Challenging default clinical practice for prostate cancer
Prostate cancer (PCa) was the second largest cause of cancer death among males in 2015, much of which is attributable to patients with intermediate-and-high-risk PCa where 10-year survival is as low as 25% without treatment.
Despite the prevalence, burden and human impact of the disease, one of the most effective treatment options for PCa is commonly overlooked: brachytherapy. A series of misconceptions continues to thwart uptake of the treatment, preventing many patients – intermediate-and-high-risk, young and old – from being offered a viable alternative to radical prostatectomy (RP) or external beam radiation therapy (EBRT).
Yet, for more than two decades low dose-rate brachytherapy (LDR-B) has been an established treatment for PCa. The treatment is a form of internal radiotherapy that involves the insertion of tiny radioactive seeds into the prostate gland. The radiation is targeted only at the site of the tumour – killing cancer cells without causing major damage to the healthy cells that surround them. LDR-B is an efficacious equivalent to traditional treatments, with overall survival (OS) and recurrence-free survival (RFS) rates comparable with those for RP and EBRT.
Moreover, it can yield important advantages in quality of life, convenience and patient experience. The procedure has a low complication rate, with most men able to return to normal activities within a few days.
The application of brachytherapy – along with the technologies and techniques that underpin it – has naturally evolved. One recent innovation is 4D brachytherapy, which involves a single stage, real-time implant technique that uses simple prostate measurements under ultrasound or MRi to calculate the number of seeds required for the procedure. This process offers better targeted treatment and an improved patient experience.
Another innovation has seen clinical practice progress from using LDR-B solely as a monotherapy. In the majority of countries, the treatment can now be used in combination with external beam radiotherapy in men with intermediate-and-high-risk PCa. Evidence shows that an LDR-B boost can improve health outcomes, highlighting real potential to transform clinical practice and extend treatment options for higher-risk patients.
However, despite the evidence and the opportunity, many HCPs remain cautious around the use of LDR-B. Why? Some of the answers are rooted in myths that need debunking.
Myth #1: There is no long-term data available for low dose-rate brachytherapy (LDR-B)
HCPs have pointed to the lack of long-term outcomes data for LDR-B as a major factor in their reluctance to use it. The perception is misplaced; the evidence is rich and growing.
A 2012 comparative effectiveness study by the Prostate Cancer Study Group – which evaluated over 50,000 patients with low, intermediate and high-risk PCa treated with all available primary options 3,4 – found that 95% of patients that have LDR-B treatment are disease-free at 15 years.
Furthermore, the ASCENDE-RT study – the first randomised controlled trial to compare the use of dose-escalated EBRT versus LDR-B boost in combination with EBRT in intermediate and high-risk PCa patients – showed a significant increase in biochemical RFS rates in patients treated with an LDR-B boost. The study shows that at nine years, RFS in the LDR-B arm was 83% compared to 62% in DE-EBRT boost subjects. ASCENDE-RT also revealed that patients receiving a DE-EBRT boost are twice as likely to experience biochemical failure compared to LDR-B boost.
Finally, a recent study on PCa overall survival outcomes – conducted by the Yale School of Medicine and published in the European Association of Urology in November 2017 – reports that LDR-B boost is associated with better overall survival for men with unfavourable PCa, when compared to DE-EBRT. The findings align with results from other large randomised trials that indicate the efficacy of LDR-B boost and suggest that improvements in biochemical control may translate to better overall survival with additional follow-up.
Myth #2: Young patients should not be given LDR-B
The misconception that younger patients should not be given LDR-B is not only wrong, it has far-reaching implications; despite active surveillance being the default position for low-risk cancer, as many as 70% of younger patients treated for PCa receive radical prostatectomy. The quality of life and patient experience implications are significant.
A recent study published in the New England Journal of Medicine revealed that RP has the greatest impact on sexual function and urinary continence compared to other treatments. Our own research reveals that younger patients are typically offered only one or two of the five current treatment options for PCa, with only 11% receiving advice on three or more available options. At 61%, surgery is the most widely recommended.
- Ascension and Ramsay Health Care partner on a new supply chain venture
- New archetypes are transforming healthcare, new PwC report finds
- GDPR - Is healthcare ready?
There is no reason why younger PCa patients should not be offered LDR-B, where clinically appropriate. The UK has clear NICE guidance to determine its use. Where it’s appropriate, the patient experience benefits make LDR-B an attractive option for younger patients. Studies show that the risk of incontinence after brachytherapy is far lower than in surgery and radiation. It’s also associated with shorter recovery times and reduced overall treatment time – making it less disruptive for younger patients.
