Dr. Sarah Hawley is keenly interested in decision-making among cancer patients and physician-patient communication. She recently completed a study that looked at using automated voice-response technology to help veterans self-manage erectile dysfunction, urinary incontinence, bowel incontinence, and general loss of vitality after prostate cancer treatment.
Prostatepedia spoke with her about her study and its implications for men with prostate cancer.
How did you come to focus on decision-making in cancer patients? Why patient-physician education?
Dr. Sarah Hawley: I have had a long-standing interest in cancer outcomes and delivery, growing out of my doctorate program. My postdoctorate program was in the area of cancer care delivery and quality and studying access. As part of that, I became interested in how decisions that patients make, both on their own and in collaboration with their providers, influence the care they get. I noticed that even in similar health systems there were groups of patients who got different types of care. Some people get too much care; some people are not getting enough care.
I became really interested in the role that the decision-making process plays in that. Could that be a potential mechanism for improving access and outcomes for patients? Part of that is the patient-physician communication process and the patient-physician-caregiver communication process. Many patients have loved ones who join them in making these very difficult and challenging decisions.
How did you come to be working with patients from the Veterans Administration?
Dr. Hawley: I’ve been on the faculty of the University of Michigan and an investigator in the Ann Arbor Veterans Administration (VA) center for clinical management research since 2004. When I came to this position, it was a joint position. I had not worked with veterans before. I had not worked in the VA system before, but I was really excited about the chance to study communication and decision making in the Veteran population.
As part of my career over the last 10 or so years, I’ve been able to do similar projects, both within and outside of the VA, and I have looked at veterans and non-veterans. It’s been very rewarding to be able to do that in both settings.
How common is prostate cancer among veterans?
Dr. Hawley: Obviously, the veteran health system is predominantly male. Although that has been slightly changing, especially in more recent years, it still predominantly services male patients. Prostate cancer is the most common cancer in veterans. Lung cancer remains the most commonly diagnosed cancer outside the VA.
Approximately 12,000 veterans are diagnosed with prostate cancer every year. Most of those men have early-stage prostate cancer, partly because of the use of PSA screening to identify potential prostate cancer as opposed to identifying later-stage cancer, which has metastasized. This means that the patient has to make a treatment decision about how to manage his cancer: surgery, radiation therapy, or, increasingly, active surveillance, which is an active management strategy without any medical intervention. That is a complicated and difficult decision and one that veterans face daily.
Talk to us about the study you did on self-managing symptoms after prostate cancer treatment.
Dr. Hawley: To do this study, we took a jump from the decision-making side of things to the survivorship side of things. A patient who has received a cancer diagnosis—of any cancer— makes a treatment decision early on: surgery or radiation. As I mentioned, in prostate cancer there is now the option of active surveillance. Early-stage prostate cancer is very survivable. Most of the patients live and thrive into survivorship.
However, many of them have received surgery or radiation. Both of those treatments have side effects, which are very present in the first few months following treatment. A lot of these side effects remain issues for men for months, and even years, following their diagnosis. Patients then transition from that initial treatment phase into survivorship. But there’s no clear time point when that happens. They are released back into their regular follow-up care and do quite well except for these symptoms.
Programs do not really exist, either within or outside of the VA, to help men who are dealing with these long-term symptoms.
The symptoms can include urinary and sexual symptoms. They can have problems with incontinence and pain with urination. Men can have impotence. There are also some bowel problems that men experience and general health or vitality issues.
Those are the grouping of symptoms that we were interested in trying to help improve in this long-term survivorship population. Again, this is a group that hasn’t really been the target of many interventions. All of these symptoms, to some extent, can be self-managed. There is a trajectory of less serious to more serious symptoms.
One of the things that we try to do is help the patient understand when the symptom is so serious it may need a consultation with a specialist.
How was your study structured? How many patients did you have?
