Updates on Use of Genomic Testing in Patients with High-Risk, Clinically Localized Prostate Cancer - Episode 3

Clinical Challenges Surrounding Treatment Decision-Making in Clinically Localized Prostate Cancer

A focused discussion on the challenges that urologists commonly face during the treatment decision-making process, and which factors typically inform treatment selection for clinically localized prostate cancer.

Stephen J. Freedland, MD: How do we make decisions in high-risk patients? Surgery vs radiation, external brachytherapy, hormone therapy. For me, it’s the proverbial fork in the road. Do you want surgery or do you want radiation? That drives the decision-making after that. There’s no easy way to make that decision. Certain patients agonize over the decision. Rightfully so; it’s a tough 1. There are no easy answers. Other patients say, “You’re the doctor. You tell me.” We try to explain that the best data we have are from 1 randomized trial from at least 12 years ago, which showed no difference in survival. There weren’t a lot of high-risk patients in that trial, so we don’t know for sure if they’re equivalent, but the best data suggest there are.

There are nuances, quality-of-life differences. What further treatments you can have, I try not to push people 1 way or another. I find it helpful to give them numbers and data. Specifically, I say that the majority of 50-year-olds will choose surgery. The majority of 70-year-olds will choose radiation. In your 60s, it’s split. Age is not the be-all and end-all. It should be physiological age, not chronological age. Putting all of that into the mix becomes challenging in the real world, in the trenches. If you’re talking to patients, and they have diabetes and this and that, give them that framework. I find comfort knowing that the majority of people in my place have chosen X. Therefore, I feel like I should choose X, or it gives me comfort because I was leaning toward X to begin with.

Certain people have the mindset of wanting the tumor out. Get that thing out of my body now. Great, we’ll take you to surgery. Other people don’t want to be cut. I don’t want to undergo anesthesia. I don’t want to risk the issues with incontinence. I don’t want surgery. Great, we’ll do radiation. You try to be abstract, keeping your own biases and emotions out of it, but we’re there to help guide the patients and work together on shared decision-making.

If they choose the path of radiation, we have a phenomenal radiation oncologist at our institution [to help with] the decisions about androgen deprivation therapy [ADT]. Yes or no? Duration of ADT, external beam vs brachytherapy vs combination. That’s all their decision-making. I wouldn’t be happy if they told me how to do the surgery. I’m not going to tell them how to do the radiation. We respect each other in that sense, but we’re often the first person seeing the patients, helping them decide. If the patient is gung ho—“I want surgery, I want this out”—that’s fine. We do the surgery. But if they show any hesitancy, then I need to think about this. I tell them to meet with the radiation oncologist because you’re going to hear a more thorough discussion from them. They’re going to give you a different perspective from what I can, so make sure you meet with them. I’m trying to push people to meet with both sides. One appropriate. I don’t think everyone needs to, but anyone who’s open to radiation should be hearing that from the radiation oncologist themselves.

Transcript edited for clarity.