Furthermore, evidence increasingly shows that there is very little – if any – survival benefit advantage between all the major treatments, including active surveillance.
Myth #3: LDR-B is only suitable for patients with low-risk prostate cancer
The recent findings of both the ASCENDE-RT and Yale School of Medicine studies blows this argument out of the water once and for all. The ASCENDE-RT study specifically focused on intermediate and high-risk patients and provides level-one evidence that an LDR-B boost in combination with EBRT is superior to DE-EBRT. The science not only revealed clear advantages in progression-free survival, it highlighted the potential for long-term cost-savings due to a reduction in treatments associated with biochemical failure. Crucially, the study showed that LDB-R boost works even for high-risk patients.
The Yale study builds on this evidence. It indicates that LDR-B boost yields better overall survival for men with unfavourable PCa when compared to DE-EBRT. Despite this, it also reveals that utilisation of LDR-B boost between 2004 and 2012 – the period of the study – actually declined. In combination – and indeed independent of each other – the ASCENDE-RT and Yale studies highlight that, for both intermediate and high-risk patients, this decline cannot be allowed to continue.
Myth #4: The side effects of LDR-B are less favourable compared to other treatments
Despite the positive findings of ASCENDE-RT, sceptics cite the study’s toxicity level data as a reason for their caution. Indeed, the study found that cumulative 5-year grade 3 urologic toxicity was significantly higher in the LDR-B group compared to the DE-EBRT group (19% vs 5%, p < 0.001). Similarly, the prevalence of late grade 3 or higher toxicity was higher in the LDR-B group (8%) compared to the DE-EBRT group (~2%).
However, brachytherapy specialist consultants believe the findings are misleading – arguing that increased GU toxicity is likely related to irregular dose planning and obsolete imaging technology, which have changed substantially in recent years.
If monitored using today’s procedures, toxicity levels would almost certainly be much lower. Equally, morbidity levels are managed more effectively today than they were at the start of the ASCENDE-RT study 10 years ago; a new clinical protocol used by treatment centres has seen the LDR-B boost change from 115Gy to 110Gy, while the prostate and seminal vesicles are treated instead of the whole pelvis.
Crucially, despite its findings being influenced by old methodologies and technologies, the ASCENDE-RT still showed that <80% of patients in the LDR group reported no or minimal GU side effects.
Myth #5: Patients who select LDR-B are not eligible for salvage treatment
On the rare occasions that recurrence occurs – and we should not forget that 95% of patients opting for LDR-B are proven to be disease-free at 15 years – surgery is a distinct possibility. There is a widespread belief that patients who opt for LDR-B are ineligible for salvage treatment should their cancer reappear. Many believe that high levels of treatment toxicity and difficulties with performing the procedure impede follow-up treatment. None of this is true.
Fundamentally, the misconception that LDR-B patients are not eligible for salvage treatment is – like all the other myths – a key factor in the limited uptake of brachytherapy. Many centres believe that if more patients realised that they could have salvage treatment should their LDR-B fail, many more would opt for it as a first choice.
There is no doubt that the evidence-base supports the greater consideration and use of LDR-B as a primary treatment option. However, common misconceptions – along with other factors such as decreases in brachytherapy training and low numbers of brachytherapy centres – have meant that many patients are not offered the option of LDR-B. This cannot continue. Too many men are missing out on the opportunity for significant improvements in quality of life and patient experience – and are instead being ushered towards a surgical procedure that is proven to have the greatest impact on sexual function and urinary continence.
The biggest barrier to wider uptake is the availability of brachytherapy services; to make LDR-B more accessible we need an increase in the number of brachytherapy centres. However, we also need a change in clinical mindset.
In a world where health systems strive to be patient-centred, many prostate cancer patients are being deprived of an effective treatment simply because their HCPs may not know enough about brachytherapy and allow their decisions to be swayed by myth. The solution is among us. If we’re to improve the quality of prostate cancer care in the UK, GPs, specialist nurses and consultants must unite as agents of change and challenge clinical practice with a shared understanding of the true benefits of brachytherapy.
How can the healthcare industry build trust with consumers?
One of the many ways the pandemic has impacted society is that it has firmly cast the healthcare industry in the public spotlight. From producing ventilators and PPE to developing life-saving vaccines, consumers have looked to pharmaceutical and healthcare companies to keep us safe and find a way out of the Covid-19 crisis.
