Status Begets Strategy: The Long View

How can physicians, patients, and patients’ families work together in a team to ensure excellent health care --- from the prevention of prostate cancer through the stages of diagnosis, evaluation, treatment, supportive care, and end of life services? This was the question Dr. Stephen Strum considered in his first presentation to the Canadian Prostate Cancer Conference held in Calgary between August 3 and August 5, 2008.

Prevention
Proactive integrative management was the focus here. Dr. Strum emphasized the integrated nature of life and the need to establish and use medical histories. In considering a man’s risk for prostate cancer, a physician should take note of

  • his genetic history (Do his parents, siblings, or other relatives have prostate cancer? Does his mother have the BRCA1 gene related to breast cancer risk?)
  • his occupational history (Has he been exposed to cadmium, Agent Orange, or extensive radiation?)
  • his overall health (Does he suffer from cardiovascular, immune, or bone health problems? Is he overweight? Does he exercise? As the body is an integrated whole, trouble in one system can point to trouble elsewhere.)
  • the medical histories of men with similar backgrounds and health conditions (What does the medical literature say about risk and preventative measures for these men, which could be applicable?)
For a useful article on taking charge of your medical records and keeping track of your medical history, see “Personal Health Records: Survival Tools.”

Diagnosis
For Dr. Strum, validity, quality, and skill are the watchwords. Important biological data, such as PSA test results and Gleason scores, should be verified. Technical equipment, medical procedures, and laboratories should be of the highest quality. And skill in physical examinations, excellence in interpreting test results and images, and objective and honest reporting should be the maxims of the medical profession.

Evaluation
A significant factor when evaluating the appropriateness or progress of any therapy is to make use of all the relevant tools and information. Dr. Strum stressed the importance of establishing baselines prior to initiating therapy. Why? These are helpful in working out biological endpoints (BEPs) --- answers to questions such as “What PSA level or bone density is our target?” --- and these endpoints aid in the assessment of treatments.

Using the wealth of medical and statistical knowledge that outlines usual responses to various treatments is also crucial. This knowledge is often presented in the form of algorithms, tables, or other statistical calculations of probable results. (See the CPCN page on prediction tools [Shan link to http://www.cpcn.org/01_prediction_tools.htm] and the article “PCATs, Partin Tables, and PTSD” for more information.) Dr. Strum recommended the forms and software made available by the Prostate Cancer Research Institute and the website entitled The Prostate Calculator.

Treatment
Again, Dr. Strum stressed the necessity of considering the context of the individual patient and his environment. His biological, philosophical, psychological, social, and economic circumstances are all crucial pieces of information, as is whether he has health conditions apart from prostate cancer. The phrase to remember: Status begets strategy. And it is important to monitor this status carefully during and after treatment so as to enable changes in strategy when these are indicated. Here, too, the biological endpoints play their part, helping to provide objective data, graph trends, and assess therapeutic efficacy.

Supportive Care
The therapeutic index (TI), or the ratio between the harmful and beneficial effects of a drug or therapy, is the prime consideration. We can view life itself (and medicine) as a two-edged sword, according to Dr. Strum. “It can either shave you or cut your throat, so the aim is to maximize the positive, and eliminate the negative.” Important considerations include
  • drug interactions
  • a patient’s individual responses to treatment and drugs, e.g., whether he has a slow metabolism
  • pharmacological multi-tasking, using one drug for multiple functions to decrease side effects and increase the therapeutic index

End of Life Services
Throughout the physician-patient relationship, “the most important aspect in the care of the patient is caring about the patient,” according to Dr. Strum. This attitude is essential when all reasonable treatment measures have been exhausted.

In the end, says Dr. Strum, “It’s all about love.” And he finished his talk, as he had begun, by taking the long view, a philosophical stance:

Out of intense complexities, these simplicities emerge. Winston Churchill