A Personal Perspective on Testing for Prostate Cancer - 2013

As an urologist who has subspecialized in just the area of prostate disease, I see men with prostate cancer every working day.  Every single consulting session I will see a number of men with advanced prostate cancer who are enduring either the side effects of the palliative drug treatment for advanced prostate cancer or who are battling the complications associated with advanced prostate cancer. 

In Australia, over 3,200 men die from prostate cancer each year.  This is a greater number than the women who succumb to breast cancer each year.  Irrespective of what the denominator is in terms of how many are diagnosed each year, as the second greatest cause of cancer specific deaths in men (after lung cancer), it is continues to astound me that anybody can sweep these facts under the carpet.  But to give the denominator, number of men who are diagnosed with prostate cancer in Australia each year currently sits at just under 20,000. 

It is well recognized that not all men diagnosed with prostate cancer will actually die from their cancer but will instead die from some other cause.  The majority of cancers will follow an indolent slow growing course and will never cause harm. This said, these statistics include men who in spite of dying with prostate cancer (and not from it) have significantly suffered from the effects or treatment for advanced prostate cancer or were successfully treated for prostate cancer that otherwise have lead to a prostate cancer related death.

The overzealous desire to fight prostate cancer has had significant consequences.  Many men who did not need treatment have been unnecessarily treated and of these, some have experienced complications associated with radical treatment.  This has been a huge problem and with its recognition, attempts are being made to rectify this problem.  Significant progress has been made in getting smarter about who needs treatment and also reducing the risks of complications associated with treatment.

Not all men diagnosed with prostate cancer need treatment.  There has been a major shift towards treating early stage prostate cancer conservatively by what we call active surveillance and watchful waiting.  Active surveillance differs from watchful waiting in that curative treatment has not been ruled out.  Active surveillance is a program of monitoring that attempts to strike the right balance between avoiding the overtreatment of prostate cancer yet at the same time attempting to minimize of missing any window of opportunity to deal with the cancer should it subsequently prove itself to be more aggressive than originally anticipated. Protocols for active surveillance vary but contemporary monitoring includes monitoring PSA blood test levels and periodically carrying out MRI scans of the prostate or progress biopsies.  If there is evidence that suggests that the cancer is more aggressive than originally thought or if the disease appears to have progressed, the option of treatment remains on the cards.  Watchful waiting implies that curative treatment has been ruled out and monitoring is carried out until such time that the disease progresses to justify the commencement of palliative drug treatment in the form of androgen deprivation therapy (commonly referred to as hormone therapy).

There has also been a significant improvement in side effects associated with treatment for prostate cancer.  The majority of men with very early stage prostate cancer are candidates for treatment that can spare both urinary and sexual function.  Commonly, detractors against prostate cancer testing attempt to connect urinary incontinence and erectile dysfunction as being consequential certainties associated with prostate cancer testing.

Now on the issue of PSA blood testing, there have been quite polarized views on whether it should be performed or not.   I have tried to avoid the word ‘screening’ because I think that most of us who have in the past supported this approach have moved very much towards selected testing on an individual basis where each man as an individual has the opportunity to participate in the decision to undergo testing or not.

I think that it is time that those who so vehemently oppose PSA testing should acknowledge that an entity that is the second greatest cause of cancer related death in men is a public health problem.  It is also time to stop assertions that if a PSA test is abnormal that it leads to a high risk of complications with the biopsy and that should cancer be confirmed that it some form of aggressive intervention will invariably follow.  Additionally, we have moved on from the outcomes of 20years ago in that treatment is NOT invariably associated with incontinence and erectile dysfunction.

The answer for PSA testing lies somewhere between widespread population screening and totally opposing any form of testing at all.  I am looking forward to those who have vehemently opposed any form of testing for prostate cancer to acknowledge this as well.

Concluding Comments

I am NOT in favor of indiscriminate population screening for prostate cancer.  Men should be risk assessed as to whether the benefits of making a diagnosis of prostate cancer individually outweighs the attendant risks.  Men should NOT be denied the right to participate in any discussion regarding a decision to undergo prostate cancer testing or not.  I completely disagree with any assertion that there should no discussion about prostate cancer testing unless raised by the patient.  When men are counseled on making a decision as to whether or not they wish to be tested, they should be given information that is relevant to their individual circumstances.  The Melbourne Consensus Statement on Prostate Cancer Testing is a good place to start. 

Acknowledgement:  I wish to thank Katy Hanlon for creating the images that accompany this piece.  Katy can be contacted on Twitter @khanlon 

Update on Transitioning From Open to Robotic Assisted Radical Prostatectomy

Since I first blogged on robotic surgery in July last year, it has become the predominant manner by which I perform prostate cancer surgery.  I continue to offer open surgery and particularly for those who cannot afford the cost of robotic surgery - it is important to not make them feel inadequate and that there is a reasonable alternative approach available.  Robotic surgery for prostate cancer is rapidly moving towards being the predominant manner by which prostate cancer surgery is being performed in Australia.  

