Prostate Cancer: New Help for Tough Choices
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What Are My Chances, Doc? continued...
"This approach is attempting to maximize the accuracy with which you can do that," Kattan says. "The nomogram generally predicts better than a doctor's prediction. ... When it comes down to predicting, we as humans tend to predict the outcome we want to happen, not the outcome most likely to happen."
A new, recently completed study of more than 4,000 patient records showed that the nomogram's predictions come amazingly close to actual patient outcomes.
"I think what the nomograms will help do is put a number on the likelihood of success with different treatments," Scardino says. "But it will not show whether one treatment is better than another. It will show that a certain treatment may be more likely to help, and then the decision will be whether the potential side effects are worth it."
Litwin and Scardino already use the program in clinical practice. "My patients love it -- even the ones that get bad news," says Litwin.
Quality of Life
"The primary purpose of prostate cancer treatment has to be a marriage of the dual goals of preserving survival and preserving or even improving quality of life," Litwin says. "Prostate cancer is an insidious, slow disease -- so dying of prostate cancer takes a long time compared to other cancers. The effects of treatment remain with a man for a very, very long time."
To Litwin, health is not merely the absence of disease but the entire spectrum of a person's physical, emotional, and social well-being. He has developed measurements capable of putting a value on each of these different components.
What these scales boil down to is the question of function vs. bother.
"In urinary domains, sexual domains, and bowel domains, function and bother are really separate," Litwin says. "Some men may have severe dysfunction and not be bothered by it, whereas it may make a huge difference to other men."
In his latest study, Litwin looked at urinary function and bother in men who underwent either external-beam radiotherapy or surgery for their prostate cancers. It is generally believed that surgery is more likely to result in a rapid cure, but that the risks of losing erectile function and urinary control are much higher.
This was true in the first year after treatment. But beginning in the second year, men who underwent surgery began to regain lost erectile and urinary function, while those who underwent radiation therapy began to lose it.
As for urinary bother, the results were surprising. Men were bothered significantly more by urinary symptoms after radiation than after surgery for the entire two years after treatment.
"Physicians tend to push their own particular type of therapy because they believe in it," Litwin says. "But I do believe that patients who choose either of the therapies have a concept of what the outcome will be. That is why patients are often surprised, and bothered, when the outcome isn't what they expected."