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Article of the Month: PROMs in the ProtecT trial of PCa treatments

November 30, 2016/by admin Z.9

Every Month the Editor-in-Chief selects an Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video discussing the paper.

If you only have time to read one article this week, it should be this one.

Patient-reported outcomes in the ProtecT randomized trial of clinically localized prostate cancer treatments: study design, and baseline urinary, bowel and sexual function and quality of life

Athene Lane*,†, Chris Metcalfe*,†, Grace J. Young*,†, Tim J. Peters‡,§, Jane Blazeby*, Kerry N. L. Avery*, Daniel Dedman¶, Liz Down*, Malcolm D. Mason**, David E. Neal††, Freddie C. Hamdy†† and Jenny L. Donovan*,§ for the ProtecT Study group

*School of Social and Community Medicine, University of Bristol, Bristol, †Bristol Randomised Trials Collaboration, University of Bristol, Bristol, ‡School of Clinical Sciences, University of Bristol, Bristol, §Collaboration for Leadership in Applied Health Research and Care West, United Hospitals Bristol, Bristol, ¶Clinical Practice Research Datalink Group, Medicines and Healthcare Products Regulatory Agency, London, **School of Medicine, Cardiff University, Cardiff, and ††Nufﬁeld Department of Surgery, University of Oxford, Oxford, UK

Read the full article

Objectives

To present the baseline patient-reported outcome measures (PROMs) in the Prostate Testing for Cancer and Treatment (ProtecT) randomized trial comparing active monitoring, radical prostatectomy and external-beam conformal radiotherapy for localized prostate cancer and to compare results with other populations.

Materials and Methods

A total of 1643 randomized men, aged 50–69 years and diagnosed with clinically localized disease identified by prostate-specific antigen (PSA) testing, in nine UK cities in the period 1999–2009 were included. Validated PROMs for disease-specific (urinary, bowel and sexual function) and condition-specific impact on quality of life (Expanded Prostate Index Composite [EPIC], 2005 onwards; International Consultation on Incontinence Questionnaire-Urinary Incontinence [ICIQ-UI], 2001 onwards; the International Continence Society short-form male survey [ICSmaleSF]; anxiety and depression (Hospital Anxiety and Depression Scale [HADS]), generic mental and physical health (12-item short-form health survey [SF-12]; EuroQol quality-of-life survey, the EQ-5D-3L) were assessed at prostate biopsy clinics before randomization. Descriptive statistics are presented by treatment allocation and by men’s age at biopsy and PSA testing time points for selected measures.

Results

A total of 1438 participants completed biopsy questionnaires (88%) and 77–88% of these were analysed for individual PROMs. Fewer than 1% of participants were using pads daily (5/754). Storage lower urinary tract symptoms were frequent (e.g. nocturia 22%, 312/1423). Bowel symptoms were rare, except for loose stools (16%, 118/754). One third of participants reported erectile dysfunction (241/735) and for 16% (118/731) this was a moderate or large problem. Depression was infrequent (80/1399, 6%) but 20% of participants (278/1403) reported anxiety. Sexual function and bother were markedly worse in older men (65–70 years), whilst urinary bother and physical health were somewhat worse than in younger men (49–54 years, all P < 0.001). Bowel health, urinary function and depression were unaltered by age, whilst mental health and anxiety were better in older men (P < 0.001). Only minor differences existed in mental or physical health, anxiety and depression between PSA testing and biopsy assessments.

Conclusion

The ProtecT trial baseline PROMs response rates were high. Symptom frequencies and generic quality of life were similar to those observed in populations screened for prostate cancer and control subjects without cancer.

Editorial: ‘Killing Two Birds With One Stone’ – PROMS from the ProtecT Trial

November 30, 2016/by David Penson

Very few areas of medicine generate more controversy than the management of clinically localised prostate cancer. This is in large part due to the somewhat conflicting nature of the scant level I evidence that exists on the subject. Whereas the Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4) demonstrated a clinically meaningful and durable survival advantage for surgery when compared to watchful waiting in a predominantly White Scandinavian population of patients with clinically palpable yet localised prostate cancer [1], the Radical Prostatectomy Versus Observation for Localized Prostate Cancer (PIVOT) trial reported a mostly null effect of surgery in a predominantly older, less healthy population of American patients with clinically indolent disease [2]. Neither trial addresses the effect of radiotherapy on prostate cancer survival and both may lack relevance in contemporary prostate cancer practice.

