Rose Kennedy once remarked, “Neither comprehension nor learning can take place in an atmosphere of anxiety.” In fact, an atmosphere of anxiety can lead prostate cancer patients to choose management strategies without the benefit of full knowledge and due diligence. In turn, the lack of full knowledge can lead to more anxiety as the consequences of poorly informed choices take hold. It’s a vicious circle.
A multicenter study (Mahal et al., 2015) from a number of prestigious institutions provides a sad illustration of how anxiety over an elevated PSA and poor understanding of choices can paint radiation recurrent prostate cancer patients into a long term, unpleasant and non-curative treatment corner.[i] The eight authors represent medical centers that are among the most knowledgeable in the country when it comes to prostate cancer, including Harvard, the Cleveland Clinic, University of Connecticut, Tulane and others. The title suggests not only knowledge but also compassion: “High PSA Anxiety and Low Health Literacy Skills: Drivers of Early Use of Salvage ADT Among Men with Biochemically Recurrent Prostate Cancer After Radiotherapy?”
The problem that catalyzed their study was the often too-early prescription of androgen deprivation therapy (ADT, also called hormone therapy or chemical castration) when a PCa patient’s PSA begins to rise after a course of radiation treatment. Although this has been a common standard of care, more recent practice shows us that a rising PSA followed by a TRUS-guided 12-core biopsy may indeed pick up cancer in the irradiated gland, but it’s not as complete a picture as could be gained by first having a multiparametric MRI of the prostate and surrounding tissues. Starting ADT as a routine course of action can result in unpleasant side effects for the patient such as
- Hot flashes
- Breast tenderness
- Mood swings
- Loss of sex drive
- Loss of muscle tone
- Loss of bone density
- Eventual resistance of the cancer to ADT
Patients with biopsy-proven recurrence are usually not considered for salvage prostatectomy, which is a difficult surgery due to the radiation’s tissue damage—and more radiation is out of the question. However, mpMRI scans and MRI-guided targeted biopsy may reveal that a patient would qualify for a salvage whole-gland ablation, or even partial-gland ablation that could be potentially curative and avoid the use of ADT.
So why would patients willingly begin ADT treatments instead of exploring other options? That’s what the Mahal study was designed to find out. Using a prostate cancer patient registry, the authors identified 375 cases of men with biochemically recurrent (rising PSA) prostate cancer after beam radiation or seed implants. Their goal was to determine if anxiety over the rising PSA and poor health information skills (research and comprehension) were correlated with the patient choice of ADT. Out of the initial patient pool, 68 men (18.1%) went on salvage ADT to manage their PSA recurrence. Those who were found to have high anxiety were twice as likely to accept ADT as those with little anxiety. Also, men with higher levels of health literacy were about half as likely to choose ADT as those with lower skill levels. The authors concluded that men with high anxiety and low health literacy receive higher rates of unproven therapy, and they wrote, “Given that early salvage ADT is costly, worsens quality of life, and has not been shown to improve survival, quality improvement strategies are needed for these individuals.”
I firmly believe that 3T mpMRI must be part of the quality improvement strategies called for in the above study. Peter Choyke and others at the National Institutes of Health are defining ways to “streamline” mpMRI for certain conditions in order to make it more efficient and less costly. Unfortunately, radiation recurrence is one of the conditions that will most benefit from a full sequence of functional parameters due to the nature of the pelvic bed and prostate after radiation, and the greater likelihood of more aggressive disease that has survived the radiation. However, the cost of a single mpMRI scanning session vs. years of expensive ADT drugs and medications to ease the side effects of hormone deprivation is incredibly cost-effective, especially if it can identify candidates for salvage ablation.
[i] Mahal BA, Chen MH, Bennett CL et al. High PSA anxiety and low health literacy skills: drivers of early use of salvage ADT among men with biochemically recurrent prostate cancer after radiotherapy? Ann Oncol. 2015 Jul;26(7):1390-5. doi: 10.1093/annonc/mdv185. Epub 2015 Apr 28.