Ted A. Skolarus, MD, MPH; and Sarah T. Hawley, PhD, MPH
Dr. Skolarus is an assistant professor and Dr. Hawley is an associate professor at the University of Michigan, Ann Arbor. Both Dr. Skolarus and Dr. Hawley are investigators at the VA HSR&D Center for Clinical Management Research, VA Ann Arbor Health Care System.
Despite the size of the veteran prostate cancer survivor population, most research documenting symptom burden and reduced QOL is from nonveterans. Because veterans often experience greater disease burden than that of the general population, their symptom burden would be expected to be similar or greater than that reported among nonveterans. Although there has been no comprehensive assessment of symptom burden across the VHA as a whole, research to understand optimal approaches to support veteran prostate cancer survivors with self- and medical management of their treatment related symptoms seems warranted.
Self-Management
Though there have been no comprehensive self-management interventions directed to help survivors limit the impact of prostate cancer treatment sequelae in everyday life, evidence suggests that such an intervention is likely to have a positive impact.37 For example, urinary symptoms can be self-managed through a variety of approaches, including emptying the bladder at regular intervals before it gets too full and pelvic floor (ie, Kegel) exercises to help decrease urinary leakage episodes. In fact, a randomized trial demonstrated a 50% decrease in incontinence episodes among prostate cancer survivors who used pelvic floor muscle training and bladder control strategies.38 A recent systematic review suggests that exercise, another self-management strategy, improves incontinence, energy level, body constitution, and QOL after treatment for prostate cancer.37 Exercise among prostate cancer survivors is also associated with decreased prostate cancer-specific and overall mortality.39
For sexual function after prostate cancer treatment, minimizing tobacco and excessive alcohol use and communicating with partners about feelings and sex are self-management strategies for improving sexual relationships.40 Avoiding spicy and greasy foods, coffee and alcohol, and staying well-hydrated may help limit the adverse bowel effects of radiation (ie, radiation proctitis) among prostate cancer survivors.41 However, there are no systematic mechanisms to share these strategies with veterans or nonveterans.
Medical Management
Recommendations for the medical management of prostate cancer-related AEs have recently been updated by the Michigan Cancer Consortium’s Prostate Cancer Action Committee and are available at www.prostatecancerdecision.org.42 Originally developed in 2009, these recommendations were directed toward the management of common posttreatment problems to minimize their impact on men who have been treated for prostate cancer, their families, caregivers, partners, and primary care providers (PCPs).
The recommendations combine expert opinion and evidence-based strategies for identifying recurrence and managing specific symptoms, including erectile dysfunction, urinary incontinence, bowel problems, hot flashes, bone health, gynecomastia, relationship issues, and metabolic syndrome. The increasing recognition that comprehensive, point-of-care resources are needed to direct survivorship care is fueling tremendous efforts targeting primary and specialty care providers from many major cancer stakeholder organizations (ie, American Cancer Society, National Comprehensive Cancer Network, etc).43-45
Primary care providers often consult prostate cancer specialists (urologists and radiation and medical oncologists) for assistance in managing prostate cancer survivors.46 However, it is not clear whether the supply of cancer specialists is capable of meeting the increasing needs of cancer survivors and their PCPs.47 VHA urologists vary tremendously in their regional availability from < 1 per 100,000 patients in Little Rock, Arkansas, to > 10 urologists per 100,000 patients in New York City.48 Similar variation exists for medical oncologists in the VHA. For prostate cancer, the urologist workforce impacts screening rates and cancer-related mortality.49,50 Yet how this workforce variation influences quality of survivorship care, particularly among PCPs dependent on specialist expertise, is unknown.
A better understanding of these relationships will help inform whether interventions to improve survivorship quality of care need to target PCPs with less access to prostate cancer specialists (eg, rural providers through telemedicine initiatives); survivorship care coordination at sites with more cancer specialists; or other potential barriers, such as knowledge gaps pertaining to AE evaluation and management. Each of these barriers to optimal care would be addressed through different interventions.
The long natural history of prostate cancer coupled with the number of survivors basically ensures that PCPs are faced with managing these men and their symptom burdens.51 However, it is often undecided who has primary responsibility for survivorship care.52,53 When queried regarding responsibility for prostate cancer survivorship care, about half of PCPs from one state-based survey felt that it was appropriate for either the cancer specialist or themselves to provide such care.12 Another study revealed high discordance among cancer specialists and PCPs regarding who should provide follow-up care, cancer screening, and general preventive care.54 Without clear role identification, poor communication between primary and specialty care fosters fragmented, expensive, and even poor quality survivorship care.55
Optimizing the delivery of survivorship care among cancer specialists and PCPs is also difficult, because comprehensive prostate cancer survivorship guidelines that might delineate responsibilities and recommend referral practices are just becoming available. In fact, the American Cancer Society just released its Prostate Cancer Survivorship Guidelines in June 2014.10,56,57 Primary care providers may be willing to take on increased responsibility for survivorship care with appropriate specialist support, including timely access to specialist evaluation.54,58 Moreover, PCPs are usually better at supporting cancer survivors’ general health as well.51,58 Therefore, defining the interface between PCPs, their medical home (ie, Patient-Aligned Care Team), and the limited supply of cancer specialists is necessary to streamline information exchange and care transitions.59