For these reasons and a myriad of others, the medical community eagerly awaits the results of the Prostate Testing for Cancer and Treatment (ProtecT) trial [3]. With a fastidiously designed protocol that involves 337 primary care centres across nine cities in the UK, the use of dedicated study nurses, the successful enrolment of pre-specified sample size targets, and the inclusion of patient-reported quality-of-life measures, the ProtecT trial is poised to make enormous inroads for men with prostate cancer and the providers who care for them.

In this issue of the BJUI, the investigators from the ProtecT trial publish baseline patient-reported outcome measures (PROMs) from the ProtecT trial [4]. While others have previously reported baseline PROMs in large comparative effectiveness studies [5], the findings from this study are notable for several reasons. First, this is the first randomised trial comparing the effect of surgery, radiation, and active monitoring on PROMs. While several high-quality prospective observational cohort studies have reported long-term quality-of-life outcomes after prostate cancer treatment [6, 7], ProtecT will offer randomised comparisons that minimise confounding and selection bias from the outset. Second, the ProtecT trial will not only measure disease-specific health-related quality of life through the use of psychometrically validated survey instruments, such as the Expanded Prostate Index Composite, but also general health-related quality of life through the use of the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ) C-30 (as well as depression and anxiety through the use of the Hospital Anxiety and Depression Scale). Finally, and perhaps most importantly, the investigators collected baseline PROMs at the time of the first biopsy before cancer diagnosis, which will offer distinct advantages when modelling patient-reported function over time, as well as avoiding recall bias associated with retrospective collection of baseline patient-reported outcomes.

In the absence of the long-term survival data from randomised trials comparing surgery and radiation, previous studies have rightly focused on understanding how the effect of prostate cancer treatments differ with respect to PROMs. With the ProtecT trial, we will not only start to have answers to longstanding questions about how surgery, radiation and active surveillance compare with respect to clinical outcomes, such as survival and cancer control, but also with respect to PROMs. By addressing both of these domains, the ProtecT investigators are in position to ‘kill two birds with one stone’ and in so doing will undoubtedly make large strides in facilitating data-driven decision-making for patients with prostate cancer worldwide.

Read the full article

Mark D. Tyson* and David F. Penson*,†,‡

Departments of *Urologic Surgery and †Health Policy, Vanderbilt University Medical Center, and‡ Geriatric, Research, and Educational Center, Veterans Affairs Tennessee Valley Health Care System, Nashville, TN, USA

References

1 Bill-Axelson A, Holmberg L, Garmo H et al. Radical prostatectomy or watchful waiting in early prostate cancer. N Engl J Med 2014; 370: 932–42

2 Wilt TJ, Brawer MK, Jones KM et al. Radical prostatectomy versus observation for localized prostate cancer. N Engl J Med 2012; 367: 203–13

3 Lane JA, Donovan JL, Davis M et al. Active monitoring, radical prostatectomy, or radiotherapy for localised prostate cancer: study design and diagnostic and baseline results of the ProtecT randomised phase 3 trial. Lancet Oncol 2014; 15: 1109–18

4 Lane A, Metcalfe C, Young GJ et al. Patient-reported outcomes in the ProtecT randomized trial of clinically localized prostate cancer treatments: study design, and baseline urinary, bowel and sexual function and quality of life. BJU Int 2016; 118: 869–79

5 Resnick MJ, Barocas DA, Morgans AK et al. Contemporary prevalence of pretreatment urinary, sexual, hormonal, and bowel dysfunction: deﬁning the population at risk for harms of prostate cancer treatment. Cancer 2014; 120: 1263–71

6 Sanda MG, Dunn RL, Michalski J et al. Quality of life and satisfaction with outcome among prostate-cancer survivors. N Engl J Med 2008; 358: 1250–61

7 Resnick MJ, Koyama T, Fan KH et al. Long-term functional outcomes after treatment for localized prostate cancer. N Engl J Med 2013; 368: 436–45

AML Poll Results

May 22, 2015/by admin Z.9

Following on from the recent #urojc discussion, it is clear opinions on managing AML’s vary widely. You are referred a fit and well 40 year old with incidental solitary 4cm AML. What is your treatment of choice?

Article of the Week: Psychometric evaluation of PRO data for the treatment of Peyronie’s disease

May 20, 2015/by admin Z.9

Every Week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Franklin Emmanuel Kuehhas, discussing his paper.

If you only have time to read one article this week, it should be this one.

