Prostate Cancer Discussion
Pt. has a new diagnosis of risk prostate cancer that is Gleason with a PSA of diagnosed on . Patient presents today to discuss his treatment options.
As per NCCN guidelines the patient is in the risk group. Because of his risk stratification, there is indication for metastatic work-up .
The natural history of this disease was explained to the patient at length and the treatment options discussed including radical prostatectomy by open or robotic-assisted laparoscopic approach, external-beam radiotherapy, brachytherapy, active surveillance, cryotherapy, watchful waiting including the probability of success and complications associated with each one of these approaches.
With respect to radical prostatectomy, the pros and cons of open versus robotic-assisted laparoscopic prostatectomy were discussed with the patient. The fact that oncologic outcomes between the two surgical modalities are similar, robotic prostatectomy stay an average of one day and have 9-10 days of urethral catheterization was discussed with the patient. The complications of this procedure were reviewed and discussed with the patient and include urinary incontinence, erectile dysfunction, infertility, anastomotic stricture, anastomotic leak, lymphocele, infection, leaving remaining malignancy in the body, hemorrhage requiring transfusion, vascular injury, rectal injury, bowel injury requiring colostomy, ureteral injury, nerve injury, injury to organs, thromboembolic event including deep vein thrombosis and pulmonary embolism, small bowel obstruction from adhesions, incisional hernia, cardiopulmonary events from anesthesia, myocardial infarction, cerebrovascular event (stroke), possibility of death and pain. Discussed that these risks can occur and there are other risks that can occur associated with this surgery. Urinary incontinence and erectile dysfunction were again discussed with the patient as these complications are at a high risk of occurring and have a significant lifestyle impact. Discussed the fact that surgery requires anesthesia and the recovery of ability of erection for sexual function is based on preoperative sexual function, age and nerve sparing technique. Furthermore, discussed that incontinence improves with time and studies suggest the majority of patients are continent by 1 year. We also discussed the potential advantage of surgery over radiation therapy in that biochemical recurrence can be detected at a relatively earlier stage and that salvage radiotherapy is successful in controlling recurrent disease in a substantial proportion of patients. I also conveyed that salvage radiotherapy was associated with a considerably more favorable morbidity profile compared to local salvage therapies for radiorecurent disease.
Discussed risks and benefits of nerve sparing technique including the risk of malignancy remaining in the body and the fact that this does not guarantee preservation of erectile dysfunction.
With respect to external beam radiation therapy (EBRT) and brachytherapy seed implants, we discussed risks including cancer recurrence, induction of second malignancy secondary to radiation, exacerbation of voiding symptoms, potential injury to the bowel and rectum and rectal bleeding, potential injury to bladder and urethra, and gross hematuria, rectovesical and rectourethral fistula formation, hemorrhagic cystitis, subsequent urethral stricture disease, urine retention, and also the possibility of anesthesia and risks of anesthesia including cardiopulmonary events, myocardial infarction, cerebrovascular event (stroke), thromboembolic events including deep vein thrombosis and pulmonary embolism with brachytherapy seed placement. Discussed there are other risks associated with EBRT and brachytherapy. Discussed that radiation can be neoadjuvant, concomitant or adjuvant. Discussed the difficulties in diagnosing recurrent disease at an early stage due to variability in PSA levels and the fact that most patients are not candidates for local surgical salvage therapy when biochemical recurrence occurs and patients that undergo salvage therapy experience significant morbidity of local salvage therapy in terms of perioperative complications including bowel injury, erectile dysfunction and urinary incontinence. Discussed that at 15 years post treatment the oncologic outcomes favor surgery.
With respect to watchful waiting, we discussed the difficulties of estimating the extent of disease preoperatively, the risk of cancer progression and metastatic spread, and the risk that salvage might not possible with progression.
With respect to active surviellance, we discussed this includes routine PSA testing with interval prostate biopsies, typically at one year to 18 months and may include MRI. Discussed the difficulties of estimating the extent of disease preoperatively, the need for repeat biopsies, the risk of cancer progression and metastatic spread, the risk that salvage might not be possible with progression and the fact that approximately one-quarter to one-third of patients undergo active treatment while on active surveillance with the majority of this due to disease progression and some due to anxiety. The favorable 10-year outcomes of active surveillance in appropriately selected patients was conveyed.
All questions were answered to the patient's satisfaction. This session was primarily focused on counseling and coordination of care, and total face to face time was approximately 20 minutes. The patient verbalized understanding of this conversation and asked appropriate questions. He acknowledged the risks of each treatment option.
We discussed that would be the preferred approach given . Also discussed that delaying treatment decision could change his treatment options.
We discussed all of the management options previously mentioned and have agreed to with
Patient states his pre-operative erections are out of 10 and he does treatment for erectile dysfunction pre-operatively.