Baseline Functional Status May Predict Decisional Regret Following Robotic Prostatectomy

Decision regret after prostate biopsy for prostate cancer diagnosis: a Korean multicenter cohort study

BACKGROUND

Many people struggle with the choice in a series of processes, from prostate cancer (PCa) diagnosis to treatment. We investigated the degree of regret after the prostate biopsy (PBx) and relevant factors in patients recommended for biopsy for suspected PCa.

METHODS

From 06/2020 to 05/2022, 198 people who performed PBx at three institutions were enrolled and analyzed through a questionnaire before and after biopsy. Before the biopsy, a questionnaire was conducted to evaluate the sociodemographic information, anxiety scale, and health literacy, and after PBx, another questionnaire was conducted to evaluate the decision regret scale. For patients diagnosed as PCa after biopsy, a questionnaire was conducted when additional tests were performed at PCa staging work-up.

RESULTS

190 patients answered the questionnaire before and after PBx. The mean age was 66.2 ± 7.8 years. Overall, 5.5% of men regretted biopsy, but there was no significant difference between groups according to the PCa presence. Multivariate analysis, to identify predictors for regret, revealed that the case when physicians did not properly explain what the prostate-specific antigen (PSA) test was like and what PSA elevation means (OR 20.57, [95% CI 2.45-172.70], p = 0.005), low media literacy (OR 10.01, [95% CI 1.09-92.29], p = 0.042), and when nobody to rely on (OR 8.49, [95% CI 1.66-43.34], p = 0.010) were significantly related.

CONCLUSIONS

Overall regret related to PBx was low. Decision regret was more significantly related to media literacy rather than to educational level. For patients with relatively low media literacy and fewer people to rely on in case of serious diseases, more careful attention and counseling on PBx, including a well-informed explanation on PSA test, is helpful.

Influential Factors Impacting Treatment Decision-making and Decision Regret in Patients with Localized or Locally Advanced Prostate Cancer: A Systematic Literature Review

CONTEXT

Treatment decision-making (TDM) for patients with localized (LPC) or locally advanced (LAPC) prostate cancer is complex, and post-treatment decision regret (DR) is common. The factors driving TDM or predicting DR remain understudied.

OBJECTIVE

Two systematic literature reviews were conducted to explore the factors associated with TDM and DR.

EVIDENCE ACQUISITION

Three online databases, select congress proceedings, and gray literature were searched (September 2022). Publications on TDM and DR in LPC/LAPC were prioritized based on the following: 2012 onward, ≥100 patients, journal article, and quantitative data. The Preferred Reporting Items Reviews and Meta-analyses guidelines were followed. Influential factors were those with p < 0.05; for TDM, factors described as "a decision driver", "associated", "influential", or "significant" were also included. The key factors were determined by number of studies, consistency of evidence, and study quality.

EVIDENCE SYNTHESIS

Seventy-five publications (68 studies) reported TDM. Patient participation in TDM was reported in 34 publications; overall, patients preferred an active/shared role. Of 39 influential TDM factors, age, ethnicity, external factors (physician recommendation most common), and treatment characteristics/toxicity were key. Forty-nine publications reported DR. The proportion of patients experiencing DR varied by treatment type: 7-43% (active surveillance), 12-57% (radical prostatectomy), 1-49% (radiotherapy), 28-49% (androgen-deprivation therapy), and 21-47% (combination therapy). Of 42 significant DR factors, treatment toxicity (sexual/urinary/bowel dysfunction), patient role in TDM, and treatment type were key.

CONCLUSIONS

The key factors impacting TDM were physician recommendation, age, ethnicity, and treatment characteristics. Treatment toxicity and TDM approach were the key factors influencing DR. To help patients navigate factors influencing TDM and to limit DR, a shared, consensual TDM approach between patients, caregivers, and physicians is needed.

PATIENT SUMMARY

We looked at factors influencing treatment decision-making (TDM) and decision regret (DR) in patients with localized or locally advanced prostate cancer. The key factors influencing TDM were doctor's recommendation, patient age/ethnicity, and treatment side effects. A shared, consensual TDM approach between patients and doctors was found to limit DR.

Patient-reported Satisfaction and Regret Following Focal Therapy for Prostate Cancer: A Prospective Multicenter Evaluation

Background

Several reports are available regarding the treatment decision regret of patients receiving conventional treatments for localized prostate cancer (PCa); yet data on patients undergoing focal therapy (FT) are sparse.