International multicentre psychometric evaluation of patient-reported outcome data for the treatment of Peyronie’s disease

Verena Kueronya, Arkadius Miernik*, Slavisa Stupar†, Vladimir Kojovic‡, Georgios Hatzichristodoulou§, Paulo H. Egydio¶, Georgi Tosev**, Marco Falcone††, Francesco De Luca‡‡, Demir Mulalic†, Miroslav Djordjevic‡, Martin Schoenthaler*, Christian Fahr* and Franklin E. Kuehhas† Department of Obstetrics and Gynecology,

†Department of Urology, Medical University of Vienna, Vienna, Austria, *Departments of Urology, Medical University of Freiburg, Freiburg, §Departments of Urology, Rechts der Isar Medical Center, Technical University of Munich, Munich, **Departments of Urology, Medical University of Heidelberg, Heidelberg, Germany, ‡School of Medicine, University of Belgrade, Belgrade, Serbia, ¶Centre for Peyronie’s Disease Reconstruction, Sao Paulo, Brazil, ††Department of Urology, Medical University of Turin, Turin, Italy, and ‡‡Institute of Urology, University College London, London, UK

Read the full article

OBJECTIVE

To compare patient-reported outcomes (PROs) of surgical correction of Peyronie’s disease (PD) with the Nesbit procedure, plaque incision and grafting, and the insertion of a malleable penile implant after surgical correction of penile curvature.

PATIENTS AND METHODS

We performed a retrospective review of men who underwent surgical correction of PD between January 2010 and December 2012 at six international centres. Treatment-related PROs and satisfaction were evaluated with a non-validated questionnaire.

RESULTS

The response rate to the questionnaire was 70.9%, resulting in a study cohort of 206 patients. The Nesbit procedure, plaque incision with grafting, or implantation of a malleable penile prosthesis was performed in 50, 48, and 108 patients, respectively. Overall, 79.1% reported a subjective loss of penile length due to PD preoperatively (range 2.1–3.2 cm). Those patients treated with a malleable penile implant reported the greatest subjective penile length loss, due to PD. A subjective loss of penile length of >2.5 cm resulted in reduced preoperative sex ability. Postoperatively, 78.0%, 29.2% and 24.1% patients in the Nesbit, grafting, and implant groups reported a postoperative, subjective loss of penile length (range 0.4–1.2 cm), with 86.3%, 78.6%, and 82.1% of the patients in each group, respectively, being bothered by the loss of length.

CONCLUSIONS

Penile length loss due to PD affects most patients. Further penile length loss due to the surgical correction leads to bother among the affected patients, irrespective of the magnitude of the loss. The Nesbit procedure was associated with the highest losses in penile length. In patients with PD and severe erectile dysfunction, a concomitant lengthening procedure may be offered to patients to help overcome the psychological burden caused by the loss of penile length.

Editorial: The impact of the surgical correction of Peyronie’s disease – a patient’s perspective

May 20, 2015/by David Ralph

Peyronie’s disease (PD) is an acquired benign connective tissue disorder of the tunica albuginea of the penis that leads to the formation of fibrous inelastic plaques. As a result of pain, worsening quality of erections, penile shortening and deformity, the quality of life of both the patient and their partner may be significantly affected, and this may lead to depression, low self-esteem and relationship difficulties [1].

At present, surgery represents the ‘gold standard’ treatment when PD is stable, and should be offered to guarantee a penis straight and rigid enough to allow penetrative intercourse.

The flow chart in the 2010 guidelines on PD indicates the type of surgery that should be offered according to the preoperative quality of the erection, degree of deformity and penile length, but patient perception of preoperative penile shortening is not taken into consideration [2]. Penile shortening does play an important part, however, with regard to postoperative patient satisfaction, as confirmed by Akin-Olugbade et al. [3], whose series of patients with PD reported the lowest satisfaction rates after penile prosthesis implantation.

According to the present series by Kueronya et al. [4], in which patient-perceived pre- and postoperative penile length loss in patients with PD was evaluated, 79.1% of patients perceived a degree of length loss attributable to PD, and a subjective loss of length of >2.5 cm translated into reduced ability with regard to sexual intercourse. In particular, patients who underwent penile prosthesis implantation reported more significant perceived shortening. This is not surprising, as patients with larger plaques, more severe forms of PD and fibrosis are more likely to have erectile dysfunction and ultimately to require a penile prosthesis implantation. Among patients who did not undergo penile prosthesis implantation, those requiring Nesbit plication reported less preoperative shortening than those requiring plaque incision and grafting, as the latter group presented with more severe deformities.

