Clinical Advances in Hematology & Oncology
Volume 14, Issue 9, September 2016
Andrew C. Peterson, MD
Professor of Urologic Surgery
Duke University School of Medicine
Durham, North Carolina
H&O How many survivors of prostate cancer are there in the United States?
AP The United States will have an estimated 18 million survivors of all types of cancer by 2022, which is far more than the less than 4 million survivors we had in the 1970s (Figure). Approximately 40% of male survivors are survivors of prostate cancer, which accounts for close to 3 million people. This number is only going to increase as treatments continue to improve. Everyone who is diagnosed with cancer is considered a survivor from the time of diagnosis to the time of death.
H&O What are the general issues that come up for survivors of prostate cancer?
AP Survival rates have improved so much over the past 20 years that the fallout from treatment has become increasingly important. Surgery can lead to urinary incontinence or erectile dysfunction. Radiation treatment can lead to these same side effects, plus fecal incontinence and symptoms such as rectal bleeding and painful defecation. All of these can be life-changing problems for otherwise healthy men, who often have a long life expectancy after prostate cancer treatment.
H&O What type of follow-up care is recommended for survivors of prostate cancer?
AP The Institute of Medicine recommends in From Cancer Patient to Cancer Survivor: Lost in Transition that we should all work to raise awareness of the needs of the cancer survivor, and that everyone who has been treated for cancer should receive a “survivorship care plan” at the end of their primary treatment. This report, which was published in 2006, was a major driver of the current emphasis on survivorship.
A survivorship care plan for prostate cancer should include the specific times when the patient should receive follow-up care and be asked about erection problems, incontinence problems, voiding dysfunction, and depression. General health also needs to be monitored. In addition to medical needs, we feel that the survivorship care program should include 3 other pillars: spiritual needs, psychosocial needs, and work/life (or practical) needs. Survivorship programs need to address all 4 of these areas.
H&O When should patients be referred to other specialists for these problems?
AP At our survivorship program at Duke, we think it’s never too early to refer a patient to a subspecialist who can help with problems such as those related to erectile dysfunction, incontinence, or voiding dysfunction. In many cases, we refer patients to these subspecialists for counseling at the time of diagnosis—before surgery or other definitive therapy.
H&O What are the treatment options for men who have side effects from prostate cancer treatment?
AP We have many well-proven therapies with excellent outcomes for incontinence. Oral therapies for overactive bladder or urge incontinence after radiation therapy are effective and well tolerated. We also have surgical options for men affected by stress incontinence following radiation therapy or surgery. The transobturator male sling is a good choice for men who have undergone surgery but not radiation and have mild or moderate urinary incontinence; this procedure produces excellent outcomes with minimal morbidity. The artificial urinary sphincter, which has been around since the 1970s, has been shown to produce excellent outcomes and positive effects on quality of life. Both of those options involve minimally invasive surgeries that are performed on an outpatient basis; they provide low morbidity and a fairly rapid recovery to normalcy.
Regarding treatment for erectile dysfunction, we have multiple oral therapies available in the United States, all of which produce excellent outcomes with minimal side effects. Men who do not respond to oral medications or are unable to take them have a number of other options. One option is vacuum erection devices, which are minimally invasive and well tolerated. Another option is medication that can be placed directly into the urethra, such as intraurethral alprostadil. If these treatments do not provide an erection that is satisfactory for intercourse, another option is injection therapy. A final option for men with erectile dysfunction is surgical placement of an inflatable penile prosthesis or a malleable penile prosthesis. These options provide significant improvements in quality of life with minimal morbidity.
H&O Could you talk about the long-term psychosocial effects of prostate cancer?
AP Depression is a well-documented problem in men who are survivors of prostate cancer that may be related to quality-of-life issues such as erectile dysfunction and incontinence. Patients who undergo hormone ablation for prostate cancer are at especially high risk for depression.
H&O What area of care for survivors of prostate cancer needs the most improvement?
AP We need to do a better job with survivorship care plans. The Movember Foundation has sponsored a large intervention called TrueNTH in which we are looking at the use of these plans. Currently, survivorship care plans may be as simple as a piece of paper that the patient may never read. We think that a real-time survivorship care plan that involves an application or a website will do a much better job of interacting with the patient throughout his survivorship journey.
H&O What are the components of a typical survivorship care plan?
AP The plan should include the date and type of diagnosis, including the stage and grade of the tumor, and a description of the primary therapy that was used. The most important part of the plan is the recommendations regarding what type of care the patient should seek as a survivor. For example, a patient who continues to experience urinary incontinence 6 to 12 months after surgery should receive a prompt to ask his doctor for referral to a specialist.
H&O What special concerns exist for survivors of prostate cancer when it comes to surveillance for recurrence and screening for second primary cancers?
AP Men who have undergone radiation therapy for prostate cancer may be at elevated risk for a secondary malignancy, such as bladder or colon cancer. The new prostate cancer survivorship guidelines from the American Cancer Society recommend routine screening for colon cancer in these patients and prompt evaluation for symptoms that may indicate colon or bladder cancer. Surveillance is pretty much lifelong for men with prostate cancer. To detect a recurrence, most experts recommend a prostate-specific antigen (PSA) test and a physical examination once a year after the end of primary treatment. The physician should personalize the surveillance plan for each patient.
H&O What are some of the barriers to implementing survivorship recommendations?
AP The largest barrier is education; primary care providers are not always aware of the treatment options for men with these side effects, and patients are not always aware that they should be speaking up about their symptoms because help is available. To improve care in this field, our institution offers a specific fellowship in Genitourinary Cancer Survivorship.
H&O What other concerns should physicians address?
AP We need to remember that not only is the patient a survivor, but all of his loved ones and caregivers are survivors as well. Spouses are affected by erectile dysfunction, incontinence, and depression, and coworkers and caregivers also can be affected by incontinence and depression.
Dr Peterson has received an unrestricted educational fellowship grant, a study participation grant, and a lecturing grant from American Medical Systems, an unrestricted educational fellowship grant from Coloplast, and a research grant from the Movember Foundation.
de Moor JS, Mariotto AB, Parry C, et al. Cancer survivors in the United States: prevalence across the survivorship trajectory and implications for care. Cancer Epidemiol Biomarkers Prev. 2013;22(4):561-570.
Gupta S, Peterson AC. Stress urinary incontinence in the prostate cancer survivor. Curr Opin Urol. 2014;24(4):395-400.
Hewitt M, Greenfield S, Stovall E, eds. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press; 2006. http://www.nap.edu/catalog/11468/from-cancer-patient-to-cancer-survivor-lost-in-transition.
Peterson AC, Chen Y. Patient reported incontinence after radical prostatectomy is more common than expected and not associated with the nerve sparing technique: results from the Center for Prostate Disease Research (CPDR) database. Neurourol Urodyn. 2012;31(1):60-63.
Skolarus TA, Wolf AM, Erb NL, et al. American Cancer Society prostate cancer survivorship care guidelines. CA Cancer J Clin. 2014;64(4):225-249.