Objective

To evaluate the treatment decision satisfaction and regret among patients who underwent FT for PCa with high-intensity focused ultrasound (HIFU) or cryoablation (CRYO).

Design setting and participants

We identified consecutive patients who underwent HIFU or CRYO FT as the primary treatment for localized PCa at three US institutions. A survey with validated questionnaires, including the five-question Decision Regret Scale (DRS), International Prostate Symptom Score (IPSS), and International Index of Erectile Function (IIEF-5), was mailed to the patients. The regret score was calculated based on the five items of the DRS, and regret was defined as a DRS score of >25.

Outcome measurements and statistical analysis

Multivariable logistic regression models were applied to assess the predictors of treatment decision regret.

Results and limitations

Of 236 patients, 143 (61%) responded to the survey. Baseline characteristics were similar between responders and nonresponders. During a median (interquartile range) follow-up of 43 (26-68) mo, the treatment decision regret rate was 19.6%. On a multivariable analysis, higher prostate-specific antigen (PSA) at nadir after FT (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.1-2, p = 0.009), presence of PCa on follow-up biopsy (OR 3.98, 95% CI 1.5-10.6, p = 0.006), higher post-FT IPSS (OR 1.18, 95% CI 1.01-1.37, p = 0.03), and newly diagnosed impotence (OR 6.67, 95% CI 1.57-27, p = 0.03) were independent predictors of treatment regret. The type of energy treatment (HIFU/CRYO) was not a predictor of regret/satisfaction. Limitations include retrospective abstraction.

Conclusions

FT for localized PCa is well accepted by the patients, with a low regret rate. Higher PSA at nadir, presence of cancer on follow-up biopsy, bothersome postoperative urinary symptoms, and impotence after FT were independent predictors of treatment decision regret.

Patient summary

In this report, we looked at the factors affecting satisfaction and regret in patients with prostate cancer undergoing focal therapy. We found that focal therapy is well accepted by the patients, while presence of cancer on follow-up biopsy as well as bothersome urinary symptoms and sexual dysfunction can predict treatment decision regret.

Decisional Regret Among Patients Undergoing Colectomy

BACKGROUND

Patients undergoing colectomy may be at risk for postoperative regret, which is associated with worse quality of life, higher rates of depression, and poorer health outcomes. A better understanding of factors associated with decisional regret may allow surgeons to better tailor preoperative discussions to mitigate the risk of regret.

OBJECTIVE

This study aimed to identify factors associated with regret in patients undergoing elective and urgent/emergent colectomy.

DESIGN

A retrospective cohort study.

SETTING

The Michigan Surgical Quality Collaborative, a 73-hospital collaborative, which collects clinical data on general surgery operations.

PATIENTS

Patients aged >18 years who underwent elective or urgent/emergent colectomy between January 2017 and March 2020 and who completed a decision regret survey.

MAIN OUTCOME MEASURES

Any degree of postoperative regret.

RESULTS

Of 3638 patients, 2,530 (70%) underwent elective and 1108 (30%) underwent urgent/emergent colectomy. Overall, 381 (10.5%) patients reported regret, with higher rates among the urgent/emergent setting compared with the elective cohort (13.0% vs 9.4%; p < 0.001). In the elective cohort, regret was associated with length of stay >7 days (OR, 2.32; 95% CI, 1.06-5.07), postoperative complication (OR, 1.95; 95% CI, 1.36-2.79), and readmission (OR, 1.90; 95% CI, 1.22-2.95). Elective colectomies for cancer/adenoma/polyp were associated with lower odds of regret (OR, 0.68; 95% CI, 0.50-0.91). In the urgent/emergent cohort, regret was associated with female sex (OR, 1.69; 95% CI, 1.15-2.50) and nonhome discharge destination (OR, 1.61; 95% CI, 0.04-1.03).

LIMITATIONS

Hospitals used different sampling strategies, limiting our ability to calculate a true response rate and characterize nonresponders.

CONCLUSIONS

One in 10 patients reported regret after colectomy with higher rates in those undergoing urgent/emergent colectomy. Factors associated with regret were different between surgical settings. Efforts are needed to mitigate patients' risk of regret with individualized discussions contingent on surgical settings to better align expectations and outcomes. See Video Abstract at http://links.lww.com/DCR/C3 .

