Issue 46 / 8 December 2014

SOME years ago I asked a friend who had prostate cancer to provide a patient perspective for publication in a special issue of the MJA on men’s health.

He wrote a moving but ultimately optimistic article about how his diagnosis and subsequent management ricocheted through every aspect of his life, leaving him depleted and bereft before he was able to slowly begin the process of reconstructing himself.

Such accounts echo the realities of clinical care and amplify them with the particular resonance that comes from first-person narratives. However, they tend to have low priority in the academic literature, where much of what is published focuses on breaking down aspects of epidemiology, therapeutics or health care so that the role of each component can be determined without contamination.

Yet, these individual pieces of information each provide a fraction of the wider story.

It was one of this week’s MJA InSight news stories that reminded me of my friend’s article. A Canadian study published last week found that only a small proportion of men treated for prostate cancer with androgen deprivation therapy (ADT) were also prescribed a bisphosphonate. The researchers concluded that this was likely to reflect undertreatment in a group known to be at high risk of bone loss.

Interpretation of this finding proved controversial among the experts InSight approached but all agreed that it told only a small part of the complex story of caring for men with prostate cancer — a story that may include balancing the adverse effects of ADT such as depression, hot flushes, high cholesterol and cardiovascular disease, sexual dysfunction, lethargy, musculoskeletal problems and diabetes, with the survival benefits.

Leading our news section this week is an article about Australian research that points to better outcomes from cardiac valve surgery if it is performed by subspecialist surgeons. The research found marked variability in mortality among the hospital–surgeon combinations studied, with surgeons who had performed more valve procedures having lower 30-day mortality and complication rates than those with less experience.

However, Professor Paul Bannon, president of the Australian and New Zealand Society of Cardiac and Thoracic Surgeons, told InSight that surgeon volume “is often used as a crude surrogate for competency but it doesn’t tell the full story”. He said more crucial was the need for improvements to the system of care for patients with valve disease, including multidisciplinary teams to supplement and support the care provided by younger and lower-volume surgeons.

A similar message can be taken from the latest national report from the Australian and New Zealand Audit of Surgical Mortality, reported in our News in brief section. Far from being a simple measure of individual surgeon competence, the audit’s independent review of deaths associated with surgery is aimed at improving the wider system of patient care.

Another InSight news story follows up an article published in the MJA, in which the authors call for the universal availability of guidelines to help doctors determine which deaths in medical settings they must report to the coroner.

Our expert agreed that having coroner’s guidelines to explain the rules in every state would help doctors make the best of a difficult lot, in which the rules were often “just too vague to produce consistent reporting”. The bigger story, however, was the need to review and possibly harmonise the rules, so it was clear to doctors working anywhere in Australia when to get the coroner involved.

It’s an essential skill of clinical practice to place the fragments of available information into the bigger story of a patient’s life. Doing it well requires pragmatism and clear priorities.

Oncologist Paul De Souza articulated this when he told MJA InSight: “In my experience … patients benefit from ADT, because it extends their life, improves their function, allows them to work and contribute to society”, and that loss of bone density “was a small price to pay” for this gain.

Everyone’s story is different but my friend, who remained positive, grateful and optimistic until his death from prostate cancer 9 years and many rounds of therapy after his initial grim prognosis, would probably have greeted that statement with a big high five.

 

Dr Ruth Armstrong is the medical editor of MJA InSight. Find her on Twitter: @DrRuthInSight

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