Sydney had the lowest concentration of robotic platforms per capita in any of the mainland capital cities and for many years there was only one hospital with the technology.  Subsequent to a second hospital acquiring the technology and the significant marketing that followed, the dominos fell rapidly.  In the space of less than two years, there are now 7 hospitals in Sydney which now gives it the highest concentration of robotic platforms in Australia.  The competition for men to undergo robotic assisted radical prostatectomy has never been more palpable.  Many surgeons feel they are being forced into the technology on the basis of marketing pressures rather than being able to transition into the technology on their own terms. There has been a sense of urgency for surgeons to enter into the robotics space and enthusiastically offer their services and there is this sense of urgency for surgeons to announce that they have reached a certain threshold of cases or are now the most experienced with the technology for a particular geographical part of Sydney.  The tenor of competitive marketing material has lowered to include accusations of how one hospital is much more expensive than another without any factual basis to make such statements.  

One surgeon's overzealous attempts to market his services went to the extremes of misleading readers of his training credentials and true level of experience.  His marketing was excessive to the extreme that he has been formally counselled by his university and reprimanded by our professional body, the Urological Society of Australia and New Zealand.  He has also been referred to the Royal Australasian College of Surgeons for investigation of breach of its Code of Practice and to the Australian Health Practitioners Regulatory Authority for investigation of breach of advertising regulations.  Others have provided more carefully crafted glossy brochures to referring general practitioners and it is becoming increasingly common to have the addition of the term "Robotic Surgeon" to their professional stationary.  I hope that I will continue to not have to resort to these measures in order to maintain my existing sub-specialised practice in prostate surgery.  

I digress for just a moment to recount how a mentor of mine once told me when I started practice that the best advertising you could do was to look after your patients well.  In other words, your patients would be your best advertisement. Maybe this is an old fashioned approach but for as long as this still works for me, then I will consider myself fortunate.  That said, back on topic.

I feel very grateful for the fact that I have been in the position to pick and choose which patients that I felt that I could safely offer robotic surgery instead of open surgery in my hands.  This enabled me to get comfortable with doing easier cases before taking on more complex cases.  I am now comfortable with offering robotic assisted radical prostatectomy for all men for whom surgery is an appropriate option.   I have been extremely fortunate to have undergone transitioning to this technology in an era where training tools (such as the virtual reality simulator), an established technique and surgical proctoring were so readily available to me.  I am particularly grateful for my friends and colleagues Damien Bolton (Melbourne) and Peter Swindle  (Brisbane) making an effort to come to Sydney to help train me without accepting any remuneration for my over and above minimum expected proctored cases.

Robotic surgery is clearly here to stay and to be fair, the advantages of  less pain and quicker recovery have turned out to be more profound than what I had anticipated.  It was very easy to be critical of such claims when I had no personal experience with the technology and given that I had thought that my patients undergoing open surgery were doing just fine with no need improve upon this.  It has also been gratifying to see that my cancer clearance rates and recovery of continence are unchanged although I have an impression that the latter is actually better.  It is too early to know for sure of my outcomes for recovery of erectile function but my impression at this early stage is that it may in fact be better.  In spite of great anxiety and trepidation in making this transition, it is pleasing to report that my personal experience with adopting robotic surgery has turned out to be a particularly positive and exciting period of my surgical career.   My only disappointment has been the aggressive marketing and collegial fragmentation seen in association with the rapid uptake of the technology.  As one very astute GP wrote to me regarding a second opinion referral that he had sent to me: "I am concerned that the joy of a new technology and one's desire to expand their series is impacting on clinical decision making" - I sincerely hope that the race to adopt robotic surgery does not become a prostate harvesting exercise after the huge leaps forward that have been made in embracing conservative approaches such as active surveillance for those with clinically insignificant disease.  

How to Make Yourself Unpopular With the Pharmaceutical Industry

There are two drugs used for prostate treatments where potentially huge cost savings could be achieved.  Such savings will work unfavorably for the drug companies responsible for these medications in a financial sense.

The first drug is dutasteride.  This has been shown to be useful in treating lower urinary tract symptoms due to benign growth of the prostate gland.  It is generally taken at a dose of 0.5mg daily.  What few people recognize is the fact that the drug has a particularly long half life, or in other words, the time that it takes for half of the drug to be cleared from the system.  The terminal elimination half life of dutasteride is approximately 5 weeks.  This does not mean that you could take one tablet every 5 weeks as it needs to be taken often enough to achieve what we call a steady state level in the blood stream.  On a daily dose, about 90% men achieve a steady state level of the drug by 3 months.  The data however, implies that we could probably achieve adequate dosing of dutasteride at far less frequent dosing intervals.  The extent to which this is possible needs to be determined with clinical trials and we could potentially discover that dosing once a week or every two weeks might be more than sufficient.  One does not need to be a rocket scientist to understand the potential savings for a commonly prescribed drug for a hugely common condition.   Do not expect the drug company to support a study that has the potential to lead to a 90% reduction or more in earnings for the drug.  Will non-industry funding bodies support such a study?  Highly unlikely given the relative non-sexy nature of the drug and condition it treats as well as the fact that the cost is currently affordable to most individuals at around $30-35 per month.

