Prostate Cancer Treatment Outcomes
William A. See, MD, Professor of Urology, Chairman of Urology
Prostate cancer is the most common solid tumor in men, with approximately one in six men being diagnosed with this disease over the course of a lifetime. Despite its prevalence, there is a remarkable lack of consensus regarding the optimal management of prostate cancer. Disease characteristics, including a long latency period, slow growth rate and a low, but unpredictable risk of progression in the individual patient, combine with patient issues of late age at detection and competing diseases to make treatment decisions difficult. The selection of a specific treatment modality is further complicated by the paucity of Level 1 data on the survival benefits of various treatment options, their comparative efficacy, or relative toxicity. This dilemma prompted the late, famous urologic oncologist Willet Whitmore, MD, to state, “if cure is necessary, is it possible and if cure is possible, is it necessary?”
An equally poignant quote attributed to Dr. Whitmore is, “There are more people making a living from prostate cancer than there are dying from it.” The pervasive societal fear associated with the term “cancer,” coupled with the tangible benefits of “active care” to providers, hospitals and health care systems, translates into the delivery of curative treatments to most patients. Multiple studies have shown that when presented with a prostate cancer case scenario, individual specialists are likely to recommend the treatment they personally can deliver. The unfortunate reality, from a population based perspective, is that while treatment associated toxicity is guaranteed, survival benefit is seen by relatively few patients.
While of paramount importance, delivering prostate cancer care in a manner that is truly patient-centric, (e.g., it places value to the patient first, if not exclusively, in the decision process, while framing complex issues in a manner that patients understand) is a difficult and time-consuming process. Difficulty aside, as the health-care professionals “responsible” for this disease, are we not obligated to insure this is the case? How do we begin to measure our progress toward and success in achieving these goals? The answer is outcomes. Appropriately collected and reported, outcomes represent a surrogate for quality. They provide a basis for comparison of quality relative to a benchmark or to other organizations providing similar services. While less than absolute, they function as a starting point from which health-care consumers can make better informed decisions. In thinking about outcomes, it is important to consider how they can be used to assess all aspects of the care delivery process. Outcomes are more than the length of stay following prostatectomy, or the isodose curves to the anterior rectal wall following external beam radiation therapy. Relevant outcomes begin with access to multidisciplinary care, appropriate staging and comprehensive counseling. The National Comprehensive Cancer Network (NCCN) and the American Medical Association’s Physician Quality reporting Initiative (PQRI) publish specific guidelines for initial steps in prostate cancer care that our organization has incorporated into a publically available website that reports our specific outcomes: froedtert.com/prostate.
Of course, outcome measures with unique relevance to individual treatment approaches are invaluable to patient choice. In the case of radical prostatectomy, our quality group collects data on 78 “treatment relevant” outcome variables from every patient treated at our institution. Highlights from this analysis are provided to patients at froedtert.com/prostate.
Few disease processes are as nuanced as prostate cancer. From offering the appropriate therapy, to optimizing quality of life outcomes, delivering the highest quality of prostate cancer care requires a level of commitment best achieved through providers and organizations focusing on urologic cancer. My personal quote that “a radical prostatectomy is an easy operation to do poorly” could be extended more broadly to encompass the general issue of prostate cancer care. We believe the investment we have made in measuring and publishing our outcomes not only raises the bar for our own performance, but allows our patients access to data they need to make informed decisions for their personal care.