BERKELEY, CA (UroToday.com) - Evidence from both the Prostate Cancer Prevention Trial (PCPT) and the REDUCE trial has provided us with insight into the role of 5-alpha reductase inhibitors in chemoprevention for prostate cancer. While these medications are not FDA-approved for this indication, the potential benefit afforded to those patients at high risk for developing prostate cancer cannot and should not be ignored. At the same time, this benefit must be weighed against the potential morbidity associated with therapy.
|"As practitioners, we are obligated to be in tune with patients and their desire for knowledge and personalized medicine."|
The therapeutic algorithm for prostate cancer has greatly increased in complexity as patients carefully consider the benefits and harms of treatment or active surveillance, and the decision to proceed with chemoprevention for prostate cancer is equally complex on similar grounds. More and more, we are coming to the realization that the goals of therapy for prostate cancer encompass more than just oncologic outcomes. Rather, the quality-of-life outcomes and psychosocial outcomes associated with cancer diagnosis and therapy may be equally important to the individual patient, and inconsistencies in therapeutic expectations may result in a decline in overall patient satisfaction. As such, it is imperative that physicians have the appropriate data and tools with which to counsel patients regarding this broad spectrum of outcomes, whether it is in the treatment or chemopreventive setting.
Large scale trials such as REDUCE provide a resource from which to extract data with excellent longitudinal follow-up, and the a priori knowledge of the potential adverse effects of dutasteride led the REDUCE investigators to capture quality-of-life outcome measures. Based on the data from this study, our goal was to develop a tool that could provide patients with individualized outcome predictions in the setting of prostate cancer chemoprevention with dutasteride. The outcomes in the metagram include predictions for development of prostate cancer, high-grade prostate cancer, erectile dysfunction, urinary retention, gynecomastia, BPH-related surgery, urinary tract infection, high-grade prostatic intra-epithelial neoplasia, and atypical glands suspicious for carcinoma and are meant to serve as a comprehensive prediction model for patients. While limited in predictive accuracy for some outcomes such as HGPIN or ASAP, the overall concordance for many of the primary measures was quite good.
Our metagram, while admittedly not definitive in nature, represents what we believe is a step in the right direction in terms of providing practitioners and patients with individualized oncologic and quality-of life-predictions. The need for this breadth of predictions is particularly evident in the realm of prostate cancer, where a patient’s value system is as individualized as his clinical history. Our hope is that the introduction of this metagram will serve as impetus for future prediction tools that incorporate all outcomes relevant to patient decision making.
As practitioners, we are obligated to be in tune with patients and their desire for knowledge and personalized medicine. It is our opinion that providing patients with a comprehensive set of predictions – as exemplified in our metagram – will lead to appropriate therapeutic expectations and, as a result, improved patient satisfaction.
Brandon K. Isariyawongse, MD1 and Michael W. Kattan, MBA, PhD2 as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
1Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
2Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH, USA