The second drug is abiraterone.  This is a breakthrough treatment for advanced prostate cancer.  Compared to any chemotherapy agent for prostate cancer, it delivers substantial and clinically meaningful effects on disease progression and prolongs survival.  The thing that many people may not be aware about is the fact that the bioavailability of the drug is significantly enhanced by food.  Data has been collected on this with registered trial NCT01798628 (clinicaltrials.gov) that was completed in 2009 but the results do not appear to have been published in any journal on my attempt to find it on a Pubmed search.  The drug is administered on an empty stomach in the form of four 250mg tablets.  It has been anecdotally suggested that the bioavailability can be increased by anywhere between 5 to 17 fold by having the drug with a fatty meal – it is incredibly difficult to find a study to actually cite for these figures that are loosely verbally discussed at meetings.  The argument against having the drug with food is the inconsistency of absorption with a meal.  Just what if we could control how much and what food was administered at the same time?  There is clearly a potential for men to take one instead of four tablets each day in order to derive the same benefit.  This would certainly work against the efforts of the drug company who would stand to lose 75% of their income – the cost in Australia would fall from around $3000 per month to $750 per month.  Fortunately, the University of Chicago are doing a study to look at this very issue and as you would have guessed, it is being funded by the university and the National Institute of Health (NCT01543776) and not by the pharmaceutical industry.  This trial is currently in progress and the results could lead to huge cost savings for men with advanced prostate cancer.

In summary, we have two drugs for which there is the potential to deliver enormous cost savings.  One is cheap but is used on a large scale whilst the other is expensive and used on a smaller scale and it would not surprise me if it could be proven that the cost savings with both would be similar. It is certainly food for thought.

Keys to a Successful International Journal Club on Twitter

The concept of an international twitter journal club in urology arose subsequent to urologist Dr Mike Leveridge tweeting from his local real time Journal Club meeting at Queen’s University in Canada catching the attention of international colleagues who wanted to join in on the discussion.  The twitter discussion that followed, came to realization that we were actually participating in a journal club discussion on twitter and agreed that this idea was worth pursuing.  Given that the ‘uro-twitterati’ were a truly global community, we were challenged with the logistical problems of a fixed time twitter chat.  The logical solution was to use an asynchronous chat model and it was agreed that we would hold journal club meetings over a 48 hour period of time to foster international engagement.

The account @iurojc was created with the agreed hashtag #urojc and history made as the first truly global surgical journal club on twitter.   From the outset, our team of supporters were eager to see that this project was not a ‘fly by night’ operation and several measures were put in place as follows:-

• 1.     Asynchronous chat over 48 hours to enable global involvement without the constraints of time zones.  Whilst ‘international’ engagement could potentially be achieved with fixed time twitter journal club chats, it could only be achieved across a relative narrow band of time zones (eg transatlantic) 
• 2.     Cutting edge publications are selected for discussion.  Papers that are within 4 weeks of publication on line ahead of print in the major urology journals provide incentive for participants who wish to be at the forefront of latest findings and opinion.
• 3.     Engage journals to provide open access of the selected articles on line for easy access for participants.  This has been a huge benefit to participants who do not have ready access to manuscripts hidden behind a journal paywall.
• 4.     Invitation of authors to participate in the twitter discussion.  This has been an essential part of the #urojc since its inception and provides insights that conventional and SoMe journal clubs could not otherwise achieve.  What if the author does not have a twitter account or does not wish to create one?  For one author, the invitation provided the incentive to join twitter and for another, we created a guest account which was actively used for one of the discussions.
• 5.     A Best Tweet Prize is offered subsequent to each month’s discussion. We specifically do not offer donated prizes from companies offering products directly associated with the patient doctor interaction.  Our supporters are primarily entities associated with medical education, particularly the major journals in urology.  Prizes are generally valuable and include annual on-line subscriptions, fee exempt open access publication fees or free major conference registration as examples. Journal article and Best Tweet Prize winners selection are made independent of prize donors.  If a journal is supporting the Best Tweet Prize, the manuscript for discussion is intentionally selected from a different journal.
• 6.     Routine follow-back of urology followers on Twitter and following of any urologists that we become aware of.  This policy maintains an open door for feedback and suggestions without users having to request a follow for direct messaging.  Our experience with direct messaging makes clear that not all followers wish to make public their questions or suggestions.