Further penile length loss caused by the surgical correction leads to bother to the patients, irrespective of the magnitude of the loss. The message from the present series by Kueronya et al. is that, to achieve higher postoperative satisfaction rates in this unfortunate cohort of patients, the choice of the type of surgery should take into consideration patient’s perceived preoperative penile shortening and not be based solely on the 2010 PD guidelines algorithm, because ultimately patients wish to obtain full restoration of the shape and size of penis they had before the onset of PD [2].

As patient’s perceived penile length plays such an important role in a patient’s postoperative satisfaction and because patients undergoing penile prosthesis implantation are those who have lost more length, length restoration should be offered simultaneously with penile prosthesis implantation [5, 6].

Kueronya et al. should be congratulated for their work, which is the first series evaluating patient’s perceived penile shortening and may represent a significant step towards the restoration of an adequate sex life in patients with PD.

Read the full article

Giulio Garaffa and David J. Ralph

St Peter’s Andrology and the Institute of Urology, University College London Hospitals, London, UK

References

1 Rosen R,Catania J, Lue T et al. Impact of Peyronie’s disease on sexual and psychosocial functioning: qualitative ﬁndings in patients and controls. J Sex Med 2008; 5: 1977–84

2 Ralph D, Gonzalez-Cadavid N , Mirone V et al. The management of Peyronie’s Disease: evidence-based 2010 guidelines. J Sex Med 2010; 7: 2359–74

3 Akin-Olugbade O, Parker M, Guhring P, Mulhall J. Determinants of patient satisfaction following penile prosthesis surgery. J Sex Med 2006; 3: 743–8

4 Kueronya V, Miernik A, Stupar S et al. International multicenter psychometric evaluation of patient reported outcome data for the treatment of Peyronie’s Disease. BJU Int 2015; 115: 822–8

5 Sansalone S, Garaffa G, Djinovic R et al. Simultaneous penile lengthening and penile prosthesis implantation in patients with Peyronie’s Disease, refractory erectile dysfunction and severe penile shortening. J Sex Med 2012; 9: 316–21

6 Egydio PH, Kuehhas FE, Sansalone S. Penile girth and length restoration in severe Peyronie’s Disease using circular and longitudinal grafts. BJU Int 2013; 111 (4 Pt B): E213–9

Video: Peyronie’s disease treatment – psychometric evaluation of PRO data

May 20, 2015/by admin Z.9

International multicentre psychometric evaluation of patient-reported outcome data for the treatment of Peyronie’s disease

Read the full article

OBJECTIVE

PATIENTS AND METHODS

RESULTS

CONCLUSIONS

Prophylaxis against the Paradox of Choice?

May 14, 2014/1 Comment/by Fardod OKelly

My wife recently dropped and smashed her iPhone screen. She didn’t have insurance, and on consultation with her phone provider was told that her only option was to purchase another phone as she was locked into a lease contract. Our initial annoyance was then amplified when we discovered that we could just have the screen fixed privately for a fraction of the cost and effort, which we duly had done.

I began to think of the old Henry Ford adage (1910) in relation to his legendary Model-T edition car “You can have it in any colour as long as its black”, and wondered how often we as urologists might be criticized of adopting a similar approach with patients in their clinics.

Urology has always been a very progressive surgical specialty. Developed in 1909, TURP was the first successful, minimally invasive surgical procedure of the modern era. The first laparoscopic nephrectomy for a renal mass was carried out in 1991 in Johns Hopkins, surprisingly around the same time as the development in robotic (PROBOT) technology for use in urology (Murphy et al. 2006). As technology advanced, fellows and consultants became more sub-specialized in tandem with this change, leading to the large repertoire of treatment options and modalities available today. However, somewhere along the way with the vast change in the playing field, there appeared a concerning pattern of failure to discuss all treatment options with patients, or to refer them to other institutions which may/may not have provided an alternative treatment path. This trend, which is not oncology-specific, can be seen across a number of sub-specialty areas such as the management of renal masses, PUJ obstruction, radical prostatectomy, reconstruction post cystectomy, and even in paediatric urology with hypospadias repair being a classic example.

The question remains as to the reasons why one would not choose to cross-refer. Allowing for variables such as patient choice or consumerism, non-established or experimental procedures, and for urologists that may be financially or institutionally coerced into only providing certain treatments, the concept of not providing cross-referral brings into question whether this is perhaps down to financial considerations, a belief that referrals will not be reciprocated back, leading to a reduction in patient base and de-skilling, or a strong sense of paternalism where the urologist genuinely feels that they can offer a superior treatment package. This theme has previously been shown by Miller et al. who described how many patients with kidney cancer were offered treatment based on the surgeon’s practice style rather than on the characteristics of their disease.

