Physician influence on decision to select active surveillance

A small study from the University of Miami has confirmed the unsurprising but important information that patients are heavily influenced by physicians in their decision to elect (or not elect) active surveillance (AS) as a management option for low-risk prostate cancer.

Gorin et al. developed a survey that was designed to get their patients to “rank order” the relative importance of factors that contributed to the patients’ decisions to elect AS as opposed to other clinical options. They then mailed this survey out to 185 patients on AS and enrolled in their institutional database. The survey also asked patients to state whether AS had been offered to them as an alternative to primary treatment by the urologist who had initially diagnosed their cancer. (We should therefore be very clear that this is a cohort of patients that was either referred to or self-selected an academic prostate cancer center for a second opinion prior to making a decision about the management of their prostate cancer.)

The results of the survey were as follows:

  • 105/185 patients (57 percent) returned the completed survey.
  • AS had initially been offered to 38/105 patients (36 percent) by the physician who had made the initial diagnosis.
  • 73 percent of patients reported physician influence as the greatest contributor to their decision to elect AS.
  • Other reasons commonly reported for selecting AS included concerns regarding the potential side effects of incontinence (48 percent) and erectile dysfunction (44 percent) associated with therapy.

In their conclusions, the authors note that even this small study offers clear evidence that:

  • Patients are heavily influenced by physicians in their decision to elect AS.
  • The majority of the patients in this study were not offered AS at diagnosis.

They also state that, “Evidence has indicated that AS is an appropriate approach for low-risk prostate cancer and should be discussed with patients in this risk category.”

Even 20 years ago, Thomas Stamey, MD, in lecturing to his students and to community urologists at prostate cancer education programs, used to place great emphasis on the influence that a urologist had in guiding patients toward specific types of treatment — and the care that needed to be used in the application of that influence.

The abstract to the paper by Gorin et al. does not tell us when the patients in this study were initially diagnosed or when  they made the decision to opt for active surveillance. What we do know, however, is that there are many patients diagnosed each year with low- and very low-risk prostate cancer who are (and probably always have been) excellent candidates for careful monitoring rather than immediate invasive treatment. The role of the urologist today is most certainly to ensure that these individuals are given clear, simple, and straightforward information about the risks and benefits of AS as a management option. This is particularly important for men who — for any one of several possible reasons — have a reasonable life expectancy of less than 15 or perhaps 20 years.

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