The #urojc has now been in operation since November 2012 on a monthly basis and typically we would have 35-40 active participants with each discussion and many more watching the discussion.  The @iurojc account currently has over 600 followers.  At the recent BJU International SoMe Awards held during the American Urological Association Annual Meeting in San Diego in May 2013, the #urojc was awarded the prize for “Innovation in Social Media”.  The #urojc continues to go from strength to strength and we welcome support and collaboration from the twitter community.

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Henry Woo is the coordinator of the International Urology Journal Club on Twitter which can be followed @iurojc and his personal account can be followed @DrHWoo.  He is a urological surgeon and Associate Professor of Surgery at the Sydney Adventist Hospital Clinical School of the University of Sydney

Maintaining Composure During A Consultation

Doctors are human.  Some things we see will make us laugh when for the circumstances it is totally inappropriate.  I was recently reminded of an episode when I came close to losing all sense of professionalism during a patient consultation but survived.

A number of years ago, I saw a young man aged in his late twenties with lower urinary tract symptoms.  Although he was young, he looked much older and could easily have passed as a man aged in his mid-40s.  He had immigrated to Australia from a dispute ravaged country and probably had good reason for looking hostile and as if carrying concrete blocks of anger and despair on his shoulders.  He spoke no English and interpreter was at hand.  I think you get the scene – it was serious and we had better get on with the job of sorting him out.  Having asked a number of questions, I then asked as to whether he had any stage seen blood in his urine.  The interpreter then turned to him and spoke in his native language a question to which he gave a moderately long reply and to which followed alternating dialogue that went on for approximately five to ten minutes.  I was sat patiently expecting to hear a complex history of how he had indeed seen blood and the circumstances in which it had been observed and so forth.  The interpreter then turned to me and said “No”.  I dug the heel of my boot onto the top of toes of my other foot as hard as I could as I politely excused myself to go into the next office.  I think it took about 10 minutes to regain my composure before going back into my consulting room to complete the interview.  I think my eye contact with the young man was subsequently kept to an absolutely as needed basis.

At the end of the consultation, I did ask the interpreter about the nature of the discussion following my question about blood in the urine.  He told me that he had essentially given him an earful for not looking after himself since being in the country.  Okay.  Next patient. 

Creating One's Own Luck

I’ve been inspired to write this blog piece after seeing the wonderful Prezi presentation constructed by Dr Marni Basto on Urology Social Media 101.  It really is a fantastic presentation that has gone viral throughout the international urological community.  Although she is yet to commence formal urological training (she deferred commencement by a year to work on her Masters of Surgery), she now has an international reputation for her skill and understanding in the area of social media and associated technology.  When you look at her presentation, it is obvious that she is an individual who has great clarity of thought and able to develop depth of understanding of a given topic – these types of skills are easily translated to any area of medicine.  One can only sense that she has a bright future ahead of her. 

I’ll now move onto what her Prezi has got me thinking about.  Over the years, I have observed a number of young urologists returning to Australia after completing post FRACS (surgical qualification) training.  I commonly see this expression of despair that they cannot find a coveted public teaching hospital position, which is always the best way to kick-start a new practice in surgery.  Here you have access to multidisciplinary care, senior collegial mentorship, teaching of surgical trainees and medical students as well as research opportunities.  These positions are in limited supply and only come about when they are to replace a surgeon who has either resigned or retired or if the waters have parted to create a new position. 

Some of these young surgeons feel a sense of entitlement that they should be able to just walk into such a position.  I recall one surgeon who complained that he was a subspecialized surgeon who had done his special post fellowship training and could not understand why no teaching hospital was making any particular effort to find space for him within their units.  Another said to me that he was technically a much better surgeon than some others who had received teaching hospital appointments. When I thought about their achievements, they had not made a single presentation at a major urological meeting, had not published a single paper whilst away and since returning home, had contributed little to the profession (eg could do volunteer work or perform committee work with the Royal Australasian College of Surgeons or Urological Society of Australian and New Zealand).   

And here lies the point that people can create their own luck.  I can usually make a prediction before one of our trainees goes overseas or interstate for post FRACS training, as to who will literally walk back into a teaching hospital position. When I look at trainees who have done research with me, the ones who reliably kept to deadlines and completed their assignments were the same who did such when abroad and the same ones who eventually found positions in teaching hospitals.  These were individuals prepared to go the extra mile and create their own luck.  The trainees where I had to repeatedly provide gentle reminders to complete tasks to help their own careers have more often struggled.   The ability to create luck had already been defined early in their careers.

Back to Marni.  She has already passed the hurdles to be selected for urological training and is yet to commence whilst she does her Masters of Surgery.  You know that Marni has already begun to create her own luck and I am excited that we will have a future urologist who will be more than just ordinary.