Transcription:
Quality of Life Considerations for Patients with Metastatic Prostate Cancer

Melanie:  Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole, and I invite you to listen as we discuss quality of life considerations for patients with metastatic prostate cancer.

Joining me is Dr. Alicia Morgans. She's an associate professor of medicine in the Division of Hematology and Oncology and a member of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University. Dr. Morgans, it's a pleasure to have you join us today. Tell us some of the most important factors that would influence a patient's quality of life when they're undergoing treatment for prostate or bladder cancer.

Dr Alicia Morgans: Well, thank you so much for having me here today. I really appreciate the opportunity to speak with you about quality of life and prostate and bladder cancer, because these are things that are sometimes overlooked by family members, by physicians, and even by patients themselves, as they focus so strongly on trying to treat the cancer and sometimes forget those things that they might do that make them feel better on a day-to-day basis.

So some of the things that I think about regarding quality of life for both prostate and bladder cancer are really related to mood symptoms, things like depression, anxiety and energy symptoms, which are things that help people just have that get up and go that they need to do the tasks that they do every day.

Some of the treatments that we use for prostate and bladder cancer can actually cause depression or put people at higher risk. And these are things that we can absolutely treat as are things like anxiety. Fatigue is something that is very common that affects patients with prostate and bladder cancer and other cancers as well, which is less easily treated with things like a pill, but can be intervened upon if we encourage people to do things like exercise.

And finally, one thing that's often overlooked in many cancer patients is sexual health and sexual wellbeing, which is something that certainly affects patients with prostate and bladder cancer as well.

Melanie: Well, I appreciate you bringing up the mental health aspect of this. And it seems to me, Dr. Morgans, that the mental health aspect and the sexual health aspect really go together. And have you seen that these things sometimes even keep men from seeking help if they're worried about erectile dysfunction or incontinence or some of the side effects of treatment for prostate and bladder cancer?

Dr Alicia Morgans: Absolutely. These are very personal things and things that are not necessarily topics of conversation in general society. When we talk to our friends, we don't always even talk about mental health issues and stresses or sexual dysfunction. So these are things that just are not discussed. And so there are these barriers, especially among men who often try to be strong and stoic and really the caregivers of their families, so don't want to admit what they might consider to be a weakness. So absolutely, there are barriers particularly among patients with prostate cancer but bladder cancer as well. And these two things do go hand in hand. Mental health absolutely affects the way that people are able to think about and experience sexual health as well.

Melanie:That's certainly true. So are there specific questionnaires or tools that you use to measure patient quality of life? What do you do?

Dr Alicia Morgans: Well, that really depends on the context in which we're measuring it. In clinical trials, there are a slew of different questionnaires that target specific symptoms, side effects and diseases that we can use. Things like the FACT-P which was developed here at Northwestern, or the FACT-Bladder also developed at Northwestern. And there are also side effects that might affect people that are measured in questionnaires that are actually specific to the treatment type that we use, whether that's surgery for prostate or whether that's immunotherapy for advanced bladder cancer, for example. Those are used in clinical trials and we have separate and hopefully shorter questionnaires that we can use between clinic visits or right before a clinic visit that are integrated into our clinical practice.

Those are things that we try to get on a routine and regular basis just to help patients standardize the way that they give us feedback related to their quality of life and make sure that we identify things that we might not necessarily remember to ask about in clinic visits. And these can be done before we take vital signs or while we're getting patients ready for their visit. So there are certainly specific tools. Just the tool that you use depends on the context in which you're using it.

Melanie: Well, then tell us about your research on quality of life in patients with prostate cancer treated with chemo hormonal therapy. Tell us a little bit about your study and what you found.

Dr Alicia Morgans: So for prostate cancer patients who are initially diagnosed with metastatic prostate cancer, we learned a number of years ago that using a combination of hormonal treatments that lower testosterone and really shut prostate cancers down in addition to chemotherapy that can be toxic to the cells, the cancer cells, and hopefully obliterate them can prolong life.

