When a patient with prostate cancer decides to take control
Three GPs discuss a problem presenting in general practice
Mr Jones, 75, was diagnosed with prostate cancer two years ago and had a transurethral resection of the prostate (TURP). He has attended the surgery infrequently since, requesting blood tests for PSA.
He comes today, again asking for a blood test. He tells you he is taking PC-SPES, a supplement from America. He has been spending time in the USA and obtained his capsules there. The label says they are for 'prostate health' and 'boosting the immune system'. He says that starting the capsules controlled his PSA, which was previously rising. Although the treatment is no longer available widely he has a stock and intends to take them on alternate days. He asks you to give him blood forms so he can monitor his PSA.
Dr David Morris
'Our responsibility is to look at scientific evidence and advise accordingly'
Before entering into the nitty-gritty of the consultation I would need to establish what the urological follow-up arrangements for Mr Jones are.
It is important to be clear about how advanced the prostate cancer is and what Mr Jones's understanding of his condition is. Has he received any other treatment apart from his TURP?
In particular, is he currently taking antiandrogens or receiving injections of a gonadorelin analogue (which might well account for the stabilisation of his PSA level)?
I would agree with Mr Jones that PSA measurements are a useful way to monitor control of his prostate cancer and may prompt further investigation or intervention, but I would emphasise that they should be undertaken at reasonably spaced intervals and in the context of a urological review. It may be that the next PSA test has already been appropriately arranged by the urology clinic, and if this were the case I would recommend adherence to the plan already in place.
If I felt it clinically necessary (for example a worsening of urinary symptoms or the development of bone pain) or if the next 'routine' PSA measurement was due, I would supply Mr Jones with a blood request form. If Mr Jones was not under urological review I would arrange referral.
There is an ever-increasing number of health 'supplements' available, and for the majority of them there is little evidence on safety and efficacy. Certainly there are charlatans about, very happy to accept money for unproven treatments, and this amounts to exploitation. As doctors we have a responsibility to look at the scientific evidence behind medical interventions and advise our patients accordingly.
I would admit to Mr Jones that I have never heard of PC-SPES supplements or indeed come across them in the medical literature and so could not recommend them. If he had any information on the supplements I would be happy to see it. I think it likely that Mr Jones will continue with his supplements but I would explain that I cannot prescribe them on the NHS and that when they are finished I could not supply him with any more.
Maintaining a good relationship with Mr Jones is important, as he is likely to need significant input from the practice in the future.
Dr Robert Hollingworth
'I'll ask him back and look up the supplement on the internet'
It's always easier to start off a consultation with a yes in answer to a request than a no. Asking for a blood form for a PSA test seems reasonable in the situation. The difficult part would be the issue of the supplement. But before jumping in the deep end it would seem sensible to explore his ideas, concerns and expectations about prostate cancer.
He was diagnosed with prostate cancer two years ago. We need to know what were the treatment options put to him and was any prognosis given. The information can either be gleaned from a review of his records or, as he is in front of me, from him directly. I would start from the TURP, which I presume was done for outflow obstruction: was the cancer the cause of this or was it diagnosed from the histology after the TURP?
The treatment options for non-metastatic prostate cancer are at best controversial and at worse downright confusing. It would hardly be surprising if the patient felt bewildered by the alternatives on offer and the uncertainty of their effectiveness. But he may simply not be a believer in modern medicine and may prefer to take his chances with what he feels to be a more natural option.
I have never heard of the supplement he has brought with him.
I would say so, and inquire more about it: was it recommended or prescribed by a doctor, was it prescription only or available OTC or by mail order? I am dubious about its claims. But a diplomatic approach is necessary in order to not offend and to gain the confidence of the patient.
He has belief in it, the capsules controlled his PSA, which was starting to rise, and he tells me this! It will be difficult telling him that what he is taking is potentially useless and even dangerous. In general, the absence of a product licence and grandiose claims are not a promising combination.
I would ask him to come back the next week for the result of his PSA test and would revisit the problem. In the meantime I would aim to review his notes and look up PC-SPES on the internet.
Dr Claire Pedder
'Blithely acquiescing to his request may be potentially negligent collusion'
The desire to take control of one's illness is an understandable one and I sympathise with Mr Jones's wish to do so. If his urological follow-up post-TURP has been simply conservative 'watchful waiting' with PSA monitoring and digital rectal examination, he may have felt powerless in the face of established medical wisdom and wanted to change this balance.
But I have a duty of care towards him and blithely acquiescing to his request may be potentially negligent collusion. I have several concerns that I would raise with him. The first is regarding the efficacy of PC-SPES, although I would have to acknowledge my immediate lack of knowledge of what they actually contain.
I am also concerned by the fact he underwent non-curative surgery and that his PSA has been rising since. While its use in screening has many pitfalls, measurement of levels in proven prostate cancer can be a good guide to tumour volume. Who has been measuring his PSA in the States and what have his results been? Cynically, I wonder if tiny falls in levels around a significantly elevated mean have been sold to him as proof of action of PC-SPES. My other concern is to why this supplement is no longer widely available what does he plan to do once he has run out? I doubt PC-SPES has been the subject of rigorous scientific scrutiny, though conventional medicine cannot claim any prizes here either. However, a little internet research may allow us to have a more informed discussion.
I am intrigued by his request for blood forms and would ask how he intended using these, though I would decline his request and offer PSA follow-up with myself. By now I would be overrunning, so I would suggest taking blood there and then and arrange to see him again to discuss the results. A rectal examination, plus assessment of any current prostatic symptoms and a tactful inquiry as to whether he has any symptoms suggestive of bony metastases, are required.