Archive for May, 2013

Prostate Cancer News

Wednesday, May 8, 2013 // Uncategorized

There have been several news items about prostate cancer in the last few days having to do with the diagnosis and treatment of prostate cancer.

Here are the new guidelines on prostate cancer screening from the American Urologic Association.  The USPSTF had recommended against screening for prostate cancer as they felt that the net harm outweighed the benefit.  The American Urologic Associations guidelines represent a response to this.

Guideline Statements

Guideline Statement 1: The Panel recommends against PSA screening in men under age 40 years. (Recommendation; Evidence Strength Grade C)

  • In this age group there is a low prevalence of clinically detectable prostate cancer, no evidence demonstrating benefit of screening and likely the same harms of screening as in other age groups.

Guideline Statement 2: The Panel does not recommend routine screening in men between ages 40 to 54 years at average risk. (Recommendation; Evidence Strength Grade C)

  • For men younger than age 55 years at higher risk (e.g. positive family history or African American race), decisions regarding prostate cancer screening should be individualized.

Guideline Statement 3: For men ages 55 to 69 years the Panel recognizes that the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, the Panel strongly recommends shared decision-making for men age 55 to 69 years that are considering PSA screening, and proceeding based on a man’s values and preferences. (Standard; Evidence Strength Grade B)

  • The greatest benefit of screening appears to be in men ages 55 to 69 years.

Guideline Statement 4: To reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening. As compared to annual screening, it is expected that screening intervals of two years preserve the majority of the benefits and reduce overdiagnosis and false positives. (Option; Evidence Strength Grade C)

  • Additionally, intervals for rescreening can be individualized by a baseline PSA level.

Guideline Statement 5: The Panel does not recommend routine PSA screening in men over age 70 years or any man with less than a 10 to 15 year life expectancy. (Recommendation; Evidence Strength Grade C)

  • Some men over age 70 years who are in excellent health may benefit from prostate cancer screening.

 

The American Urologic Association and american Society of Radiation Therapy released new guidelines on treating patients who have had their prostates removed with radiation if their are determined to be at high risk for recurrence.  Formerly, they had radiation if their cancer recurred.

 

Guideline Statements:

1. CLINICAL PRINCIPLE

. Patients who are being considered for management of localized prostate cancer with radical prostatectomy should be informed of the potential for adverse pathologic findings that portend a higher risk of cancer recurrence and that these findings may suggest a benefit of additional therapy after surgery.

2. CLINICAL PRINCIPLE

. Patients with adverse pathologic findings including seminal vesicle invasion, positive surgical margins, and extraprostatic extension should be informed that adjuvant radiotherapy, compared to radical prostatectomy only, reduces the risk of biochemical (PSA) recurrence, local recurrence, and clinical progression of cancer. They should also be informed that the impact of adjuvant radiotherapy on subsequent metastases and overall survival is less clear; one of two randomized controlled trials that addressed these outcomes indicated a benefit but the other trial did not demonstrate a benefit. However, the other trial was not powered to test the benefit regarding metastases and overall survival.

3. STANDARD.

Physicians should offer adjuvant radiotherapy to patients with adverse pathologic findings at prostatectomy including seminal vesicle invasion, positive surgical margins, or extraprostatic extension because of demonstrated reductions in biochemical recurrence, local recurrence, and clinical progression. (Body of Evidence Strength Grade A)

4. CLINICAL PRINCIPLE.

 

Patients should be informed that the development of a PSA recurrence after surgery is associated with a higher risk of development of metastatic prostate cancer or death from the disease. Congruent with this clinical principle, physicians should regularly monitor PSA after radical prostatectomy to enable early administration of salvage therapies if appropriate.

5. RECOMMENDATION

 

. Clinicians should define biochemical recurrence as a detectable or rising PSA value after surgery that is ≥ 0.2 ng/ml with a second confirmatory level ≥ 0.2 ng/ml.

