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Tran et al. They found considerable diversity among treating physicians about which side effects they felt were essential to inform patients about. In contrast, there was strong agreement about informing patients about the following side effects: osteoporosis, erectile dysfunction, hot flashes, loss of libido, and loss of muscle mass. Respondents were also surveyed about side effect management strategies [reviewed in 13 ] they recommended to patients 12 and a lack of concordance was also observed for management strategies.
Given the relative lack of agreement in the Canadian context, we sought to explore whether similar perspectives on educational practices with patients starting on ADT exist for urologists treating prostate cancer patients in other countries. We hypothesized that variation in access to healthcare, the stage at which the cancer is diagnosed, agents used for ADT, and cultural differences in physician-patient relationships would be manifested in differences between uro-oncologists in Canada versus other countries.
Here we identify such diversity and explore how these differences might influence what information physicians in the two settings feel their patients need to know. Urologists were anonymously surveyed about their perspectives on patient education regarding ADT adverse effects. Healthcare systems vary widely around the world and how medicine is practiced can be greatly influenced by economic factors. As such, countries were sorted into top, middle and bottom groups based on their per capita GDP 14 ; the top GDP countries with number of responses in brackets included: United States , Netherlands , Australia , Denmark , Ireland , Canada , Germany , United Kingdom  and France .
Not including the 4 Canadian responses, these tallied as 18, 17 and 14 respondents for high, middle, and lower GDP countries respectively. Recruitment strategies included online invitations posted by professional associations to their members, and in-person recruitment at an international urology conference held in Vancouver, BC in the fall of i. The majority of international respondents were recruited in person at the aforementioned urology congress. The most common reason for declining was a lack of efficiency in English.
Online invitations were successful for Canadian respondents and 4 international respondents only. The four additional Canadian responses collected at this conference, were added to the large sample of urologists who had previously completed the same survey in the Tran et al. Our subsequent data analysis compared these two samples. In fact, the same analyses described below, were conducted on the Canadian vs.
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The same survey used by Tran et al. Demographic variables of the respondents were also collected e.
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The first two sections of the survey contained two ranking exercises. To quantify the size of the difference of importance ranking for each individual side effect, an additional comparison was performed by applying a scoring system of 1 through 4 to each aforementioned ranking category, i. A series of chi-square tests were performed 16 in order to identify statistically significant differences between the two groups of respondents using a conservative P value cut-off of 0. To statistically evaluate the difference between the two groups of urologists in the importance they gave to telling patients about specific side effects a series of Mann-Whitney U tests were performed, using a P value of 0.
Significance was determined at P value of 0. All 41 respondents were male. The average length of practice was The average number of patients the physicians started on ADT per year was 6. The urologists from lower GDP countries ranged in age from 30 to 70 years The average number of patients the physicians started on ADT per year was 7.
Excluding these three individuals did not change the patterns of significance for any of the following analyses, so they were retained in the sample. An additional These and all other side effects examined are plotted in Figure 1.
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The side effects are arranged left to right in order from those that Canadian urologists consider most important to least important to discuss with patients starting on ADT. Side effects rated as essential or important are depicted above zero on the x-axis and those rated as not important, or a topic to be avoided, are depicted below the x-axis. ADT, androgen deprivation therapy. A gap was noticed between the side effects that were considered important and not important by urologists in the low GDP countries.
Only 4 side effects were consistently considered important to inform the patients about, by both groups of urologists: hot flashes The perceived importance of informing patients about specific ADT side effects is summarized in Table 1. Differences in importance ranking for each individual side effect, are shown in Table 2. Lower scores indicate higher importance. A comparison of the overall number of side effects determined important to tell patients about was also conducted.
Interestingly, only one side effect, infertility, was given an importance rating of larger than 3 by Canadian urologists, denoting that on average they categorize it as a topic on which to outright avoid discussion with patients. In the lower GDP countries however, 9 out of 19 ADT side effects were given an importance score of 3 or higher by the urologists.