ARREPENTIMIENTO DEL PACIENTE EN LA DECISIN DE SOMETIMIENTO A COLECTOMA

ANTECEDENTES:Los pacientes que se someten a una colectomía pueden estar en riesgo de arrepentimiento post operatorio, la cual está asociada con una peor calidad de vida, mayores tasas de depresión y peores resultados de salud. Una mejor comprensión de los factores asociados con el arrepentimiento de dicha decisión, puede permitir a los cirujanos adaptar de una mejor manera las discusiones preoperatorias y así mitigar el riesgo de arrepentimiento.OBJETIVO:Identificar factores asociados al arrepentimiento en pacientes sometidos a colectomía electiva y urgente/emergente.DISEÑO:Estudio de cohorte retrospectivo.ESCENARIO:The Michigan Surgical Quality Collaborative, una colaboración de 73 hospitales.PACIENTES:Pacientes ≥18 años sometidos a colectomía electiva o urgente/emergente entre enero de 2017 y marzo de 2020, y que hayan completado una encuesta de arrepentimiento en cuanto a la decisión.PRINCIPALES MEDIDAS DE RESULTADO:Reporte de cualquier grado de arrepentimiento postoperatorio.RESULTADOS:De 3.638 pacientes, 2.530 (70%) fueron sometidos a colectomía electiva y 1.108 (30%) a colectomía urgente/emergente. En general, 381 (10,5%) pacientes informaron arrepentimiento, con tasas más altas en el grupo relacionado con el escenario urgente/emergente en comparación con la cohorte electiva (13,0% frente a 9,4%, p < 0,001). En la cohorte electiva, el arrepentimiento se asoció con una estancia hospitalaria >7 días (OR 2,32, IC 95% 1,06-5,07), complicación posoperatoria (OR 1,95, IC 95% 1,36-2,79) y reingreso (OR 1,90, IC 95% 1,22-2,95). Las colectomías electivas por cáncer/adenoma/pólipo se asociaron con una menor probabilidad de arrepentimiento (OR 0,68, IC 95%: 0,50-0,91). En la cohorte urgente/emergente, el arrepentimiento se asoció con el sexo femenino (OR 1,69, IC 95% 1,15-2,50) y el destino del alta no domiciliario (OR 1,61, IC 95% 0,04-1,03).LIMITACIONES:Los hospitales utilizaron diferentes estrategias de muestreo, lo que limita nuestra capacidad para calcular una tasa de respuesta real y caracterizar a los que no respondieron.CONCLUSIONES:Uno de cada diez pacientes reportó arrepentimiento después de la colectomía con tasas más altas en aquellos sometidos a colectomía urgente/emergente. Los factores asociados con el arrepentimiento fueron diferentes entre los entornos quirúrgicos. Se necesitan esfuerzos para mitigar el riesgo de arrepentimiento de los pacientes con discusiones individualizadas supeditadas al entorno quirúrgico para caracterizar de una mejor las expectativas y los resultados. Consulte Video Resumen en http://links.lww.com/DCR/C3 . (Traducción-Dr. Osvaldo Gauto).

Patients Regret Their Choice of Therapy Significantly Less Frequently after Robot-Assisted Radical Prostatectomy as Opposed to Open Radical Prostatectomy: Patient-Reported Results of the Multicenter Cross-Sectional IMPROVE Study

Patient’s regret (PatR) concerning the choice of therapy represents a crucial endpoint for treatment evaluation after radical prostatectomy (RP) for prostate cancer (PCA). This study aims to compare PatR following robot-assisted (RARP) and open surgical approach (ORP). A survey comprising perioperative-functional criteria was sent to 1000 patients in 20 German centers at a median of 15 months after RP. Surgery-related items were collected from participating centers. To calculate PatR differences between approaches, a multivariate regressive base model (MVBM) was established incorporating surgical approach and demographic, center-specific, and tumor-specific criteria not primarily affected by surgical approach. An extended model (MVEM) was further adjusted by variables potentially affected by surgical approach. PatR was based on five validated questions ranging 0−100 (cutoff >15 defined as critical PatR). The response rate was 75.0%. After exclusion of patients with laparoscopic RP or stage M1b/c, the study cohort comprised 277/365 ORP/RARP patients. ORP/RARP patients had a median PatR of 15/10 (p < 0.001) and 46.2%/28.1% had a PatR >15, respectively (p < 0.001). Based on the MVBM, RARP patients showed PatR >15 relative 46.8% less frequently (p < 0.001). Consensual decision making regarding surgical approach independently reduced PatR. With the MVEM, the independent impact of both surgical approach and of consensual decision making was confirmed. This study involving centers of different care levels showed significantly lower PatR following RARP.

