Prostate cancer survivors currently approach 3 million in number and comprise 43% of all male cancer survivors in the United States.1 These men face myriad unique oncologic, functional, emotional, and psychological issues that require evaluation and management throughout the survivorship phase of the disease. To address a perceived unmet need in care delivery, the American Cancer Society convened a multidisciplinary panel to develop prostate cancer survivorship care guidelines,2 which were subsequently endorsed by ASCO.3
The American Cancer Society guidelines and subsequent ASCO endorsement outline multiple domains that merit attention in the delivery of high-quality, comprehensive survivorship care and offer specific recommendations to facilitate both care delivery and care transitions. While the publication and endorsement of the guidelines, without question, serve as a roadmap for optimizing prostate cancer survivorship care, there remain significant limitations to our current knowledge surrounding “what care to deliver to which patients in what setting.”
Recognizing Gaps in Knowledge
Despite extensive literature reviews as part of the methodology for the guidelines as well as the ASCO endorsement, many questions remain unanswered. While the endorsement panel uniformly agreed that routine measurement of serum prostate-specific antigen (PSA) levels to detect disease recurrence was necessary, there is little evidence upon which to base management decisions surrounding appropriateness of the interval between measurements.
The panel agreed upon a qualifying statement encouraging individualizing surveillance schedules to risk of disease recurrence with an eye toward balancing the potential benefits and harms of high-frequency PSA testing. While there may be benefits to early detection of biochemical recurrence, particularly in patients who are candidates for salvage local therapy, one must consider the harms of PSA surveillance, including both unnecessary cancer-related anxiety and added financial cost.
Oncologic surveillance is just one of many examples of the contemporary knowledge gaps in prostate cancer survivorship. Given the prevalence of prostate cancer survivorship in the United States in the context of both the aging population and improvements in treatment, there is no question that survivorship research will become increasingly important to provide a platform of evidence upon which future recommendations may be based.
Redesigning Prostate Cancer Survivorship Care
The American Cancer Society guidelines and ASCO endorsement may ultimately serve as a springboard for redesigning prostate cancer survivorship care. While prostate cancer specialists have historically delivered survivorship care, optimizing comprehensive prostate cancer survivorship care may require creative and novel approaches to care delivery.
Gilbert and colleagues recently reported changes in quality of life after deployment of a prostate cancer survivorship clinic incorporating point-of-care patient-reported outcome assessment and dedicated nursing and sexual health therapist engagement.4 Patient-reported sexual function and satisfaction with care were significantly higher among patients treated in the prostate cancer survivorship clinic than in those undergoing routine care.
There is high-quality evidence that nurse-led symptom management programs result in consistent improvements in patient-reported outcomes. Andreyev et al randomly assigned patients with new-onset gastrointestinal symptoms after pelvic radiotherapy to usual care, gastroenterologist-led algorithm-based treatment, or nurse-led algorithm-based treatment. Investigators determined that the nurse-led program resulted in significant improvements over usual care and was noninferior to the gastroenterologist-led program.5 These data suggest that the development and deployment of novel survivorship programs may, ultimately, improve the quality of care we are able to deliver to prostate cancer survivors.
Importantly, the American Cancer Society guidelines may provide a platform for care transitions between prostate cancer specialists and primary care physicians, particularly once survivors achieve oncologic, functional, and psychological stability. Indeed, survivorship guidelines may ultimately serve as a basis for the development of pragmatic care plans that may be shared between prostate cancer specialists and primary care physicians to facilitate effective and efficient survivorship care.
While there remain no specific recommendations surrounding the optimal time for transition between the prostate cancer specialist and primary care physician, there is little question that the guidelines will encourage high-quality transitions of care. Redesigning the process of prostate cancer survivorship care will undoubtedly address unmet needs faced by prostate cancer survivors across multiple domains.
Need for Reliable Tools
The American Cancer Society guidelines and ASCO endorsement also underscore the need for reliable and valid tools to ascertain patient-reported data in routine clinical practice. The development of brief point-of-care instruments that may be used at each clinic visit offers the provider insights into the patient experience and permits targeted evaluation and management.
There is no better example of such tools than the EPIC-CP (Expanded Prostate Cancer Index Composite–Clinical Practice), a 16-item questionnaire that correlates strongly with the parent EPIC-26. Additionally, and importantly, the EPIC-CP can be completed quickly and poses little disruption to routine clinical care.6
While the EPIC-CP facilitates point-of-care evaluation of patient-reported prostate cancer–specific function, there are few tools to aid providers in evaluating unmet needs, psychological health, and emotional health related to prostate cancer or its treatment. The development and incorporation of such tools into clinical practice using a real-time dashboard platform, as was done by Gilbert et al, may serve to underscore those domains and elements that are most important to individual patients. Doing so permits translation of guideline recommendations into patient-centered survivorship care.
Needs of the Individual
Prostate cancer survivors face unique physical, psychological, and emotional challenges. The delivery of high-quality, patient-centered survivorship care will undoubtedly require critical evaluation of current practice and engagement of multidisciplinary teams to effectively meet individual unmet needs.
Moreover, as a prostate cancer community, we must begin to routinely and systematically collect patient-reported data and use such data to develop survivorship plans tailored to the needs of the individual patient. Doing so will require investment in the development of novel tools for data collection, information technology infrastructure for feedback, and education of both patients and providers. ■
Disclosure: Dr. Resnick reported no potential conflicts of interest.
References
1. DeSantis CE, Lin CC, Mariotto AB, et al: Cancer treatment and survivorship statistics, 2014. CA Cancer J Clin 64:252-271, 2014.
2. Skolarus TA, Wolf AMD, Erb NL, et al: American Cancer Society prostate cancer survivorship care guidelines. CA Cancer J Clin 64:225-249, 2014.
3. Resnick MJ, Lacchetti C, Bergman J, et al: Prostate cancer survivorship care guideline: American Society of Clinical Oncology clinical practice guideline endorsement. J Clin Oncol 33:1078-1085, 2015.
4. Gilbert SM, Dunn RL, Wittmann D, et al: Quality of life and satisfaction among prostate cancer patients followed in a dedicated survivorship clinic. Cancer 121:1484-1491, 2015.
5. Andreyev HJN, Benton BE, Lalji A, 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.
6. Chang P, Szymanski KM, Dunn RL, 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.