However, given a choice of a number of options, it has previously been shown many times, that patients are more likely to build a strong rapport with the first specialist clinician they meet, and therefore likely to revert back to the first treatment option. Perhaps a lack of cross-referral is based on a pre-emptive sense of patient autonomy. Often the greatest power of autonomy is relinquishing it, and letting the consultant decide the best course of treatment offers the greatest solace. Despite the optimism and favorability of newer technology and techniques, and a general demand for minimally invasive procedures (Duchene et al. 2011), no-one is simply advocating technology for its own sake, or that a robotic-assisted circumcision could be currently seen as acceptable, however the idea of communication, cross-referral and the confidence in asking for further sensible treatment options should always be embraced.

In many ways, our annoyance with the mobile phone screen could have been avoided had the mobile provider been honest, and provided us with further options. It may not have stopped us from fixing the screen elsewhere due to institutional constraints however; a rapport and confidence would have been maintained.

One would do well to find a specialty in which the addition of a constructive (competitive) second opinion has not driven progress. Cross-referral is not a matter of failure, nor a lack of progress, but a continued determination to ensure the highest level of patient care available, to improve patient perception of the specialty as one committed to open communication, and a means to foster concrete inter-institutional relationships. Should we have to document that a second modality opinion was at least sought by the specialist, or waived by the patient?

“The single biggest problem in communication is the illusion that it has taken place” – G.B. Shaw

Fardod O’Kelly is a Specialist Registrar in Urology at AMNCH, Tallaght, Dublin 24, Ireland. Twitter @FardodOKelly

Stunned

February 27, 2014/2 Comments/by James Duthie

If you needed inspiration to pursue cognitive ergonomics as a career or hobby, you could do worse than starting with the book “Set Phasers On Stun” by Steven Casey. Presented as a series of bite-sized real-life vignettes, the book illustrates the inherent fallibility in humans who design and use systems in a very engaging manner.

The most relevant story for doctors is the titular tale about a man receiving radiation therapy for a tumour on his shoulder. Ray lay on the treatment table. The tech in the next room attempted to set the machine to an appropriate radiation dose, but accidentally turned it on to full power. She noticed her error, and reset the machine before firing. Unfortunately the software was not sufficiently powerful to acknowledge her rapid typing, and the setting stayed on full. Furthermore, after firing, the screen told the tech there was an error and that no dose had been delivered. She tried twice more, inadvertently dosing Ray each time, unable to hear Ray’s screams from the lead lined treatment room. He only avoided further doses by running away. As Ray died from the treatment over the ensuing weeks, he jokingly told people that “Captain Kirk forgot to put the machine on stun”.

As clinical doctors, we should acknowledge the fact that individually, we do not make that many people better. Disappointing though this is, as it is the Raison d’être for many of us, I think we understand on some level that it is the “Big Picture” people, the Epidemiologists and Public Health physicians that really make the difference. However many cancers I cut out in my career, I’m still likely to make less of a difference than one well in Sub-Saharan Africa. Many of us are prevented from entering the “Big Picture” career paths due to the fact that they are interminably boring. It is much more interesting to counsel and educate patients, and certainly more exciting to perform complex (and at times terrifying) operations than to sit in a small office in the medical school’s worst-funded department crunching numbers. And who is more likely to be invited to appear on Dr. Oz? The Robotic Surgeon? Or the Epidemiologist with meticulously gathered records of malaria rates in South East Asia? The sad truth of the world is that glamour and excitement are usually more revered than self-sacrifice for enduring positive change.

It took a tragedy, and software engineers to solve the problem that killed Ray on the radiation table, but fortunately, there are simpler avenues for clinicians to make a difference beyond the patients they personally treat. This does not necessarily mean being involved in research on expensive new drugs that often have an incremental (or even arguable) benefit over the existing standard. And you don’t have to be Atul Gawande, creating the WHO surgical checklist, but it helps to use his approach. Devoting some time and mental resources to identify problems that affect a large number of people, even if only in a small way adds up to a significant total benefit. This week I was sent a review article on inadvertent diathermy injuries. These are uncommon, but can be debilitating, as in the index case where a patient essentially lost the use of his right hand due to thermal injury-induced tendon contractures. A consistent problem was a loss of contact between skin and earthing plate. Sweat and traction can loosen the plate and result in occult burns, particularly during prolonged cases, or emergency cases where the plate was applied in a rush. Maybe another surgical check should be done at four, or six hours into an operation to assess the need for a second antibiotic dose, and check diathermy plate. If the case is taking significantly longer than expected, should we take the opportunity to ask; “Why is this taking so long? Do I need help, or a second opinion here?”

