Hypothesis / aims of study
Informed consent is required for all treatment decisions. Consent can only be given by someone who has capacity for that treatment decision. So, the concepts of informed consent and capacity are core to medical practice. Consent is an expression of a person’s autonomy to make decisions about their own body and healthcare. In Ontario, this is enshrined in the Health Care Consent Act (1). Serum Prostatic Specific Antigen (PSA) is a protein that has been found useful in detecting and monitoring response to treatment in prostate cancer management. Rising serum PSA > 0.25 ug/l post-prostatectomy, is an indication for additional therapy as progression of disease and mortality increase (2) The healthcare professional recommends treatment following clear, guided informed consent process and the patient makes the decision. There is room for persuasion but coercion is forbidden.
We present a case of a 57year old gentleman with a serum PSA 4.5ug/l who chose radical prostatectomy for presumed localized disease that turned to locally advanced pathologically in addition to rising serum PSA after one year. Counselled regarding preferred/prevailing treatment options, he elected and stayed on watchful waiting for over 25 years. He had a stable life with co-morbid factors well controlled, good urinary control with highest serum PSA 14.5 ug/l Bereaved of his wife, sometime, he lived in his home with support and love of family and passed away from another malignancy from the lungs
Study design, materials and methods
A Case Study: In June, 1997, a 57year old man presented with annual serum PSA 4.5ug/l and positive family history of prostate cancer in the brother. .Co-morbid conditions include Diabetes Mellitus on Metformin 500mg BID; Rheumatoid Arthritis on Methotrexate, Hypertension , Peptic ulcer and degenerative disc disease. Mother had coronary artery disease, sister had Breast cancer and thyroid disease. Repeated serum PSA still elevated to 5.5 ug/l. Transrectal ultrasound guided prostate biopsy yielded adeno-carcinoma Gleason Grade 6/10.Staging procedures including Bone scan, Chest X-ray, CT scan abdomen and pelvis were completed. Following review of results, counseling and opportunity for second opinion, he opted for surgery. Bilateral lymph node dissection with radical prostatectomy and vesiculectomy was done. He had 7 days in hospital and satisfactory healing at home with good urinary control, and follow up serum PSA testing.
Pathology-Radical Prostatectomy: Macro: Prostate gland 25 gm; Adenocarcinoma 80% right and 20% left lobe; micro: Tumour involved base of right seminal vesicle and multifocal distal resection margin. Gleason 7/10 (3+4) T3 L0 M0. No vascular nor lymphatic invasion.7 large nodes-tumour free. Present were multi-focal prostatic intraepithelial neoplasia (PIN) and multifocal Atypical Basal cell Hyperplasia. Nodular Benign Hyperplasia (BPH) Review of pathology reports with detailed discussion of treatment options: radiation, hormonal therapy or combination or watchful waiting (2,3)was done. Consultations with 2 other urologists, a radiation oncologist and a multidisciplinary team were arranged. Patient preferred watchful waiting and surveillance in our program. He was assessed every 3 months in the first year, then every 6 months for the second and third year and thereafter once per year or as requested by patient. physical and digital rectal examination, and serum PSA By year 1 post op, the serum PSA had dropped to <0.i ug/l from the pre-op value of 4.5. Soon after this, the PSA levels rose to higher levels that raised concerns and resulted in review of his decision to stay on watchful waiting protocol. Additional consultation including reviews of all his diagnostic imaging studies and pathology specimens were obtained. We solicitated a uro-oncologist with the same ethnographic features to assess and counsel him.
As he was asymptomatic, he felt well and did not see any reason for radiation nor hormonal therapy Over the period of 25 years, the serum PSA levels varied from 0.1ug/l first year to 11.46 in the 20th and rose to 14.5 ug/l in year 25. By August 2022 , he developed bothersome pelvic and rib cage pain. This was investigated and found to be secondary to sclerotic lesions thought to be from lung metastases but the biomarkers and immunohistochemistry did not suggest prostate cancer. Last virtual urology encounter was on 06 December, 2022 There was no relief from palliative radiation. He passed on mid January 2023 about 25.5 years of watchful waiting on rising serum PSA following radical prostatectomy
Interpretation of results
This case illustrates the nuances of ethics of ‘informed consent’, ’autonomy’ and ‘beneficence’. Good communication and professionalism came into play all the way in the 25 years post prostatectomy. The value of second opinion and multidisciplinary collaboration was helpful in guiding our patient in decision making and choice of treatment. For some patients, offering an opportunity for a health care provider of similar ethnographic background to be part of then team could be helpful as was in this case.