Patient perceptions and prostate cancer treatment choices

At urology clinics in three states in the USA, prostate cancer patients were asked, after diagnosis but before treatment, about their likes and dislikes of five common treatment options. The five options were radical prostatectomy, brachytherapy, external beam radiation therapy, hormone therapy, and watchful waiting

The objective of this study by Zeliadt et al. was to assess factors that might be affecting the men’s preference for surgical as compared to non-surgical options for treatment for local-stage prostate cancer.

The patient completed a detailed survey, with the following results:

  • 198 eligible men returned the baseline survey.
  • 117/198 (59 percent) indicated they only considered surgery as an option
  • 81/198 (41 percent) considered at least one non-surgical option.
  • Patients who thought treatment efficacy was a primary concern were significantly more likely to prefer surgery only.
  • Patients with concerns about personal burdens were significantly more likely to prefer non-surgical options.
  • Advice of friends and relatives and concerns over side effects were not significantly associated with a preference for surgery versus other treatments.

It is clear from this study that patient’s perceptions about efficacy and the personal burden of treatment dominated their preferences for surgical as compared to non-surgical treatment options.

The authors further state that, “Interventions to aid treatment decision making should account for these elements to minimize the impact of physician biases and patient misperceptions on men’s decisions as how best to manage their prostate cancer.” The “New” Prostate Cancer InfoLink has not seen the actual survey questions used. However, we suspect that the use of the term “watchful waiting” is, in itself, part of the problem, and that the term “active surveillance” might have been a more appropriate choice of terminology.

There is little doubt that patients who see only a urologist have a high probability of selecting surtgery as a treatment option. The appropriateness of that decision, absent other relevant data, is harder to assess.

4 Responses

  1. Unless surgery included robot-assisted prostatectomy, I found it interesting that over 50% would opt for surgery with the risk of erectile dysfunction if the nerves are cut or damaged.

  2. Since this study is just published, and would have required minimal follow-up over time, I think it would be pretty safe to assume that the surgical option included robot-assisted laparoscopic prostatectomy, but I am not aware that RALP is any less likely to result in ED than open surgery.

  3. Was it disaggregated by age, satisfaction with personal relationships, stage of disease, etc.? If not, this really tells one nothing.

    This abstract screams “type I error.” How many of these men knew and understood the treatment bias of the urologists they were being advised by? How about a little intellectual honesty on this topic? RP is the most common treatment option because that’s the skill that most urologists in the US have. It’s their bread and butter.

    It may or may not be the most effective way to treat indolent, low-grade cancers — in fact, it almost certainly is NOT, but doing lots of them sure makes for a profitable practice … a lot more profitable than sending patients somewhere else for treatment, and more comfortable and profitable than adopting new treatment technologies that keep men fully functional.

    The term “side effects” should be banished from conversation about prostate cancer treatment. Impotence and incontinence are not side effects. They’re a direct, and in many cases, intentional — if unfortunate — components of the “treatment.”

    If the medical industry had to admit and embrace the impact of their work, we’d already have focal therapies and a culture of treatment that valued “quality of life” (can you get anymore snidely dismissive than that hateful term?) over the public health model that uses maintenance of “life expectancy” as its sole criterion for success.

    We don’t let oncology neurosurgeons get away with claiming success when a brain tumor surgery patient ends up in a permanent vegetative state — that’s not a meaningful life. So, why do we accept the utter failure of the oncologic urologists to acknowledge that they are systematically failing men by minimizing and trivializing potency and continence issues?

  4. Dear Tracy:

    At age 44, and with (apparently) a fully functional sexual ability, there is every reason to believe that your husband could and should expect to recover sexual function in well under a year after surgery (and possibly within weeks) — assuming, of course, that (a) he even has prostate cancer; (b) he can have nerve-sparing surgery if he does have prostate cancer; (c) you both decide to take a positive attitude to dealing with this problem as opposed to a negative one. Just ask some of the other 40-year-olds on the social network.

    The options for the treatment of prostate cancer today are less than wonderful. However, there are also many forms of treatment available to your husband today that would lower his risk for ED post-treatment (brachytherapy, HIFU, CyberKnife). Of course they might also increase his risk for biochemical recurrence 5 or 10 years from now. I am sure anyone would like to be able to tell you they could cure prostate cancer without any risk to erectile function, but anyone who did would be lying.

    You also have a whole other option, which is to stop pursuing a diagnosis with such passion. Have your husband go onto active surveillance, and go back to enjoying your sex life. Your husband may never have prostate cancer — or then again he may. No one can give you the cake and let you eat it too.

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