Treat the patient or the cancer?

Do you think that treating the whole patient rather than just the cancer can improve their outcome?

Dr Gerhardt Attard, Institute of Cancer Research, London:

It's definitely important to treat not just the cancer but the whole patient. And we've become increasingly appreciative of this, especially in prostate cancer where we use hormone therapy, which has other side effects. And we increasingly will tailor the type of hormone treatment, and the level of androgen suppression we aim to achieve to the patient's other conditions, age, and preference. And this has been happening for many decades; for example we've used anti-androgens in patients who preferred not to use castration in certain settings of the disease. So this has always been a factor that's been considered, but as we improve our ability to identify the more aggressive cancers versus the less aggressive ones, and as we improve our personalisation of treatment, we will be in a better position to select treatment for a specific cancer in a specific patient, and minimise the side effects and risks of other conditions.

Professor Malcolm Mason, Cardiff University:

I would like to think that there is a shift towards a more holistic approach to patient care – that is one which looks at the whole patient. I think it's coming, especially for patients with very early disease with the whole question of whether they're going to have treatment at all, or whether they'll be managed by active surveillance. Then, if they're going to have treatment, what treatment? That's a very, complicated discussion, and it really does involve not only the patient, but their family too. It depends on all the other factors, for example any other illnesses they may have, what they expect from a treatment and how they feel about the possible side effects of treatment.

There's been a little bit of work in trying to make some sort of decision analysis tools for patients, and I've seen some research that's looked at that. I think it's promising, but it's quite complicated and hasn't really been taken up. Perhaps we need to look at that again and try and develop those sorts of things, because there's definitely potential there. 

And of course, when it comes to advanced disease, and the question about whether and when we're going to use treatments - sometimes with quite major side effects and disadvantages - that's where we really do need to think about the whole patient, and again, just what they want. And it's got to be very much a joint decision, between, the patient, the doctor and their family.

Do more men choose active surveillance now?

Have recent advances in diagnosing aggressive prostate cancer made active surveillance a more attractive option for men who don't obviously have aggressive disease? And have health professionals taken those advances on board in advising men about active surveillance?

Mrs Caroline Moore, University College London Hospital:

I think the situation for men on active surveillance is very different now to even five years ago. And to my mind, the most important of the additional tests that men are offered is MRI. This gives us the opportunity to find the men who have more aggressive disease that wasn't detected on their first standard biopsy, and then to offer them a targeted biopsy and appropriate treatment. In the past, those men would have had to wait until they had a repeat biopsy, which may or may have not detected that more aggressive tumour.

I think health professionals, doctors in particular, have particularly welcomed the NICE guidelines that have suggested that MRI should be offered to all men [before a repeat biopsy], because that means the likelihood of missing somebody with aggressive disease on active surveillance is really low.

I've been doing some work with Southampton University looking at how men feel when they're on active surveillance. And Sam Watts, a PhD student working with Professor George Lewith, has done interviews with men who say that PSA testing alone isn't a very secure safety net. From our work at UCLH, we know that men do feel a lot safer with an MRI. In the clinics we run at UCLH we show men their MRI scans, so when they see the MRI and then they see it again the next year and nothing's changed, they really know that there's no difference. On the other hand, PSA can fluctuate over time and so I think that’s less reassuring.

Read more about the NICE guidelines for prostate cancer treatment in the Spring 2014 issue of Progress

Gleason 6 : Surgery or active surveillance?

Are there any circumstances in which someone with Gleason 6 should opt for surgery rather than active surveillance?

Mrs Caroline Moore, University College London Hospital:

Many men with Gleason 6, the lowest histological grade of prostate cancer, will opt for active surveillance. But some men with Gleason 6 prostate cancer will opt for active treatment such as surgery or radiotherapy. And I think for those men with higher burden disease, or a family history of prostate cancer, or levels of anxiety that really might make active surveillance difficult, this can be a very sensible option too.

Read more about prostate cancer treatment options

What about alternative therapies?

Why do clinicians pay so little attention to exercise, diet, acupuncture and reflexology, which can all have an influence on survival times and quality of life?

Professor Malcolm Mason, University of Cardiff:

I think actually clinicians are becoming much more aware of these things. One comment that we heard from an epidemiologist [at the Prostate Cancer UK Forum in June 2014] was that actually there's good evidence that exercise can make a difference to outcomes in prostate cancer. So why aren't we promoting it more?Certainly, we're very aware of quality of life, andI think these days we're much more aware when we're designing clinical trials that quality of life is a really important outcome.

As researchers, we get very hung up on the differences, maybe even tiny differences, in how well different forms of treatment for localised disease work. And I think we're probably out of step with at least some of our patients, who maybe aren't quite so concerned about that, but are more concerned with the differences in quality of life associated with each treatment. So we've got to wake up and look at that.

Finally, complementary therapies and things like reflexology or acupuncture… well people vary, and there are obviously a lot of clinicians who are very skeptical about these things, but there are an increasing number who are fairly broad minded.  In my hospital, patients do have access to reflexology within the hospital and increasing numbers of cancer centres do that sort of thing too. I'm sure that's a good thing for patients.

Read more about our work to improve access to services in local communities.

What stops men choosing active surveillance?

Do you think there are psychological barriers to men choosing, and health professionals advising, active surveillance as a preferred option?

Professor Cory Abate-Shen, University of Columbia, USA:

There are absolutely major psychological barriers against active surveillance. And although I'm not a clinician and I don't deal with patients directly, the patients that have contacted me about our work because it really impacts active surveillance, have all been looking for some test, or something definitive, that can help them be assured that active surveillance is the right decision.

Sometimes people will say, that 90, maybe 95 per cent, of Gleason 6 patients will never progress and develop advanced disease - which is fine, unless you're one of the ten, or the five per cent, that do. And being able to catch those tumours early is critical, because otherwise, by the time they're caught, it might be too late, whereas they could have been very effectively addressed early on. And that's really the complexity of the issue.

I think the ideal active surveillance analysis [and something we’re definitely aiming for] would be analysis of biopsy samples, combined with some kind of quantitative assessment of a marker protein and prostate imaging. Then the patient would get information like ‘you have X, Y and Z results, so we're confident of the diagnosis on multiple levels, and not relying on a single test’. In that case, I think people would really have clarity as to whether they need treatment or not.

Read more about Professor Abate-Shen’s work in our blog post from the Prostate Cancer UK Forum.

Why use Docetaxel Chemotherapy?

Why is Docetaxel Chemotherapy still used when its success rate is so poor?

Ellen de Morree, Erasmus University, the Netherlands:

It actually isn’t that docetaxel doesn’t work. Taxanes like docetaxel or cabazitaxel are very potent chemotherapy agents, it’s just that they don’t seem to work in all men – we need a better trick for figuring out who they are going to work for.