6. OPTION.

 

A restaging evaluation in the patient with a PSA recurrence may be considered. (Body of Evidence Strength Grade C)

7. RECOMMENDATION.

 

Physicians should offer salvage radiotherapy to patients with PSA or local recurrence after radical prostatectomy in whom there is no evidence of distant metastatic disease. (Body of Evidence Strength Grade C)

8. CLINICAL PRINCIPLE.

 

Patients should be informed that the effectiveness of radiotherapy for PSA recurrence is greatest when given at lower levels of PSA.

9. CLINICAL PRINCIPLE

 

. Patients should be informed of the possible short-term and long-term urinary, bowel, and sexual side effects of radiotherapy as well as of the potential benefits of controlling disease recurrence.

 

And finally, whose prostate cancers should be treated aggressively?  Not all cancers are the same.  Some are low grade and won’t affect longevity and others are aggressive and will.  Avoiding treatment of low grade cancers would help avoid the cost and side effects.  Presently these decisions are made based on the Gleason’s score (an estimate of aggressiveness based on the appearance under the microscope) and the number of biopsies which have cancer in them.  The following is an article from today’s New York Times which details a new genetic test which may help stratify risk in men with prostate cancer.  It’s effectiveness has yet to be proven and it is expensive costing around $3800!

May 8, 2013
New Test Improves Assessment of Prostate Cancer Risk, Study Says

A new test can help distinguish aggressive prostate cancer from less threatening ones, potentially saving many men from unneeded operations for tumors that would never hurt them, researchers are reporting.

The test, developed by Genomic Health, could triple the number of men who could confidently monitor their tumors rather than undergo surgery or radiation treatments, according to the company and to researchers.

Results of a study assessing the test’s performance will be presented Wednesday at the annual meeting of the American Urological Association in San Diego.

Many of the 240,000 cases of prostate cancer diagnosed each year in the United States are considered to pose a low risk of hurting or killing the man. But sometimes those assessments are wrong. So many men, reluctant to take the chance, undergo treatments that can cause impotence and incontinence.

“It’s very hard to tell a surgeon ‘I’d like to leave a cancer in place,’ ” said Dr. Jonathan Simons, president of the Prostate Cancer Foundation, a research and advocacy organization. “Having objective information is going to help a lot of patients make that decision.”

Dr. Simons, who was not involved in the study, said the development of new genetic tests like the one from Genomic Health represented a “watershed,” akin to going from pulse rate measurements to electrocardiograms in cardiology.

Still, some experts said it was too early to assess how accurate the test really was and whether it would make a difference in men’s decisions. Insurers are going to want to know that before deciding to pay for the test, which will be available starting Wednesday at a list price of $3,820.

Even the senior investigator of the study, Dr. Peter R. Carroll, said he was not sure.

“Certainly for a group of men it will have an impact,” Dr. Carroll, who is chairman of urology at the University of California, San Francisco, said in an interview. “The question is how many men and how many physicians.”

The new test, which is called the Oncotype DX Prostate Cancer Test, is one of more than a dozen coming to market that use advanced genetic methods to help better manage prostate cancer. The most direct competitor to the Oncotype test is likely to be the Prolaris test, introduced last year by Myriad Genetics.

But Genomic Health’s test has attracted attention because of the company’s track record. It already sells a similar test for breast cancer, also Oncotype DX, that is widely used to help women decide whether they can forgo chemotherapy after their tumor is surgically removed.

Some analysts say that with the breast cancer test facing intensified competition, the company’s future growth could hinge on the prostate test, which could take time to gain acceptance. Genomic Health’s stock closed Tuesday at $33.87, up 1 percent.

The test looks at the activity level of 17 genes in the biopsy sample and computes a score from 0 to 100 showing the risk that cancer is aggressive.

To see how well the test worked, testing was performed on archived biopsy samples from 412 patients who had what was considered low or intermediate-risk cancer but then underwent surgery.

In many such cases, the tumor, which can be closely studied after it is surgically removed, turns out to be more aggressive than thought based on the biopsy, which looks at only a tiny sample of the tumor.