Examples and Analogues
Table 3 and Figure 2 show ADT side effect management strategies in which significant differences in endorsement were found between urologists in Canada and urologists in lower GDP countries. Seven side effects had one or more management strategies that differed significantly between Canada and lower GDP countries Figure 2.
Comparison of strategies recommended for managing side effects of ADT between Canadian urologists and urologists from lower GDP countries. The strategies are arranged left to right in order from those that Canadian urologists endorse most to least often. The biggest differences between the two populations are in management strategies recommended for gynecomastia, followed by hot flashes and osteoporosis. Although urologists in both groups rated hot flashes as an adverse effect that is essential to discuss with patients, they do not agree on what patients might do to reduce the burden of this side effect.
For hot flashes, most pharmaceutical options are not strongly recommended in either group. But, in the lower GDP countries, the behavioral intervention, which has no cost associated with it, i. Canadian urologists do appear to endorse pharmaceuticals more than those in lower GDP countries, in the management of hot flashes This specific finding may reflect economic disparities. Though recommended strategies differ, recall that there is no difference between the two groups in how important it is to talk to patients about this side effect.
Gynecomastia is the one side effect where urologists in lower GDP countries endorsed more management strategies and offer more advice to patients, than do urologists in Canada. This suggests that gynecomastia is perceived as a more stigmatizing or burdensome condition for men in those countries than in Canada. However, it is also possible that the greater focus on gynecomastia in the lower GDP countries reflects a racial or regional difference in the prevalence of gynecomastia and concomitant mastalgia for men on ADT in those countries.
There have been documented racial differences in the prevalence of hot flashes in menopausal women 17 , 18 , though this has not yet been studied in an ADT population. For side effects such as weight gain, loss of muscle mass, osteoporosis, and elevated cholesterol one management strategy—increased physical exercise—is consistently endorsed by Canadian urologists, significantly more so than by urologists in lower GDP countries. Canadian urologists are more likely to endorse vitamin D Gender biases i.
With regards to sarcopenic obesity, Canadian urologists are far more likely to recommend exercise as a management strategy for the side effects of muscle loss and weight gain. Differences were not significant between the two analyzed groups of urologists.
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In Canada, Most urologists rarely screen their ADT patients or their partners for signs of grief and loss. Canadian urologists reported that they rarely refer their patients to counseling and, if they do, most An overview of these findings is given in Table 4. Throughout the world countries establish national guidelines for when to prescribe specific medications and there is a global consensus that some form of ADT is appropriate for treating systemic prostate cancer. The data show profound differences between the side effects that Canadian urologists consider important to discuss with patients compared to urologists in lower GDP countries.
Several factors may account for this overall difference, starting with the agents used to suppress testosterone. These drugs induce both testosterone and estrogen deprivation and have different side effect profiles than drugs that do not cause estrogen deprivation. LHRH agonists and antagonists are among the most expensive drugs licensed in Canada and are out of economic reach for many patients in lower GDP countries.
Cheaper alternative agents include the synthetic steroidal antiandrogen, cyproterone acetate, the synthetic non steroidal estrogen diethylstilbestrol, and even conjugated equine estrogen commercially sold as Premarin; pers. These cheaper agents all have estrogenic effects. Where physicians prescribe estrogenic agents for androgen suppression, gynecomastia would be expected to be a more common concern and therefore, more emphasized by the urologists.
Similarly hot flashes and osteoporosis would be less frequent in their patients and thus less heavily emphasized in their discussions with those patients. A second possibility is that there may, in fact, be substantial variation in the incidence or severity of specific side effects along both racial and regional climatic lines. Our data suggests that this could be relevant for the side effect of gynecomastia. These differences may also be present for bone density loss strategies, given the high incidence of vitamin D deficiency in Canada associated with its high latitude global position.
In comparison with lower GDP countries which are largely more equatorial citizens in those countries are more likely to have adequate sunlight exposure for the natural production of endogenous vitamin D. However at this time we are unaware of any studies documenting ADT side effect incidence and burden across racial or geographic lines.
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