NEWS & VIEWS PROSTATE CANCER
Optimizing prostate cancer survivorship care Matthew J. Resnick
Prostate cancer survivors face a myriad of unique physical, psychological and emotional challenges during the often lengthy survivorship experience. Efforts to better characterize the unmet needs of this large patient population will undoubtedly improve the quality of survivorship care we offer to our patients. Prostate cancer survivors comprise 43% of all male cancer survivors, including nearly 3 million individuals in the USA.1 Given the major health-care burden of prostate cancer survivorship in the context of the unique issues faced by the many survivors, the American Cancer Society (ACS) published prostate cancer survivorship care guidelines2 in 2014 that were subsequently endorsed by the American Society of Clinical Oncology.3 The ACS guidelines outline multip le domains that merit attention in order to offer comprehensive prostate cancer survivor ship care. Despite a substantial amount of research into functional impairments after treatment for prostate cancer, a considerable knowledge gap remains with respect to the magnitude and evolution of psychological and emotional needs of prostate cancer survivors. Furthermore, little consensus exists among prostate cancer specialists regarding the most effective setting in which to deliver high-quality survivorship care. Recognizing this knowledge gap, Watson and colleagues4 performed a survey-based cross-sectional study that aimed to elabor ate the physical, psychological, and emotional health of a population of prostate cancer survivors and to identify potential unmet needs. The investigators determined that, consistent with previously published reports, prostate cancer survivors reported high levels of overall satisfaction with their prostate cancer care; however, survivors reported that their satisfaction with the degree to which their emotional, relationship and social problems were addressed was less favourable than their satisfaction with
other evaluated domains. Additionally, and importantly, the investigators ascertained the distribution of unmet needs reported by prostate cancer survivors, identifying sexual issues, concerns about significant others, and anxiety regarding cancer recurrence as being the most commonly reported unmet needs. How, then, might we translate the lessons learned from the study by Watson et al.4 into practice? Optimizing care for prostate cancer survivors begins well before an individual patient undergoes radical prostatectomy, radiation therapy, or surveillance prostate biopsy. Although often practically challenging at the point of care, attempting to ascertain individualized patient preferences might ultimately improve alignment between individual treatment goals and satisfaction with care, inclusive of both oncologic control and functional outcomes. One practical approach that might facilitate this process is the use of decision aids. A highquality decision aid offers information about management options, individualizes probabilities of specific outcomes, crystallizes a patient’s values in relation to the possible outcomes and encourages the patient to make choices that are congruent with their values and preferences.5 Incorporating decision aids into clinical practice might ultimately result in better quality decisions, namely decisions based upon scientific evidence and congruent with a patient’s values and preferences.6 Efforts to improve the quality of decisions in men with localized prostate cancer might improve satisfaction during the survivorship experience, although more work is necessary to completely characterize this relationship.
NATURE REVIEWS | UROLOGY
Szepy/iStock/Thinkstock
Refers to Watson, E. et al. Symptoms, unmet needs, psychological well-being and health status in prostate cancer survivors: implications for redesigning follow-up. BJU Int. http://dx.doi.org/10.1111/bju.13122
The results of the study by Watson et al.,4 in concert with the ACS prostate cancer survivorship guidelines, might ultimately serve as a springboard for redesigning prostate cancer survivorship care. Historically, care has been delivered by prostate cancer speciali sts such as urologists, radiation oncologists and medical oncologists, but interest has been growing in the development of multidisciplinary prostate cancer survivorship programmes to specifically address the unmet needs elaborated by Watson and colleagues. In their 2015 paper, Gilbert and colleagues7 reported the changes in quality of life that occurred after deployment of a prostate cancer survivorship clinic incorporating point-of-care patientreported outcome assessment and dedicated consultations with nursing and sexual health therapists. Patient-reported sexual function and satisfaction with care were significantly higher in patients treated in the prostate cancer survivorship clinic than in those who received routine care.7 Indeed, ample evidence exists to indicate that nurse-led symptom management programmes result in consistent improvements in patientreported outcomes. Andreyev et al.8 randomly assigned 218 patients with new-onset gastrointestinal symptoms after pelvic radiotherapy to usual care, gastroenterologist- le d a lgor it hm-b as e d t re at ment, or nurse-led algorithm-based treatment. The investigators determined that the nurseled programme resulted in significant improvements in radiotherapy-induced gastrointestinal symptoms over usual care, and that outcomes in the nurse-led ADVANCE ONLINE PUBLICATION | 1
© 2015 Macmillan Publishers Limited. All rights reserved
NEWS & VIEWS group were noninferior to those in the gastroenterologist-led programme. Taken together, these data suggest that the development and deployment of novel survivorship programmes to comprehensively address the unmet needs of prostate cancer survivors might ultimately improve the quality of care that we deliver to our patients.