The electronic age has given us unprecedented opportunity to reach patients with quality information on the nature of their disease, what to expect from their surgery, and advice on when to seek urgent help. In many cases it just takes a person to assume responsibility for writing content for a web page. The more quality health content we write, the more we drown out the snake-oil merchants and charlatans that prey on credulous patients.

My challenge to you in the coming week is to devote some time to thinking of a “Big Picture” issue that could benefit more patients than those you see yourself, or alternatively dig a well in Africa.

James Duthie is a Urological Surgeon/Robotic Surgeon. Interested in Human Factors Engineering, training & error, and making people better through electronic means. Melbourne, Australia @Jamesduthie1

Avoiding treatment in prostate cancer: time and money, please?

January 13, 2014/1 Comment/by Peter Acher

It seems impossible to say anything regarding prostate cancer without inciting emotionally charged controversy, even when based on high-level evidence. The updated prostate cancer guidelines from the National Institute of Clinical Health and Excellence (NICE) this week sparked media attention that focused on the role of active surveillance for low and intermediate risk groups.

The newspaper headlines state that patients with prostate cancer have been told to avoid immediate treatment. Whether patients are to go against advice given by their doctor or whether this is an attempt by the government to save money is unclear if the online comments are anything to go by. On a local level, patients who are awaiting treatment are questioning their choices.

The sensational implication is that active surveillance is a novel management strategy that was previously not considered. In fact, the equally controversial guidelines from 2008 promoted this alternative: the phrase “suitable for all options including active surveillance” is expressed frequently throughout the country when discussing individual cases at multidisciplinary team meetings.

There is no doubt that a proportion of men who undergo radical treatments may not benefit. The challenges arise in determining who these men are within the constraints of NHS pathways. A standard pathway for a UK man is to request a PSA blood test from his GP, commonly sparked by concerned relatives or friends and endorsed by high-profile survivors and campaigners. A raised result then triggers a “two-week” urgent suspected cancer referral and a clock ticks with diagnosis, staging and treatment to be completed within a 62-day target.

Inevitably, the urgency of referral will influence patient beliefs regarding the seriousness of their condition. A quick online search of comments on recent mainstream articles will throw up anecdotes from men who have sadly failed “wait and see” policies by progressing and finding themselves with incurable disease. A well informed patient will know that a standard transrectal biopsy will have under-estimated his risk in a third of cases. In this emotional state and limited time-frame, our patients are expected to make a rational decision regarding complex management choices – definitive treatment with associated side effects but the knowledge that every effort has been made to “cure” the disease, or what may be a lifetime of repeated, potentially dangerous, biopsies, blood tests and prostate examinations with risk of failure and “living with cancer”. Active surveillance is hardly an attractive option when considered in these terms.

What’s the answer? Detailed evaluation of prostate disease can be achieved with improved imaging with multiparametric MRI in conjunction with a modern transperineal biopsy technique that evaluates the prostate more thoroughly. Suitable patients for active surveillance (and radical treatment) can then be potentially better selected and counseled with higher confidence. Of course, resources are required for this, but shouldn’t this be what we should be campaigning for? And time to deliver this.

Benjamin Disraeli said, “He who gains time gains everything” and perhaps this is the greatest gift we can give to our patients. The lack of time pressure in terms of clinical urgency in low risk prostate cancer gives ample opportunity to get it right in these patients.

I can’t agree that the NICE guidelines are designed to cut NHS costs (active surveillance may cost the same as surgery) but I do fear that without better resources and the reduction in target pressures for low risk prostate cancer, active surveillance will remain an under-utilized management option for many who would benefit from it.

Peter Acher

Increasing importance of truly informed consent: the role of written patient information

October 21, 2013/by Roger Kirby

Roger Kirby*, Ben Challacombe*^†, Simon Hughes*^†, Simon Chowdhury*^† and Prokar Dasgupta*^†*The Prostate Centre, London W1 and ^†Guy’s and St Thomas’ NHS Foundation Trust Hospital, London, UK

Published as a comment article in BJU International 2013; 112: 715–716. doi: 10.1111/j.1464-410X.2012.11787.x

Video Commentary by Roger Kirby, BJUI Associate Editor.

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