Prostate cancer and treatment choices: Decision shared by doctor and patient?

When a man is diagnosed with localised prostate cancer, he usually faces a range of treatment options, from active surveillance to radiation therapy or surgical removal of the prostate. The patient's personal values and preferences should be key in this choice: Is curing the cancer the only thing that matters or should he also consider a variety of quality of life issues, such as avoiding incontinence or erectile dysfunction?

The frequent difficulty in determining the prognosis of localised prostate cancer complicates matters. Many men have low risk prostate cancer that is thought to be slowly progressing and may have no impact on their life expectancy.

The doctor must reach an agreement with the patient when making treatment decisions. However, truly shared decision-making is possible only when the patient understands what the different treatment options entail for him personally, and the doctor understands the patient's personal situation and desires.

"Such truly shared decision-making is a relatively new phenomenon in medicine. Traditionally we assumed that the doctor always knows best," says Kari Tikkinen, Academy of Finland clinical researcher and adjunct professor of clinical epidemiology from the Department of Urology at the Helsinki University Hospital.

Discussing prostate cancer diagnoses and treatment options are part of a urologist's everyday work. Tikkinen wanted to examine the impact of decision aids on the treatment decision. His international research group began to explore the issue through a systematic literature review and meta-analysis.

The meta-analysis identified 14 randomised studies that evaluated the impact of decision aids for the patient's choice of localised prostate cancer treatment. Ten of the studies were conducted in North America, three in Europe, and one in Australia. Together, the studies enrolled 3,377 patients. The average age of the participants was between 61 and 69; they represented a broad range of educational and employment backgrounds, and most were in domestic partnerships.

The most common form of decision aid provided to the patients was written information on the different treatment options. Information was also offered as videos, lectures and discussions, and in some cases, interactive computer applications. Fewer than half of the aids provided had been customised in some way to meet that specific patient's individual need for information.

The aids provided were intended for perusal prior to the clinical consultation to determine treatment. In practice, this meant that the patient bore the primary responsibility for studying and understanding the information.

The impact of the decision aids on the perceived difficulty of the decision as well as patient satisfaction and understanding varied from study to study. Use of the aids seemed to have no effect on the use of any individual treatment option, but two studies suggested a modest impact on reducing feelings of regret about the chosen treatment. The studies did not measure the impact of the decision aids on the flow of the decision process, the time spent making the decision or the costs associated with it, nor did they evaluate the impact of the use of the decision aids on the doctor-patient discussion.

"Studies in other fields of medicine indicate that separate decision aids for the clinical consultation would be beneficial. That way, doctors may ensure that patients sufficiently understand the matter at hand and map their values and choices," Tikkinen states.

According to the first author of the study, Dr. Philippe Violette from the Department of Urology, Woodstock General Hospital, Canada, "Ideally, patients would first receive an information package in the format most useful to them -- such as a booklet or an interactive computer application -- which they could then study privately or together with his loved ones and nurses before the clinical consultation. In addition, the doctor should have a concise information package available for the appointment, so the patient can revise the main points together with his doctor both visually and in writing."

For any major decision, such as choosing a robot-assisted radical prostatectomy, it is vital that the patient understands what will happen and commits to the decision. "The patient will be more committed to the decision if he is involved in it. This may also lead to better treatment results and, ultimately, to greater satisfaction among both patients and medical staff," Tikkinen points out.