The researchers found that the Oncotype test predicted such unfavorable pathology more accurately than existing methods, which depend mainly on the Gleason score based on how the biopsy sample looks under the microscope.

Genomic Health said that 26 percent of the samples were classified as very low risk by its test, compared to only 5 to 10 percent for the existing methods. In some cases, however, the new test showed the cancer to be more aggressive than the existing methods.

Some experts not involved in the study were cautiously optimistic.

“They showed a pretty good correlation with the score and how it predicts things,” said Dr. E. David Crawford, a professor of urology, surgery and radiation oncology at the University of Colorado. He has consulted for Myriad Genetics and said he might become a consultant to Genomic Health.

Dr. Stacy Loeb, assistant professor of urology at New York University, said, “I think it will help — they definitely showed it improves upon what we are using now.” She said it was not clear, however, how the Genomic Health and Myriad tests compared to each other.

 

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Doctor’s Don’t Scold

Wednesday, May 1, 2013 // Uncategorized

I can remember three patients who each lost over one hundred pounds.  I asked each one how they had done it and they each answered because they were tired of being obese and wanted to change.  I asked if there was something that I could’ve said that would have helped them come to this conclusion sooner.  they all said, “No”.  We always look for what will motivate change in our patients.  This is from the Wall Street Journal.

To Motivate Patients to Change, Doctors Stop Scolding

  • By LAURA LANDRO

Health-care providers are helping patients kick bad habits and start new regimens by turning the tables on the traditional doctor-patient relationship.

They are using a technique called motivational interviewing, which was developed and used effectively in the 1980s in substance-abuse and addiction counseling. It has since been adapted for chronic-disease management, medication adherence, smoking cessation and weight-loss counseling by health systems and companies including Aetna AET +1.41%and Weight Watchers International Inc. WTW +0.50%

Doctors are using a new untraditional strategy to help patients achieve health goals like quitting smoking or starting diet and exercise programs. Laura Landro and Healthwise founder and chief executive Donald Kemper explain. Photo: Getty Images.

Instead of telling patients what to do and scolding them when they don’t do it, clinicians ask the individual what changes he or she is willing and able to make, and then promote patients’ desire, confidence and commitment to following through.

Doctors who lecture or give scary warnings can cause patients to become defensive and disengage, says Stephen Rollnick, a professor of health-care communication at Cardiff University, in Wales, and a founder of the nonprofit Motivational Interviewing Network of Trainers, whose members provide training, coaching and consultation in 35 countries. “When people are struggling, they don’t like to be told what to do, and they dislike being labeled and blamed,” Dr. Rollnick says. Motivational interviewing “can bring patients back on board and empower them to consider difficult changes.”

In workshops and courses, doctors, nurses and health coaches are trained to collaborate with patients on treatment decisions, offering choices rather than prescriptions and avoiding terms like “must,” “should” and “have to.” They might ask patients why they think they aren’t losing weight or taking their medications properly, and they elicit goals from patients, such as being able to dance comfortably at a wedding.

While one aim is to resolve the ambivalence of patients who aren’t ready to cooperate, clinicians also learn a technique known as “roll with resistance,” which encourages small initial steps toward a goal the patient sets, such as cutting down on sweets or cigarettes a little at a time. Some programs incorporate the motivational interview into interactive online tutorials for patients at home.

[image] Brenda StarksMona White had back surgery in 2010 and began to gain back weight she had lost after a 2009 lap band procedure. “The desire to change has to come from within and you get a much better result if a person is involved in setting goals for their own recovery,” she says.

Motivational interviewing can help patients control blood pressure and diabetes, lose weight, start exercising and quit smoking, recent studies have found. A large federally funded study with sponsors including the American Academy of Pediatrics is looking at the effectiveness of motivational interviewing by pediatricians who are helping parents of obese children make progress toward a healthier diet and weight loss.

