New ACS Guide for PCPs Managing Prostate Cancer Survivors

Jenni Laidman

June 11, 2014

The American Cancer Society has issued new guidelines to help primary care physicians (PCPs) get up to speed in the management of prostate cancer survivors.

The guidance is greatly needed because the care of these men increasingly falls to PCPs.

In the United States, the number of prostate cancer survivors is approaching 2.8 million, which represents 1 in 5 of all American cancer survivors, write the guideline team, led by senior author Rebecca Cowens-Alvarado, MPH, director, Cancer Control Mission Strategy, American Cancer Society.

Oncologists cannot keep up with this ballooning population.

"There is a shrinking number of oncology providers to care for newly diagnosed patients," Cowens-Alvarado said in an interview with Medscape Medical News.

Prostate cancer patients with local or regional disease have a 5-year survival rate of nearly 100% and a 15-year survival rate of 91.4%. "So the responsibility for care is more and more provided by primary care physicians," she said.

The new guidelines are both evidence- and expert-based. They advise oncologists to provide PCPs with treatment summaries and posttreatment follow-up recommendations for prostate cancer patients.

The guidance was published online in CA: A Cancer Journal for Physicians.

Many prostate cancer survivors contend with long-term and late effects of their cancer treatment that require medical management, including the common problems of urinary incontinence, sexual dysfunction, bowel issues, adverse psychosocial effects, and relationship effects.

Notably, 20% of patients experience treatment-related regret or feelings of loss or distress.

The guidelines follow 2 Institute of Medicine reports, including one issued in 2006 entitled From Cancer Patient to Cancer Survivor: Lost in Transition , that called for clinical care guidelines for prostate cancer survivors.

The new guidelines offer clinicians advice about a wide range of issues, including recurrence surveillance. Clinicians should measure serum prostate-specific antigen (PSA) levels every 6 to 12 months for the first 5 years, then recheck annually. Survivors with elevated or rising PSA levels should be referred back to a specialist for follow-up. Also, a digital rectal examination should be performed annually.

There are also recommendations about screening for second primary cancers and assessing and managing physical and psychosocial effects of prostate cancer and its treatment ― including anemia, cardiovascular and metabolic effects, depression and anxiety, osteoporosis, sexual dysfunction and sexual intimacy, urinary dysfunction, and vasomotor symptoms. In addition, the guidelines offer advice on confronting obesity, physical inactivity, nutrition, and smoking cessation.

A PCP's management of a prostate cancer survivor should be tailored to the type of treatment the patient received.

For instance, the guidelines advise periodic monitoring for anemia for patients treated with androgen-deprivation therapy (ADT), but advise against routine treatment of asymptomatic men receiving ADT. There is some suggestion that ADT can have an effect on cardiovascular health and diabetic disease, with some studies showing increased cardiovascular mortality, although a meta- analysis failed to show a significant difference.

Another risk associated with androgen deprivation is an increased occurrence of metabolic syndrome and obesity. Further, levels of osteoporosis and the attendant risk for fracture are also associated with ADT, with several cohort studies and 1 cross-sectional study linking accelerated bone loss to treatment with ADT. Men treated with ADT have a 2-fold to 5-fold increased risk for fracture compared with men not so treated. External-beam radiation also appears to greatly raise the risk for hip fracture. Combined with ADT, the risk rises even higher.

For men receiving ADT, the guidelines recommend baseline assessments of calcium and vitamin D levels, dietary counseling, and, if necessary, supplements, in addition to bone-density scanning and a variety of therapeutic interventions.

Prostate cancer treatments are also famously associated with a decrease in sexual function.

There is no standard posttreatment approach to minimizing erectile dysfunction (ED), the guidelines note. Those at highest risk for ED are older men with preexisting ED and patients who did not undergo nerve-sparing surgery. The guidelines advise PCPs and primary treating specialists to inquire about sexual function during routine clinical care.

The guidelines note that early penile rehabilitation after surgery is controversial but may improve sexual function and prevent damage due to neurovascular injury and fibrosis. The guidelines point to phosphodiesterase type 5 (PDE-5) inhibitors such as sildenafil (Viagra, Pfizer Inc), vardenafil (Levitra, Bayer HealthCare Pharmaceuticals), and tadalafil (Cialis, Eli Lilly and Company), which may preserve smooth muscle function when administered early in recovery. The guidelines note that 2 to 4 years post surgery, some men recover erectile function. Patients who are not candidates for PDE-5 treatments may be referred to a urologist or sexual health specialist to review treatment options, including dissolvable prostaglandin pellets, prostaglandin injections, vacuum erection devices, and penile prosthesis.

In patients treated with radiation therapy, ED may not appear until 6 months to 36 months after treatment, most likely accompanying local neurovascular changes.

ADT, on the other hand, disrupts libido and erectile function, but in some patients, these effects can be alleviated with PDE-5 inhibitors or referral to a urologist to explore other options. Guideline authors say that men may wish to continue sexual activity even if physiologic desire for sex declines with ADT. Loss of erectile function, the demasculinizing effects of hormonal treatment, and bowel and urinary symptoms may all put men at increased risk for depression and anxiety; for some patients, this require a counseling referral.

More Cancer Guidance on the Way for PCPs

The prostate cancer survivorship guidelines are the first of 4 sets of guidelines that will be published in the next year, Cowens-Alvarado she said.

Later this year, Cowens-Alvarado expects that clinical care guidelines will be published for breast cancer and colorectal cancer, and by early 2015, guidelines for head and neck cancer are expected.

"We also hope to tackle gynecological cancers such as ovarian cancer, cervical cancer, endometrial cancer, and uterine cancel, as well as lung cancer and melanoma," Cowens-Alvarado told Medscape Medical News.

Many of the authors of the guidelines have financial ties to industry.

CA Cancer J Clin. Published Online June 10, 2014. Full article

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