And when we learned that, we wanted to understand whether that combination was not just effective in treating the cancer, but also to understand how it treated people from their perspective. How did men feel when they received that treatment? So in order to do that, we used a series of questionnaires throughout the clinical trial that asked men to answer for themselves. How are you feeling? What is your energy level? Are you having things like hot flashes or depression, urinary symptoms? And they did this over time during their treatment with their hormonal therapy alone or their hormonal therapy with the combination chemotherapy.

And what we were able to do was really track over time the patient's quality of life. And we were able to compare their quality of life between the two treatment arms. We already knew that the chemotherapy plus hormonal therapy combination was associated with a longer survival. And we found actually that at, around the one-year mark, those patients who had that same combination as compared to patients who had only the hormonal therapy actually had quality of life that was similar.

So even though they had some detriment in their quality of life or paid some price to have that more intensive therapy in the first few months, the three months or so when they were getting the chemotherapy, they actually had recovery of those symptoms and at least as good of a quality of life at a year as those patients who had just the hormonal treatment, which is generally considered to be less toxic.

So they were able to make up for that difference and they were able to have a good quality of life and better disease control, which was really important as we, as clinicians, try to make decisions with our patients on how to best move forward with treatment and to understand whether the toxicity of treatment is really worth it. And in this case, it looked like it was.

Melanie: Well then, how are you translating that to patient care? How are you incorporating what you've learned into patient reported outcomes into clinical trials? What are the implications of this research?

Dr Alicia Morgans: Well, for that research and all of the research that's been done on multiple therapeutic advances in prostate cancer, we actually talk about the effectiveness of the treatment in terms of cancer control and its effect on their quality of life when we're having these treatment conversations. Patients with prostate cancer in that particular setting, this newly diagnosed, but metastatic setting actually have access to a number of different treatment combinations.

And so understanding both the effectiveness of the treatment against the cancer itself and the way that patients are expected to feel actually helps patients sort through all these options and make a choice that's most consistent for them in terms of what they expect, what they want, the side effects they're willing to deal with and the side effects they really want to avoid.

It just provides them with more information so that they can make really informed decisions. And the more informed the decision that the patient can make, the better the patient is able to choose the best treatment for him.

Melanie: So how would you like providers to incorporate quality of life assessments into their practices? And what other strategies would you like to recommend that they implement to optimize patient quality of life?

Dr Alicia Morgans: Well, a few years ago, we actually learned that if we can ask patients how they're feeling between clinic visits, we can certainly address the symptoms that they're having. And importantly, and interestingly, the study actually found that we can help patients live longer just by addressing those symptoms that they have between visits.

What's incredible about that particular work is that the survival benefit that was identified in the study and this included patients with lung cancer and colon cancer and prostate cancer who were starting chemotherapy. What's most important is that survival benefit was actually similar to the survival benefit that is obtained by new drugs that are also approved.

So with a similar benefit in terms of survival and improvement in quality of life, this is actually the combination of the best of both worlds. We make people feel better and live longer and as much as new treatments. So accomplishing that in clinical practice is what I think we should all strive to do.

We should all strive to be connected with our patients when they need us between clinic visits, by asking them how they feel, if we can, if we have the methods to do so. And many systems are developing these methods to ask patients to complete patient-reported outcomes between visits and if we can respond to them and keep them well between visits, and certainly when we see them at visits, I think we can help them feel better and live longer.

So that's what I hope that we see. I know that systems like Northwestern are trying to do this and other systems across the country are too. And if we can continue to strive to ask patients between visits and at visits how they're doing and we help respond to their complaints, their concerns, and congratulate them when they're doing well, I think we can all improve the outcomes of patients with cancer and certainly make a difference in their lives.

Melanie: Very well said. And what an important aspect of patient care. Thank you so much, Dr. Morgans, for joining us today.

To refer your patient, please visit our website at nm.org to get connected with one of our providers. And that concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts.

I'm Melanie Cole,