Counselling the patient with prostate cancer
The announcement of prostate cancer is a source of great anxiety for a patient and his family. Unfortunately, there is not one single treatment for all prostate cancer patients. The choice of treatment must be based on a global approach to the patient that goes beyond his cancer. The patient's history, philosophy, as well as fears and expectations are important elements that will guide the choice of treatment. The general practitioner is the interlocutor of choice in this discussion because he or she masters all the important aspects of the patient's file.
The oncology care coordination nurse and the psycho-oncologist are key players in helping the patient make the decision. Because one cancer is not the other and one patient is not the other, we have included a few important elements.
In the process of announcing the cancer and initiating a follow-up strategy, two questions/steps are important.
- Is immediate treatment necessary?
Given the slow progression of most prostate cancers, urgent treatment is very rarely necessary, with the exception of symptomatic metastatic cancers. In all other cases, time should be taken to explain to the patient the advantages and disadvantages of immediate treatment. More than one third of cancers discovered by screening are indeed not very aggressive cancers that can benefit from simple surveillance..
Active surveillance is therefore a very good option for cancers with a Gleason score ≤ 6 and a PSA < 10 ng/ml. The recently published PIVOT study demonstrates that immediate treatment by prostatectomy does not increase the chances of survival compared to simple monitoring.
- When treatment is necessary, which local treatment should be chosen?
It is important to remember that only local treatment can cure cancer. Hormone therapy, given as the only treatment, is not a cure. Even in an older man, local treatment can be given safely when necessary. In the absence of comparative studies, it is difficult to classify the oncologic outcomes of surgery, external beam radiation therapy, and brachytherapy.
In a general way, it can be said that
- Brachytherapy should be reserved for small, moderately aggressive cancers (Gleason ≤ 7) in patients whose prostate volume is ≤ 50 cc and who do not have urinary symptoms
- In case of total radical prostatectomy, it is important to perform a wide resection and extensive lymph node dissection in case of PSA > 20 ng/ml, Gleason score ≥ 8, or clinical extracapsular invasion (cT3a). In case of a positive resection margin, it may be necessary to complement treatment with radiation. In contrast, hormone therapy is rarely indicated immediately after radical prostatectomy, with the exception of patients with extensive lymphatic invasion.
- External radiotherapy should be combined with hormone therapy for six months to three years to be started before treatment when PSA ≥ 20 ng/ml or Gleason score ≥ 8 in case of extracapsular extension.
It is important that the final choice be the patient's, not the therapist's. Some patients feel the need to remove their tumor, others less so. The importance of sex life is also an essential aspect of the treatment decision. In all cases, the patient should be encouraged to consult several specialists (urologists, radiotherapists) (second opinion) and to discuss with his family and friends. Above all, the patient must be reassured that he must take his time.