Expert Opinion / Commentary · November 12, 2015

Urology Practice Changer in 2015: Counseling Patients About Radiation Therapy After Radical Prostatectomy

Written by Tony Nimeh MD

In a study published in 2009 in The Journal of Urology, the Southwest Oncology Group (SWOG; trial S8794) showed an overall survival benefit and a metastasis-free survival benefit with the use of adjuvant radiation in patients with positive margins of resection after surgery, extracapsular extension, or seminal vesicle invasion within 4 months of prostatectomy in comparison with treatment delayed until evidence of recurrence.1

Adjuvant radiotherapy before biochemical recurrence is a clinically challenging scenario for several reasons. Some patients who ultimately don't require the treatment might be subjected unnecessarily to the side effects of radiation. Of course, clinicians can wait until biochemical recurrence is diagnosed, thereby providing adjuvant radiotherapy as a treatment for clinically demonstrated recurrence rather than empirically. Waiting for clinical recurrence not only protects a patient who would never recur from unnecessary treatment, but provides a stronger rationale for treatment recommendation in a patient conversation.

Another reason why the scenario is a difficult one is that patients who have recently undergone prostate cancer surgery often feel that they have already made a significant sacrifice by going through the surgery itself and do not have an expectation of undergoing further treatment without clinical evidence of cancer recurrence. Furthermore, the recommendation to undergo additional treatment in the form of radiation may be perceived as a sign of primary surgical treatment failure. Patients are often given a choice between surgery and radiation at their initial cancer diagnosis and may feel resentful if asked to undergo a second treatment modality after having selecting one of the two. They may blame the surgeon for a technical failure if they are subsequently recommended to undergo radiation.

In a June 2015 interview with PracticeUpdate, Dr. Neha Vapiwala, a radiation oncologist and expert in genitourinary cancer, shared her approach to counseling patients about radiation therapy after radical prostatectomy, at best a difficult conversation.2

Dr. Vapiwala discusses the way she conducts the conversation with her patients to involve them in a shared decision. Her approach helps contextualize the recommendation by using an analogy that is patient-friendly, supportive, and empowering to prevent potential feelings of fear, resentfulness, and discouragement on the part of patients confronted with additional treatment when they had been expecting to have completed their original—recommended—treatment course.

Dr. Vapiwala provides clinicians with real-life discussion tools to help better communicate to their patients the parameters of the decision being made. These tools help shift the focus of discussion from the clinician making a recommendation toward the clinician and patient making a joint decision. This is helpful in a situation where both available options have benefits and disadvantages and where patients' specific personalities and life-situations may play a significant role in the decision-making process. 

Dr. Vapiwala's first shares with the patient the details of relevant randomized studies in a tailored manner and then relates the trial outcomes to that particular patient’s situation. In a clinical scenario, given that we cannot know which particular patient will have an oncologic recurrence and will actually benefit from adjuvant radiation, Dr. Vapiwala tries to explain to the patient the concept of relative risk.

Second, Dr. Vapiwala uses an insurance policy analogy to help contextualize the type of decision being made and to relate it in an accessible manner to the patient. This also helps differentiate the current decision point (for adjuvant treatment) from the one made at diagnosis (for primary treatment). Dr. Vapiwala's describes the analogy she uses in detail:

We recognize that, when we buy insurance, we're paying an ongoing premium upfront, and we're paying a price for the reassurance that we're doing whatever we have in our power to cover our bases. That doesn't mean that the insurance will cover everything. Similarly, even if you get adjuvant radiation, that doesn't reduce your risk to zero, but at least it lowers the risk to something better than what it was with no radiation.

You're willing to go uninsured, but you recognize and accept the risk if something does happen—to your house or car, for example—that you are uninsured and you may end up paying more later, and that amount you pay later may or may not cover everything.

Focusing in on this particularly challenging clinical scenario in such a detailed manner will hopefully help clinicians more confidently navigate the ambiguity of the clinical decision in a safe and patient-centric manner in which patients feel empowered to choose the best options for them according to their risk profile, personality, and life situation.

 
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