“The customer is always right” is a motto or slogan which exhorts service staff to give a high priority to customer satisfaction. It was popularised by pioneering and successful retailers such as Harry Gordon Selfridge, John Wanamaker and Marshall Field. (Wikipedia)
“The customer is always right” is sometimes wrong, as many companies have learned when disgruntled customers use this slogan as an excuse to speak abusively to employees. In such cases, the customer is wrong because there are courteous, respectful ways to issue a grievance. As consumers of medical care, prostatectomy patients are also customers, but they often avoid expressing complaints to their surgeon about urinary or sexual side effects of treatment. Perhaps this is sometimes due to a feeling of gratitude for being “cured”. Or maybe they feel they surrendered their right to complain by signing informed consent.
How can we find out about the medical consumer’s post-treatment experience? Herein lies the importance of unbiased research. It is even better if there is a way to do an apples-to-apples comparison based on randomization to different treatments
In October, 2016 the prestigious New England Journal of Medicine published such a study. A multicenter team of investigators authored the paper, “Patient-Reported Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer.”[i] The team followed 1643 prostate cancer patients for 5+ years. Upon diagnosis, those enrolled in the trial were randomized to have either monitoring, surgery, or radiotherapy. This was done under the auspices of the UK ProtecT trial, designed to determine which treatments are best. The self-reports of the patient population were based on questionnaires that were administered before diagnosis, at 6 and 12 months after randomization into treatment or monitoring, and annually from then on. According to the study, “Patients completed validated measures that assessed urinary, bowel, and sexual function and specific effects on quality of life, anxiety and depression, and general health. Cancer-related quality of life was assessed at 5 years.”
Randomization resulted in an even distribution of three groups according to treatment strategy. 545 men were assigned to active monitoring, 553 to prostatectomy, and 545 to radiation. For those who were tracked for 10 years, there were no significant differences in prostate cancer-specific death, but there was a greater incidence of cancer spread (metastasis) and progression (becoming more aggressive) in the monitoring arm. Since progression during monitoring is a trigger for treatment, ultimately 54.8% of that group went on to whole gland treatment.
The investigators noted that “patterns of severity, recovery, and decline in urinary, bowel, and sexual function and associated quality of life differed among the three groups.” As might be expected, those in the monitoring group had no treatment-related side effects (until they went on for treatment) but given 50-69 years of age range among all participants at the start of the study, it makes sense that urinary and sexual function gradually declined for these men even without treatment. For those who underwent radiation, its impact on sexual function was worst at 6 months but “recovered somewhat and stabilized.” There was no dramatic effect on urinary continence, with any symptoms worst at 6 months but gradually returning to a level similar to the two other groups by 12 months.
Prostatectomy urinary and sexual side effects were the worst across all groups, and remained so over the longer term of the study. While there was some improvement, according to the patients’ own reports urinary and sexual outcomes “remained worse vs radiotherapy and monitoring over 6 years.”
Since those who took part in this excellent study were sharing their experience by means of standardized questionnaires to a scientifically neutral team for analysis, their responses weren’t complicated with emotions they might have had if speaking with their own urologists. In that sense, the patient feedback is about as honest and objective as is possible to obtain – which is why it’s so vital to conduct these types of studies.
Perhaps in the future, we will see randomized studies in which 1) biopsy-naïve patients undergo 3T mpMRI without an endorectal coil, 2) those with suspicious areas have in-bore MRI-guided targeted biopsy, 3) those positive for low-risk cancer have additional genomic analysis, and then 4) those who are finally determined to be low-risk are randomly assigned to Active Surveillance, prostatectomy, radiation therapy, or focal laser ablation. Then all patients would be followed for a minimum of 5 years by annual mpMRI and questionnaires (with the understanding that a suspicious mpMRI would trigger a targeted biopsy, etc.) Meanwhile, I conclude with a note of gratitude to the work of the ProtecT Trial and the researchers involved with it.
[i] Donovan JK, Hamdy FC, Lane JA, Mason M et al. Patient-Reported Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer. N Engl J Med. 2016 Oct 13;375(15):1425-1437. Epub 2016 Sep 14.