“Many doctors struggle finding the right balance between supporting patient choice and autonomy, and meeting their obligations to make informed recommendations,” says Ken Resnicow, a University of Michigan health-behavior and education researcher who is leading the pediatric study. He owns Academic Assistance, a for-profit provider of motivational health-care training based in Ann Arbor. Generally, Dr. Resnicow says, these techniques are most effective with patients “who have low energy for change and a high level of resistance.”

A major goal is to help patients resolve their own lack of commitment—such as the person who wants to quit smoking but enjoys it too much to give it up, says Chet Fox, a professor of family medicine at the University at Buffalo in New York, who works with the American Academy of Family Physicians on motivational interviewing courses.

Rather than push a person beyond what they think they can do, the technique aims to get patients to set their own minimum goals. It makes it clear they can exceed the goals at any time and encourages them to stay motivated and committed. Often, he says, it helps patients set their own more ambitious goals.

One of Dr. Fox’s patients, Mona White, had back surgery in 2010 and began to gain back the weight she had lost after a 2009 lap band procedure. The weight gain was endangering her health and made a needed knee replacement out of the question. Ms. White, getting over a breakup and feeling depressed, turned to cookies, ice cream and a peanut butter, sugar and coconut candy called Chick-O-Sticks.

A recovered addict now working as a client advocate in a mental-health court, Ms. White says her own experience with drugs and alcohol taught her “the desire to change has to come from within, and you get a much better result if a person is involved in setting goals for their own recovery.”

Try, Try Again

  • Nearly 69% of adult smokers in 2010 wanted to quit. More than 50% tried. Only 6.2% succeeded.
  • Over a six-year period, 43% of the patients in a weight-management program dropped out before achieving sustainable weight loss.
  • Overall, about 20% to 50% of patients don’t follow through on prescribed treatment and medication.

Sources: Centers for Disease Control and Prevention; Canadian Journal of Surgery; Archives of Internal Medicine

Dr. Fox suggested an easy first step to get her into the weight-loss mind set: Cut back the number of Chick-O-Sticks by one box per week. “Dr. Fox would always be encouraging, saying we are going to get the weight back off, you know what you need to do and you’ve done it before,” Ms. White says. She was motivated to do better, cutting down to three boxes from five. She has continued limiting sweets and portion sizes and says she is starting to see results.

Weight Watchers began training meeting leaders in motivational interviewing in 2005. Chief Scientific Officer Karen Miller-Kovach says leaders all have successfully lost weight, but “it doesn’t mean the choices they made will work for everyone, and this helps them with the empathy to coach others and identify solutions that are going to work for them.”

Insurers and health systems find the technique helps manage large populations with chronic illness. Aetna worked with Dr. Resnicow to train nurses who work as telephone coaches in the technique. Before its wide adoption in 2010, “we could identify where an individual was on the continuum to take action but couldn’t really motivate them or help them motivate themselves,” says Susan Kosman, chief nursing officer. More members are agreeing to participate in disease-management programs and dropouts have fallen 55%, she says.

HealthPartners, a large nonprofit health system and insurer based in Minneapolis, asks members who have an employer-sponsored wellness program to fill out a survey assessing health risks. Those at risk for diabetes or other chronic illness are contacted by a nurse or health coach, and they work together to create an improvement plan.

The plan may include a motivational-interviewing program called Conversations, developed by Healthwise, a nonprofit that designs patient-education materials. With the soothing voice of a virtual coach named Shelley, the program asks patients about weight, sleep and positive thinking. Employers may offer incentives such as a $200 reduction in a patient’s deductible. It “gives people a little push to get over the hump and get engaged,” says Nico Pronk, HealthPartners vice president of health management.

Doctors and even health coaches often have limited time, but Shelley “has all the time in the world,” says Donald Kemper, Healthwise founder and chief executive. The program helps provide patients with “empathy, clarity on the changes they want, acceptance of the limits they set and support for doing what they think they can accomplish successfully,” Mr. Kemper says.

Write to Laura Landro at [email protected]

A version of this article appeared April 30, 2013, on page D1 in the U.S. edition of The Wall Street Journal, with the headline: To Motivate Patients to Change, Doctors Stop Scolding.

 
 

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