they’re measured over ten years or more. And right now, the very long term data just isn’t there yet, because it hasn’t been done for long enough for a large enough population. So it’s really about getting that across to the patient, and to try to interpret and explain the medium-term results as best as possible.
Also, if they’re discussing this with a patient who is in his mid-to-late 70s or 80s, it’s a very different conversation than with a patient who is 50. So, for example, for a 70 year old there’s probably more data to say that active surveillance is very appropriate and very safe, and the likelihood of missing a serious cancer is rather small. But for a 50 year old, whose life expectancy will naturally be longer, it’s more difficult to extrapolate results from surveillance trials that have been done in men who were older when enrolled in trials and whose life expectancy is potentially shorter.
How do you help a patient who has been identified for active surveillance cope with living with prostate cancer?
Once the patient has decided this is the route he wants to take, the health-care professional really needs to support that decision and provide ongoing reassurance. One of the difficulties for men is they wonder “did I miss the boat for treatment?” But you really need to reassure them and intervene if it appears that the cancer is changing its nature and becoming more aggressive. On the flipside, you also need to support patients if they change their minds, because that’s also okay. Dealing with uncertainty of the situation is always difficult for the men and trying to make the ‘right’ choice for the specific individual is about working with them and understanding the journey after diagnosis, together with dealing with the uncertainty.
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 really incumbent on the health-care system to provide these resources. But, unfortunately, not every community has enough of them. There are some communities that have an abundance of psychosocial help and an abundance of support groups, but others don’t. In those places it can be hard for physicians to provide the sole emotional support. In Canada, it’s about geography, and some more sparsely populated regions won’t have the resources that are available in, say, Toronto or Montreal, where there are many more people living with prostate cancer.
We 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?
I think it has to do with patient and physician education, as well as the availability of radiation resources in the community. It also comes down to geography again. Cancer agencies try to ensure there are enough treatment spots for the demand, but even in places where the resources are adequate and available, the physicians may not know about it, or the patient may think it’s too far for them to travel. Particularly when the patient is nearing the end of his life, it can be very difficult for the patient to travel, even just down the street to the hospital. So, overall, it’s a combination of knowledge of the availability and appropriateness, together with accessibility.