Improvements in research, diagnostics and treatments for long-term conditions have inevitably lead to better survival rates. Therefore, focus is shifting to achieving optimal quality of life.
Although prostate cancer is the most common cancer among men in the UK, with 47 000 men being diagnosed every year (Clinical Services Journal, 2019), it develops gradually and usually has no signs or symptoms for many years, sometimes even decades (NHS, 2018). Diagnosis can therefore be delayed and treatment is often not immediately necessary (NHS, 2018). Once the prostate has enlarged enough to see symptoms, patients may notice an increased urge to urinate, straining while urinating or a feeling that the bladder has not been fully emptied (NHS, 2018). These symptoms do not necessarily mean a person has prostate cancer, as prostate enlargement itself can cause these symptoms, but they should not be ignored, as early stage prostate cancer can be cured by removing the prostate or via radiotherapy, either as a standalone treatment or alongside hormone therapy (NHS, 2018).
Surgery and radiotherapy come with their own side effects, which can affect a person's quality of life. For example, conventional radiotherapy delivers X-ray beams to a tumour site, but leaves radiation deposits in the surrounding tissues (Rutherford Cancer Centres, 2019) and can lead to short- and long-term effects such as diarrhoea, erectile dysfunction and rectal pain (Cancer Research UK, 2016).
For these reasons, researchers have been investigating not only therapies that may offer treatment without these side-effects, but also lifestyle interventions for men living with and beyond prostate cancer – a term becoming more frequently used as awareness, diagnosis and treatment improve.
Targeted therapy
Precision medicine takes into account individual variability in genes, environment and lifestyle. It is an emerging approach to disease prevention and treatment that is being increasingly considered as a tailored treatment option for specific types of cancer (Children with Cancer UK, 2019).
Proton beam therapy is one such treatment that was a hot topic at the recent 58th Annual Conference of the Particle Therapy Co-Operative Group in Manchester from 10–15 June. The conference is one of the biggest gatherings of oncologists and radiotherapists in the world. Although proton therapy has been used for the treatment of prostate cancer for some time (Mouw et al, 2013; Pugh et al, 2013), it was only introduced in the UK last year by the Rutherford Cancer Centre (2019) in Newport, and took centre stage at the conference with a testimony from one of the first patients in the UK to receive the treatment, Timon Colgrove, who commented:
‘Having proton beam therapy meant that I did not suffer from the grueling side effects that come with conventional treatments, which in the case of prostate cancer can be incontinency and impotency. I was able to fight the disease with minimal disruption to my life and work, which I think is a remarkable feat for anyone facing cancer.’
The theoretical benefit of proton beam therapy is that it can deliver a high dose of radiation that is much more targeted than conventional radiotherapy, and would spare the healthy surrounding structures from being potentially damaged. However, research comparing conventional radiotherapy with proton beam therapy has yielded mixed results, and it has been unclear whether this theoretical benefit converts into meaningful clinical outcomes in practice.
Last month, just before the conference, the University of Pennsylvania published a large-scale study of 14 00 patients, which concluded that the risk of side effects from toxicity to the body was two-thirds lower in people treated with proton beam therapy compared with patients receiving traditional radiation therapy (Rutherford Cancer Centres, 2019).
There is an ongoing debate about which cancers would be better treated with proton beam therapy; the NHS estimates that 1% of radical radiotherapy patients would be better treated with proton therapy, but European and North American estimates are much higher at 10–15% (Rutherford Cancer Centres, 2019).
Personalised prescription
In addition to therapies becoming increasingly targeted, prescriptions are also becoming more personalised. In a new phase II feasibility study published in the British Medical Journal reporting both quantitative and qualitative data, it has been reported that men living with prostate cancer have benefitted considerably from pharmacy lifestyle interventions, which improve cardiovascular health and increase physical activity (Lemanska et al, 2019).
Nine community pharmacy teams received training before the study to deliver a health assessment including fitness and strength testing to men living with and beyond prostate cancer (Robinson, 2019). The first intervention was attended by 116 men with prostate cancer. The intervention consisted of a personalised risk assessment considering clinical history, cardiovascular risk, strength, fitness, physical activity and diet (Robinson, 2019). An algorithm was then used to generate a personalised lifestyle prescription to each patient, accompanied by an intervention kit.
Follow-up calls were made to the patient 1 and 6 weeks post-intervention, after which a second intervention was carried out at 12 weeks. This was attended by 99 of the original 116 patients. A personalised risk assessment was repeated and followed by issue of another lifestyle prescription. This second intervention was then followed up 3 and 6 months afterwards with questionnaires, focus groups and interviews. The study found that upper limb and lower limb strength had both increased, and the participants' weight, BMI and total cholesterol fell by the second pharmacy visit (Robinson, 2019).
Prescribing outlook
As research develops and effective therapies become less toxic, patient outcomes appear more positive. Equally, as care is increasingly being carried out in communities in an effort to reduce avoidable hospital admissions and treat people closer to home, the role of non-medical prescribers will become more and more significant.
While the community intervention described was delivered by pharmacy teams, such lifestyle interventions will likely become increasingly commonplace, and other non-medical prescribers may be the ones to carry these out in the future. The study is being called an essential step towards a randomised controlled trial to test the effectiveness and cost-effectiveness of the intervention (Robinson, 2019).
Traditional radiotherapy for prostate cancer can lead to short and long-term effects such as diarrhoea, erectile dysfunction and rectal pain
Prostate cancer survival has improved considerably and has tripled in the last 4 decades largely because of more effective diagnosis, treatments and efforts to improve the day-to-day lives of the people living with and beyond prostate cancer. Enhancing patients' quality-of-life is one of the most important aspects of healthcare delivery today.
The National Institute for Health and Care Excellence (2018) recommends that people with prostate cancer who are on the hormone therapy androgen deprivation therapy, be encouraged to exercise at least twice a week for 12 weeks to reduce fatigue and improve quality of life. Non-medical prescribers can play a vital role in offering lifestyle advice such as this, providing essential information about the condition as well as its physical and mental health effects, and possibly delivering personalised interventions.