Direct-to-consumer television ads for pharmaceuticals are supposed to target end users, but the truth of the matter is that any unassuming physician just trying to unwind in front of the tube is also a captive audience for these monotonous, hammering messages.

So it was this past Saturday that with my newly born son, Joseph Jacob (Neilly) Love, perched on my lap, I tried to enjoy the University of Miami’s Titus Pullo-like football dismembering of the University of Virginia, while being buried by a video avalanche of PDE5 inhibitor- inspired “educational” ads related to erectile dysfunction.

Fortunately, TiVo^® was on our side, and as we zipped through these and other mindless commercials without losing our focus on the U’s ground game, I was struck, even in their rapid passing, by the sheer number of messages openly promoting what used to be a very private matter.

The integration of the “ED” concept into the Western psyche over the last few years is an awe-inspiring testimonial to the power of marketing, and it seems as though we have almost reached the point of accepting erectile dysfunction as just another “parts” defect that may require medical attention. But all ED is not created equal, and nowhere is this more apparent than with the currently accepted clinical management options for men with prostate cancer.

One of the great challenges of being a physician is utilizing therapies with significant side effects and toxicities, and in prostate cancer, we encounter perhaps the most provocative and personal set of downsides that exist in current cancer and maybe even noncancer medicine.

For localized disease, the patient experience is very different for men who have their prostates removed surgically compared to those who receive some variant of radiation therapy. During this very stressful waiting game, patients who choose surgery almost universally experience complete postoperative ED, and men lucky enough to have nerve-sparing procedures wait nervously for many months or longer to see whether functional recovery occurs.

Patients who sit under the beam or seed of their friendly radiation oncologist experience a reverse waiting process as gradual vascular compromise in some or most patients eventually results in ED.

The story is even more complicated when systemic therapy enters the equation. Chemical castration results in a highly toxic internal milieu with complex sequelae including ED and loss of libido, diminished muscle and bone mass, and uncomfortable vasomotor symptoms.

Bicalutamide monotherapy, which does not result in many of these problems but does cause gynecomastia, is a largely ignored therapeutic alternative, apparently because the existing clinical research database on this fascinating agent has not sufficiently impressed clinical investigators or the FDA to make it available to patients.

With this as background, let us consider the findings from our CME group’s first national prostate cancer patterns of care study. With the expert input of Drs Adam Dicker and Mark Soloway, we designed a case-based telephone survey focused on intermediate and high-risk localized disease, PSA relapse and metastatic disease. (Our 2006 survey will be expanded to include low-risk localized disease.) In September 2005, we contracted the independent market research firm ReedHaldyMcIntosh to conduct this study, which randomly recruited 50 radiation oncologists and 100 urologists practicing in the United States.

As with our prior Patterns of Care studies in breast cancer and colorectal cancer (www.PatternsofCare.com), considerable heterogeneity is evident in the treatment recommendations made to men with prostate cancer.

What is unique about this variability is the profound difference in quality-oflife endpoints that exists with prostate cancer treatments compared to treatments for other tumors.

The findings obtained from this survey are probably not that surprising to physicians, who on a daily basis confront practice situations in which the available clinical research database does not clearly delineate the most favorable therapeutic option.

However, I predict that any patient or layperson seeing these data will take a deep breath or gasp and then strongly consider the importance of obtaining a second or third opinion when confronting this disease.

— Neil Love, MD
NLove@ResearchToPractice.net
December 8, 2005

The clinical investigator commentary in this book is from the
Prostate Cancer Update audio series (www.ProstateCancerUpdate.com).

Select publications