Systematic counseling and rates of acceptance of active surveillance

According to a newly published paper in European Urology, a simple, hour-long lecture and training session can improve the ability of physicians to counsel patients systematically about active sureveillance and, at one major center, improved patient acceptance of active surveillance by as much as 17 percent.

This new paper by Ehdaie et al. discusses the development and implementation of a systematic method by which physicians can and potentially should counsel patients with very low- and low-risk prostate cancer to increase acceptance of active surveillance. The approach is based on the use of “framing techniques” that underlie principles of communication studies by negotiation scholars. The goal was to find ways to overcome perceived difficulties experienced by physicians in convincing newly diagnosed, low-risk prostate cancer patients about the merits of active surveillance and thus to avoid the tendency of many patients to unnecessarily elect immediate radical treatment for low-risk forms of prostate cancer.

There were four basic phases to this study:

  • The systematic counseling approach was initially developed by a core team of clinicians and clinical educators.
  • The approach was then piloted in one clinic by the  core team’s lead clinician.
  • After the pilot phase, five other surgeons participated at a 1-hour lecture and training session when they were also taught this systematic approach.
  • The five additional surgeons then used the systematic approach in > 240 patients counseled after the initial training session.

Here are the core findings from this study:

  • Rates of acceptance of active surveillance were 69 percent among 761 men with low-risk prostate cancer counseled at the Memorial Sloan-Kettering Cancer Center before implementation of this initiative.
  • During the pilot phase, 81/86 patients with low-risk prostate cancer (94 percent) accepted active surveillance after counseling by the physician who developed the approach.
  • During the follow-up phase, 195/242 patients with low-risk prostate cancer (81 percent) accepted active surveillance after counseling by the five newly trained physicians.
  • Of the 1,003 patients counseled during the entire 24-month program, 80 percent met Epstein criteria for very low-risk disease.
  • This change in rate of acceptance of active surveillance is a relative increase of (81 – 69)/69 = 17 percent compared to acceptance prior to training.
  • After adjustment for time trends and case mix, the rate of acceptance of active surveillance after the intervention
    • Was 9.1 percent higher than expected
    • Represented a relative reduction of approximately 30 percent in the risk for unnecessary curative treatment

Ehdaie et al. were able to show that:

  • A systematic approach to counseling can be taught to physicians in a 1-hour-long lecture and training session.
  • Even this minimal intervention can significantly decrease risk for unnecessary over-treatment.
  • Despite the fact that decisions related to cancer treatment are often guided by emotions and biases that lead most patients to seek radical treatment, …
  • Such biases can be overcome, and more patients will choose active surveillance, … if discussions about treatment choices are framed differently.

It is worth considering the ramifications of this set of findings in the context of the paper by Odom et al. on emotional distress and prostate cancer treatment choices that we discussed yesterday.

One Response

  1. Reblogged this on Northeast Georgia Urological Associates and commented:

    If your doctor has not mentioned active surveillance as an option for your prostate cancer … consider a second opinion. It may not be the best option for you but it should be mentioned for your consideration.

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