‘‘
Prostate cancer survivors face unique physical, psychological and emotional challenges
’’
In addition to highlighting the distribution of unmet needs among prostate cancer survivors, the study by Watson et al.4 also draws attention to the need for the develop ment of reliable and valid tools to better ascertain patient-reported data in clinical practice. Certainly, the development of brief point-of-care instruments that can be used at each clinic visit might facilitate the identification of unmet needs at the indivi dual level as opposed to the population level. A good example of the development of an efficient point-of-care instrument is the development of the EPIC-CP (Expanded Prostate Cancer Index Composite for Clinical Practice), a 16-item questionnaire that was found to correlate highly with its parent questionnaire, the EPIC‑26 (26-item Expanded Prostate Cancer Index Composite). Additionally, and importantly, the EPIC-CP questionnaire can be completed quickly and poses little disruption to
routine clinical care.9 Although a clinically useful tool for the evaluation of patientreported prostate-cancer-specific function is available in the EPIC-CP, few instruments are available that can be used at the point of care to assess an individual’s unmet needs, psychological health and emotional health. Indeed, the development and incorporation of such tools into clinical practice using a real-time dashboard platform, such as that used by Gilbert et al.,7 might serve to underscore the domains and elements that are most important to an individual patient, ultimately facilitating patient-centred care. Prostate cancer survivors face unique physical, psychological and emotional challenges. The delivery of high-quality, patientcentred survivorship care undoubtedly requires the critical evaluation of current practice and engagement of a multidisciplinary team in order to effectively address an individual’s unmet needs. Additionally— and importantly—as a prostate cancer community, we must begin to routinely and systematically ascertain patient-reported data to guide individualized survivorship care. Doing so will require investment in the development of both suitable tools for data collection and a suitable infrastructure for real-time feedback to the treating clinician at the point of care.
doi:10.1038/nrurol.2015.123 Published online 2 June 2015 Competing interests The author declares no competing interests. 1.
2.
3.
4.
5.
6.
7.
8.
9.
Department of Urologic Surgery, Vanderbilt University Medical Center, A-1302 Medical Center North, Nashville, TN 37232, USA. [email protected]
2 | ADVANCE ONLINE PUBLICATION
DeSantis, C. E. et al. Cancer treatment and survivorship statistics, 2014. CA Cancer J. Clin. 64, 252–271 (2014). Skolarus, T. A. et al. American Cancer Society prostate cancer survivorship care guidelines. CA Cancer J. Clin. 64, 225–249 (2014). Resnick, M. J. et al. Prostate cancer survivorship care guideline: american society of clinical oncology clinical practice guideline endorsement. J. Clin. Oncol. 33, 1078–1085 (2015). Watson, E. et al. Symptoms, unmet needs, psychological well-being and health status in prostate cancer survivors: implications for redesigning follow-up. BJU Int. http:// dx.doi.org/10.1111/bju.13122. O’Connor, A. M. et al. Toward the ‘tipping point’: decision aids and informed patient choice. Health Aff. (Millwood) 26, 716–725 (2007). Berry, D. L. et al. The Personal Patient Profile‑Prostate decision support for men with localized prostate cancer: a multi-center randomized trial. Urol. Oncol. 31, 1012–1021 (2013). Gilbert, S. M. et al. Quality of life and satisfaction among prostate cancer patients followed in a dedicated survivorship clinic. Cancer http://dx.doi.org/10.1002/ cncr.29215. Andreyev, H. J. N. et al. Algorithm-based management of patients with gastrointestinal symptoms in patients after pelvic radiation treatment (ORBIT): a randomised controlled trial. Lancet 382, 2084–2092 (2013). Chang, P. et al. Expanded prostate cancer index composite for clinical practice: development and validation of a practical health related quality of life instrument for use in the routine clinical care of patients with prostate cancer. J. Urol. 186, 865–872 (2011).