Dr. Hawley: We developed an intervention, which was based on some prior work that our team had done, using automated voice-response technology: you get a phone call and can interact with the phone system, not a person on the other end. We used that approach to measure symptoms using an established measure of prostate cancer symptoms. The EPIC, or the expanded prostate cancer index, is an established measure that assesses urinary, sexual, bowel, and general health.
We programmed that into an automated system and allowed men to interact with it. After that interaction, they could choose through the automated system one of the symptoms that they felt they wanted help with. We then mailed them a tailored newsletter with information about the symptom they had chosen to focus on and what they could do at home. We also included information about when it’s more important to seek specialist care.
We also had a component of the newsletter that focused on coping. Some patients deal with these symptoms for a long time. Whether we can actually improve the symptom or not, we felt it was important to offer coping strategies based on cognitive behavioral therapy.
The intervention consisted of four automated phone call assessments followed by a newsletter over a four-month period.
What did the control group get?
Dr. Hawley: They got one newsletter, which focused on general symptom self-management. Symptoms can be self-managed. Be aware of that. These are things that you can do at home. You can talk to your physician if things get worse. The newsletter wasn’t tailored to a symptom of their choice. It didn’t include the coping strategies based on behavioral therapy approaches.
What did you find?
Dr. Hawley: The overall study was a randomized control trial. We enrolled men from four VAs and randomized them online to one of those two groups. At five months, we evaluated their symptoms using the EPIC, their confidence and their ability to manage symptoms, and then some secondary outcomes related to how they viewed cancer and their outlook. What we found in the overall comparison between intervention and control arm was a slight signal in some of the intervention measures of being better than in the control measures but nothing was statistically significant.
When we did a more detailed analysis we saw a positive effect in the intervention arm in each area that men chose to focus on. That was really exciting to see.
It suggests that this intervention can be useful in helping men improve their symptoms over time. We also found that the patients themselves thought the intervention was extremely positive. We had extremely good participation and experience rates, even in the intervention arm, which did require a fair bit of work with four phone calls over four months. We had really positive reports among the participants at the end of the intervention; they found it useful and helpful.
We even found positive reports in the control arm as well. We think some of this is probably a reflection of the fact that there just is not a lot available for this population. To be offered help, and to identify that there’s a problem and that the VA is interested in trying to help support prostate cancer survivors was genuinely appreciated by all participants, even if they only received the nontailored newsletter.
What are the implications of this study?
Dr. Hawley: An intervention like this shows promise for helping improve symptoms over time if tailored to an area of focus that the patient desires to focus on. We would like to look at this in a bigger sample and match interventions, control and a choice of symptom, which we weren’t able to do in this study.
Interventions like this are very well received in prostate cancer survivors in the VA. Enrollment rates were good. Persistence with the intervention was good. Fidelity to the intervention was good. There’s a need for some kind of program for prostate cancer survivors to help them get through these debilitating symptoms.
There’s always further work to be done. We would love to continue to refine the intervention and then perhaps roll it out to some type of dissemination or implementation study to see if we could continue to see an improvement for these patients.
What do you think are the obstacles to implementing something like this across the entire Veterans Administration?
Dr. Hawley: The obstacles are the same for any system the size of the VA. It’s more of a technology system challenge, I think, which is always there for any health system. I think if it were solved, veterans would use it.
Do you have any final thoughts for patients about self-managing symptoms?
Dr. Hawley: Management of symptoms is possible. Self-management is one way to manage symptoms, and for some better than others. I encourage patients to keep having conversations with their providers if they’re not satisfied with the management that they experience.
Finally, I’d like to acknowledge the critical input of Dr. Ted Skolarus, Section Chief of Urology at the Ann Arbor VA. I would also like to acknowledge the study team in Ann Arbor, as well as the 4 study sites—the VA Ann Arbor Healthcare System, the St. Louis VA Medical Center John Cochran Division, the Louis Stokes VA Medical Center, and the VA Pittsburgh Healthcare System University Drive Division.