Dr. Fred Saad, MD, FRCS, is Professor and Chairman of Urology, and Director of Genitourinary Oncology at the University of Montreal Hospital Center.
Dr. Saad’s main research interests include novel therapies for advanced prostate cancer and molecular prognostic markers in prostate cancer.
Prostatepedia spoke with him about how he talks to patients about clinical trials.
What are some of the pros and cons a prostate cancer patient might want to consider before joining a clinical trial?
Dr. Fred Saad: Depending on what state or stage of the disease you’re at, it wouldn’t be a reflex of most patients to think about a clinical trial. When you’ve reached the very latest stage of the disease and you’re told there are no other options, then I think most patients would ask if there are no other options available that are standard of care, is anything going on in research. In that situation, patients are sometimes the motor: they ask their physicians about what is available and many don’t accept an answer of nothing else.
Unfortunately, in all the other stages of the disease, it is on those who face the unanswered questions of the disease every day to explain to patients the importance of answering those questions. We can only answer those questions through clinical trials.
Some of those questions come at the very beginning. Screening for prostate cancer: Who should we screen? Who should we diagnose? What should we do once we have a diagnosis? Those questions continue through to localized disease: what is the best treatment for that patient at that time? What is the best approach once a patient fails therapy?
We have clinical trials at every single step of the prostate cancer journey. It’s up to doctors to inform patients that the reason we’re still asking ourselves questions is because we don’t have all the answers. We’re going to get those answers through clinical trials. It becomes our responsibility to tell patients that clinical trials are available, that they’re of minimal risk to the patient, but could actually help him and especially help future patients.
I explain to patients that breast cancer is way ahead of prostate because of clinical trials. There are other diseases, that we’ve almost cured because of clinical trials. We’ve got a ways to go with prostate cancer, but fortunately, we’ve made a lot of progress over the last 25 years.
Why do you think clinical trial participation isn’t as common in the prostate cancer population as it is in the breast cancer population? Do you think doctors aren’t bringing up the subject with men or there is some reluctance on the part of prostate cancer patients?
Dr. Saad: When I bring up clinical trials to my patients, over 80% agree to be a part of a clinical trial. Part of that may be our way of presenting the pros and cons of a clinical trial. But some patients may be uncomfortable or unwilling to be a part of a clinical trial even if there is one that might be appropriate for him. If presented in a proper way—honestly, transparently—the vast majority of patients accept.
Unfortunately, many patients aren’t offered clinical trials, whether their physicians aren’t involved, might not be convinced of the importance of the question, or are reluctant to refer a patient to another physician.
Also, in general, men with prostate cancer are not as proactive as women with breast cancer in pushing for research and clinical trials. This has some effect on the speed at which we make progress.
There are unfortunately a lot of roadblocks that lead us to having less than 5% of patients in clinical trials. This is really unfortunate because we’ve got a lot more questions than answers in prostate cancer. It’s critical that more patients join clinical trials.
At my clinic we don’t ask why a patient is in a clinical trial, but why isn’t a patient on a clinical trial? We have to think of clinical trials every time we see a patient with prostate cancer if we want to advance our understanding of the disease as fast as possible.
Not all clinical trials would change a patient’s treatment path, per se. For example, an active surveillance or imaging study wouldn’t necessarily change paths?
Dr. Saad: Absolutely. It’s not a question of changing the patient’s treatment path. It’s about making an active effort to put patients in clinical trials. It is more work. I hear many of my colleagues say that we already do a really good job. We don’t need to put a patient in a randomized clinical trial. That’s unfortunate because it slows down the speed with which we get answers. Given the number of men with prostate cancer, we should have answered a lot of these questions a long time ago.
There are some institutions that have a long and very strong history of putting patients on clinical trials. Those institutions are the ones that are contributing a lot to our knowledge of prostate cancer. We need more physicians and centers committed.
For individual patients, a clinical trial may or may not make a huge difference, but for the patients who come after him in that same situation it will.
Clinical trials do not always imply that more is better. Sometimes in trials we do add more treatments to have a better chance at curing that patient, but sometimes we reduce the intensity of treatment to determine if outcomes are similar but with improved quality of life.
We’re learning slowly through clinical trials what are the most appropriate approaches for different scenarios.