www.nature.com/nrurol © 2015 Macmillan Publishers Limited. All rights reserved
Optimizing prostate cancer survivorship care Matthew J. Resnick
Prostate cancer survivors face a myriad of unique physical, psychological and emotional challenges during the often lengthy survivorship experience. Efforts to better characterize the unmet needs of this large patient population will undoubtedly improve the quality of survivorship care we offer to our patients. Prostate cancer survivors comprise 43% of all male cancer survivors, including nearly 3 million individuals in the USA.1 Given the major health-care burden of prostate cancer survivorship in the context of the unique issues faced by the many survivors, the American Cancer Society (ACS) published prostate cancer survivorship care guidelines2 in 2014 that were subsequently endorsed by the American Society of Clinical Oncology.3 The ACS guidelines outline multip le domains that merit attention in order to offer comprehensive prostate cancer survivor ship care. Despite a substantial amount of research into functional impairments after treatment for prostate cancer, a considerable knowledge gap remains with respect to the magnitude and evolution of psychological and emotional needs of prostate cancer survivors. Furthermore, little consensus exists among prostate cancer specialists regarding the most effective setting in which to deliver high-quality survivorship care. Recognizing this knowledge gap, Watson and colleagues4 performed a survey-based cross-sectional study that aimed to elabor ate the physical, psychological, and emotional health of a population of prostate cancer survivors and to identify potential unmet needs. The investigators determined that, consistent with previously published reports, prostate cancer survivors reported high levels of overall satisfaction with their prostate cancer care; however, survivors reported that their satisfaction with the degree to which their emotional, relationship and social problems were addressed was less favourable than their satisfaction with
other evaluated domains. Additionally, and importantly, the investigators ascertained the distribution of unmet needs reported by prostate cancer survivors, identifying sexual issues, concerns about significant others, and anxiety regarding cancer recurrence as being the most commonly reported unmet needs. How, then, might we translate the lessons learned from the study by Watson et al.4 into practice? Optimizing care for prostate cancer survivors begins well before an individual patient undergoes radical prostatectomy, radiation therapy, or surveillance prostate biopsy. Although often practically challenging at the point of care, attempting to ascertain individualized patient preferences might ultimately improve alignment between individual treatment goals and satisfaction with care, inclusive of both oncologic control and functional outcomes. One practical approach that might facilitate this process is the use of decision aids. A highquality decision aid offers information about management options, individualizes probabilities of specific outcomes, crystallizes a patient’s values in relation to the possible outcomes and encourages the patient to make choices that are congruent with their values and preferences.5 Incorporating decision aids into clinical practice might ultimately result in better quality decisions, namely decisions based upon scientific evidence and congruent with a patient’s values and preferences.6 Efforts to improve the quality of decisions in men with localized prostate cancer might improve satisfaction during the survivorship experience, although more work is necessary to completely characterize this relationship.
NATURE REVIEWS | UROLOGY
Szepy/iStock/Thinkstock
Refers to Watson, E. et al. Symptoms, unmet needs, psychological well-being and health status in prostate cancer survivors: implications for redesigning follow-up. BJU Int. http://dx.doi.org/10.1111/bju.13122
The results of the study by Watson et al.,4 in concert with the ACS prostate cancer survivorship guidelines, might ultimately serve as a springboard for redesigning prostate cancer survivorship care. Historically, care has been delivered by prostate cancer speciali sts such as urologists, radiation oncologists and medical oncologists, but interest has been growing in the development of multidisciplinary prostate cancer survivorship programmes to specifically address the unmet needs elaborated by Watson and colleagues. In their 2015 paper, Gilbert and colleagues7 reported the changes in quality of life that occurred after deployment of a prostate cancer survivorship clinic incorporating point-of-care patientreported outcome assessment and dedicated consultations with nursing and sexual health therapists. Patient-reported sexual function and satisfaction with care were significantly higher in patients treated in the prostate cancer survivorship clinic than in those who received routine care.7 Indeed, ample evidence exists to indicate that nurse-led symptom management programmes result in consistent improvements in patientreported outcomes. Andreyev et al.8 randomly assigned 218 patients with new-onset gastrointestinal symptoms after pelvic radiotherapy to usual care, gastroenterologist- le d a lgor it hm-b as e d t re at ment, or nurse-led algorithm-based treatment. The investigators determined that the nurseled programme resulted in significant improvements in radiotherapy-induced gastrointestinal symptoms over usual care, and that outcomes in the nurse-led ADVANCE ONLINE PUBLICATION | 1
© 2015 Macmillan Publishers Limited. All rights reserved
NEWS & VIEWS group were noninferior to those in the gastroenterologist-led programme. Taken together, these data suggest that the development and deployment of novel survivorship programmes to comprehensively address the unmet needs of prostate cancer survivors might ultimately improve the quality of care that we deliver to our patients.