As a result, healthcare companies have an opportunity to build upon this and utilise their marketing to drive greater engagement and trust with consumers. When it comes to effective marketing, it’s vital to remember the important role which visuals play. Consumers increasingly engage with brands through the visual communications and storytelling they absorb while online or browsing through media channels. These visual communications can have a huge impact not only on consumer purchasing decisions but also the relationship between brands and customers.
At Getty Images, we work with healthcare companies throughout Europe to advise them on their visual content. This study forms part of the research for our insight platform Visual GPS, which looks at the key factors affecting consumer decision making and how that impacts their visual choices.
In partnership with YouGov, we surveyed 10,000 consumers globally and have been tracking this consumer sentiment for the past two years. This latest deep-dive into the healthcare industry is part of our wider on-going research, and aims to better understand how consumers in different regions are interacting with the healthcare sector and what motivates their visual preferences.
Our research revealed that many companies are not using visuals as effectively as they could. In the UK, for instance, the vast majority of consumers do not feel represented by the visual communications which businesses are producing – only 7% of British respondents to our global Visual GPS survey say they felt represented. That is even lower than the global average of 14%.
This latest deep dive into the healthcare industry has uncovered some important insights that can help us better understand how consumers in different regions are interacting with the healthcare sector.
Mental health should be centre stage
A key finding shows that mental health remains a highly relevant issue for consumers. Over nine in ten British consumers think it is important to talk about mental health and put it on an equal footing with physical and emotional health. Not surprisingly, 55% of British consumers believe that more people are being diagnosed with depression due to the Covid-19 pandemic.
There is a growing awareness of the importance of mental health across Europe. Health and pharmaceutical companies should acknowledge this in their visual communications but do so in an empathetic and compassionate way. Only five years ago, visuals around mental health often depicted people alone, isolated and expressing feelings of shame, whereas now we are seeing a more empathetic and supportive approach to visualising mental health - with an increasing number of positive visuals showing support groups, or individuals proactively seeking and finding support.
Visual communications that show support for mental well-being in a meaningful way will resonate deeply with consumers.
A more holistic approach
Another key finding is that consumers want to focus more on holistic health. Our survey found that the majority of UK consumers place an almost equal importance on emotional, physical and mental health, and almost three quarters (73%) placed the health and well-being of family as a top priority.
It’s important that healthcare companies reflect this. Our research paired with ongoing image testing revealed that consumers want to see visuals that humanise healthcare, so companies should consider visualising inclusive care across intersecting factors such as age, ethnicity and gender. Brands can help establish trust with their customers by highlighting a collaborative relationship between medical professional and patient, as well as ensuring that their visual choices feel genuine.
Technology and innovation in healthcare are gaining traction
Thirdly, eHealth and purposeful innovation was another key finding. Consumers want innovation that will meaningfully support their care. Particularly in Europe, the older generation will pay more for brands that use technology to provide advice and recommendations, while Gen Z & Millennials are willing to pay for self-service capabilities. It’s important therefore for healthcare companies to incorporate purposeful innovation in their visual communication and demonstrate consumers at the centre of accessible eHealth.
Given these insights, what visual content do consumers expect to see from pharmaceutical brands? Our research highlighted three key themes.
- Consumers want to see how healthcare companies fit into people’s lives. Accessible health services are a key factor here. Decision makers should build trust by showing consumers at the centre of a holistic healthcare ecosystem.
- Consumers want to see the emotional rewards others get from using a healthcare company. This can be achieved by building brand loyalty through empathetic and inclusive visual storytelling.
- Finally, consumers want to see people who are similar to them and their lives. British consumers want to see people that look like them and reflect their lived experiences in advertising and brand communication. Decision-makers should ensure that their visual communication is inclusive and authentic and represents the diverse population of the market in which they’re operating.
Ultimately, the key to successful visual storytelling for pharma and healthcare businesses is to ensure that they understand what matters to their audience while establishing trust of care. An important element of this is authentically representing the full spectrum of the population. That means representing all ethnicities, ages, abilities, body shapes, sexuality, religion and genders, to ensure patients of all backgrounds feel included and represented.
Healthcare brands should bear in mind that, as a result of the pandemic’s impact on healthcare systems around the world, consumers may be feeling anxious about whether they will be able to access care if they need it. The healthcare industry has an opportunity to reassure customers and build greater engagement and trust by showing them that they matter through inclusive visuals that represents them authentically at the heart of brand storytelling.