Why men choose specific first-line types of management for localized prostate cancer

The need for patients diagnosed with early stage prostate cancer to be highly involved in the decision as to which form of management they wish to be given is well understood. However, there has been a relative dearth of data on why patients actually make their individual decisions.

Anandadas et al. have compiled data on the management decision process from 768 British patients diagnosed with low- or intermediate-risk prostate cancer (clinical stage T1/2, Gleason score  ≤ 7, PSA level < 20 ng/ml). The men were all diagnosed and treated at one of seven different centers in the north-west of England between 2000 and 2006. 

All patients were initially counseled about their management options by a urologic surgeon, a radiation oncologist, and a specialist uro-oncology nurse. They were also provided with specially designed information leaflets on the management options available, which were: radical prostatectomy, brachytherapy, conformal beam radiation therapy, and active surveillance. A further meeting with the uro-oncology nurse was available for those having difficulty reaching a decision.

After the patients had made a management decision, they were asked to complete a baseline survey that assessed a range of pre-treatment characteristics as well as their reason for making their specific management decision. Six different reasons were offered:

  • Desire for physical removal of the tumor
  • Fear of one or more other options
  • Greater convenience for the patient’s lifestyle
  • Fear of the side effects of one or more other options
  • A combination of reasons (i.e., more than one of the four abovementioned reasons, where no one reason could be given as the ‘main reason’)
  • “Other” reasons

This is a complex study, and patients’ choices may have been affected by factors as varied as their ages, the communication skills of the counseling healthcare professionals, and a range of other factors. However, the basic results of the study were as follows:

  • 305/768 (39.7 percent) chose surgery.
  • 237/768 (31.0 percent) chose conformal beam radiation therapy.
  • 165/768 (21.0 percent) chose brachytherapy.
  • 61/768 (8.0 percent) chose active surveillance.
  • Of the men who chose surgery, 60 percent were motivated by the desire for physical removal of the tumor.
  • Conformal beam radiation therapy was chosen most commonly by patients who feared other treatments (n = 63/237 or 27 percent).
  • Brachytherapy was most commonly selected because it was perceived to be more convenient for the patient’s lifestyle (n = 64/165 or 39 percent).
  • Active surveillance was chosen for a variety of reasons, none of which stood out from the others.
  • The proportion of men selecting surgery increased between 2000 and 2003 but fell from 2003 to 2006.
  • The proportion of men selecting active surveillance appears to have increased consistently from 2000 to 2006.
  • The proportion of men selecting brachytherapy was at its highest in 2005 and 2006.
  • Men choosing conformal beam radiation therapy and active surveillance were (perhaps not surprisingly) significantly older — by an average of about 2 years — than those selecting surgery and brachytherapy.

The most striking reasons for specific decisions are clearly the belief in the need to remove the tumor entirely (as a justification for selection of surgery) and “lifestyle” as a reason for selecting brachytherapy. However, we found it interesting to note the gradual increase in the numbers of patients electing active surveillance over the time period of the study (from none of the patients enrolled in 2000 to about 25 percent of the patients enrolled in 2006). We have to assume that the counsel provided to patients at the time they were making their management choice gave a gradually increasing emphasis to the benefits of active surveillance over the 7-year period (which would reflect the increasing quality of the data demonstrating the benefits of active surveillance).

Anandadas et al. also compiled data on the “satisfaction” of a subset of 354 of their patients at 3 months, 1 year, and 2 years post-treatment. The value of these data is less compelling to us, however. Consumer satisfaction scores always tend to be high for the simple reason that, as humans, we are loath to admit that our initial decisions may have been faulty. Thus, when asked if they are “satisfied” with the cars they have purchased, drivers tend to be highly satisfied regardless of the quality of the car. We have to assume that the same is true of “satisfaction” with prostate cancer management decisions.

Perhaps more compelling are the data in answer to the question whether these patients would select the same form of treatment if they had to make the decision all over again. In considering these data it is important to note that patients who had progressive disease after first-line treatment were excluded because of the assumption that disease progression would have a negative influence on their response to this question. For what it is worth:

  • At 2 years of follow-up, 171/184 patients (92.9 percent) said they would choose the same treatment again.
  • The 13 patients who would not have chosen the same treatment were
    • One who originally chose active surveillance
    • Five who originally chose surgery
    • Seven who originally chose conformal beam radiation therapy
  • Patients who had elected brachytherapy were not asked this question.

Taken as a whole, this paper provides some interesting insights into the patient decision process in the “modern” treatment era. It also offers us a model for larger prospective studies of this type in which more data can be collected over time. It should, however, be noted that there are a number of limitations to this study, of which the most apparent is that we do not know whether all patients were actually eligible for all of the management options that were theoretically on offer. It is safe to assume, for example, that a significant percentage of the patients were probably too young to be candidates for active surveillance (based on current protocols) and that at least some patients may not have been good candidates for surgery.

2 Responses

  1. Was a four-fraction and the new single-fraction HDR brachytherapy with all its advantages part of the survey?

  2. Well the new single-fraction option certainly wasn’t (because it wouldn’t have been available), and there is no suggestion in the actual paper that any form of brachytherapy other than conventional permanent seed implantation was used.

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