‘‘
Prostate cancer survivors face unique physical, psychological and emotional challenges
’’
In addition to highlighting the distribution of unmet needs among prostate cancer survivors, the study by Watson et al.4 also draws attention to the need for the develop ment of reliable and valid tools to better ascertain patient-reported data in clinical practice. Certainly, the development of brief point-of-care instruments that can be used at each clinic visit might facilitate the identification of unmet needs at the indivi dual level as opposed to the population level. A good example of the development of an efficient point-of-care instrument is the development of the EPIC-CP (Expanded Prostate Cancer Index Composite for Clinical Practice), a 16-item questionnaire that was found to correlate highly with its parent questionnaire, the EPIC‑26 (26-item Expanded Prostate Cancer Index Composite). Additionally, and importantly, the EPIC-CP questionnaire can be completed quickly and poses little disruption to
routine clinical care.9 Although a clinically useful tool for the evaluation of patientreported prostate-cancer-specific function is available in the EPIC-CP, few instruments are available that can be used at the point of care to assess an individual’s unmet needs, psychological health and emotional health. Indeed, the development and incorporation of such tools into clinical practice using a real-time dashboard platform, such as that used by Gilbert et al.,7 might serve to underscore the domains and elements that are most important to an individual patient, ultimately facilitating patient-centred care. Prostate cancer survivors face unique physical, psychological and emotional challenges. The delivery of high-quality, patientcentred survivorship care undoubtedly requires the critical evaluation of current practice and engagement of a multidisciplinary team in order to effectively address an individual’s unmet needs. Additionally— and importantly—as a prostate cancer community, we must begin to routinely and systematically ascertain patient-reported data to guide individualized survivorship care. Doing so will require investment in the development of both suitable tools for data collection and a suitable infrastructure for real-time feedback to the treating clinician at the point of care.
doi:10.1038/nrurol.2015.123 Published online 2 June 2015 Competing interests The author declares no competing interests. 1.
2.
3.
4.
5.
6.
7.
8.
9.
Department of Urologic Surgery, Vanderbilt University Medical Center, A-1302 Medical Center North, Nashville, TN 37232, USA. [email protected]
2 | ADVANCE ONLINE PUBLICATION
DeSantis, C. E. et al. Cancer treatment and survivorship statistics, 2014. CA Cancer J. Clin. 64, 252–271 (2014). Skolarus, T. A. et al. American Cancer Society prostate cancer survivorship care guidelines. CA Cancer J. Clin. 64, 225–249 (2014). Resnick, M. J. et al. Prostate cancer survivorship care guideline: american society of clinical oncology clinical practice guideline endorsement. J. Clin. Oncol. 33, 1078–1085 (2015). Watson, E. et al. Symptoms, unmet needs, psychological well-being and health status in prostate cancer survivors: implications for redesigning follow-up. BJU Int. http:// dx.doi.org/10.1111/bju.13122. O’Connor, A. M. et al. Toward the ‘tipping point’: decision aids and informed patient choice. Health Aff. (Millwood) 26, 716–725 (2007). Berry, D. L. et al. The Personal Patient Profile‑Prostate decision support for men with localized prostate cancer: a multi-center randomized trial. Urol. Oncol. 31, 1012–1021 (2013). Gilbert, S. M. et al. Quality of life and satisfaction among prostate cancer patients followed in a dedicated survivorship clinic. Cancer http://dx.doi.org/10.1002/ cncr.29215. Andreyev, H. J. N. et al. Algorithm-based management of patients with gastrointestinal symptoms in patients after pelvic radiation treatment (ORBIT): a randomised controlled trial. Lancet 382, 2084–2092 (2013). Chang, P. et al. Expanded prostate cancer index composite for clinical practice: development and validation of a practical health related quality of life instrument for use in the routine clinical care of patients with prostate cancer. J. Urol. 186, 865–872 (2011).
www.nature.com/nrurol © 2015 Macmillan Publishers Limited. All rights reserved