Evaluation of Older Age and Frailty as Factors Associated With Depression and Postoperative Decision Regret in Patients Undergoing Major Head and Neck Surgery

Importance

Clinicians should understand the prevalence of depression and decision regret in patients with head and neck cancer and whether these factors differ with age or frailty.

Objectives

To assess whether age and frailty are associated with preoperative and/or worsening postoperative depression and postoperative decision regret in patients undergoing major head and neck surgery and to identify additional factors associated with depression and decision regret.

Design, Setting, and Participants

This prospective cohort study was conducted at a single institution, with patients aged 50 years or older undergoing major head and neck surgery recruited from December 1, 2011, to April 30, 2014. Statistical analysis was performed from July 1, 2018, to June 30, 2019.

Main Outcomes and Measures

Frailty, functional, and geriatric depression assessments were completed before surgery and 3, 6, and 12 months after surgery. Decision regret assessment was completed 6 months after surgery. The prevalence of depression and decision regret was determined by age group. Change in depression over time was compared between age groups using a linear-effects model. Variables potentially associated with moderate to severe depression and decision regret were analyzed using a logistic regression model.

Results

The study included 274 patients (68 women and 206 men; mean [SD] age, 67.8 [9.5] years). Of these, 105 (38.3%) were 50 to 64 years of age and 169 (61.7%) were 65 years or older. The rate of preoperative moderate to severe depression was 9.6% (21 of 219), with no difference between younger and older adult cohorts. For both age groups, depression scores increased in the postoperative period from baseline to 6 months. At 12 months, there was a difference in depression scores between the younger and older adult cohort (4.8 [4.6] vs 3.1 [3.6]). A higher preoperative Fried Frailty Index score (odds ratio, 2.58 [95% CI, 1.63-4.06]) was associated with preoperative moderate to severe depression. For all patients, the mean Decision Regret Scale score was 18.2 (range, 0-95), and 26.7% of patients (48 of 180) had moderate to severe regret. There was no difference in Decision Regret Scale scores between younger and older patients. Preoperative depression but not frailty is associated with postoperative moderate to severe decision regret (odds ratio, 1.17 [95% CI, 1.06-1.28]).

Conclusions and Relevance

In this cohort study, there was no difference based on age in the prevalence of moderate to severe depression or decision regret. A higher preoperative frailty score was associated with depression but not decision regret. Preoperative depression was the only factor associated with moderate to severe decision regret on multivariate analysis. Understanding the prevalence of and factors associated with moderate to severe depression and decision regret may aid in identifying patients who would benefit from more extensive preoperative counseling and preoperative and postoperative multispecialty assessment and treatment.

Preoperative exercise interventions to optimize continence outcomes following radical prostatectomy

Urinary incontinence is a common and predictable consequence among men with localized prostate cancer who have undergone radical prostatectomy. Despite advances in the surgical technique, urinary continence recovery time remains variable. A range of surgical and patient-related risk factors contributing to urinary incontinence after radical prostatectomy have been described, including age, BMI, membranous urethral length and urethral sphincter insufficiency. Physical activity interventions incorporating aerobic exercise, resistance training and pelvic floor muscle training programmes can positively influence the return to continence in men after radical prostatectomy. Traditional approaches to improving urinary continence after radical prostatectomy have typically focused on interventions delivered during the postoperative period (rehabilitation). However, the limited efficacy of these postoperative approaches has led to a shift from the traditional reactive model of care to more comprehensive interventions incorporating exercise-based programmes that begin in the preoperative period (prehabilitation) and continue after surgery. Comprehensive prehabilitation interventions include appropriately prescribed aerobic exercise, resistance training and specific pelvic floor muscle instruction and exercise training programmes. Transperineal ultrasonography is a non-invasive and validated method for the visualization of the action of the pelvic floor musculature, providing real-time visual biofeedback to the patient during specific pelvic floor muscle instruction and training. Importantly, the waiting time before surgery can be used for the delivery of comprehensive prehabilitation exercise-based interventions to increase patient preparedness in the lead-up to surgery and optimize continence and health-related quality-of-life outcomes following radical prostatectomy.

Patient Satisfaction and Regret After Robot-assisted Radical Prostatectomy: A Decision Regret Analysis

OBJECTIVE

To assess treatment satisfaction and decision regret post robot-assisted radical prostatectomy (RARP) and correlate these with clinical, demographic and quality of life indicators. Our study took place at a high-volume United Kingdom center and patients were assessed at a minimum of 18 months postsurgery.

METHODS

Patients who underwent RARP between June 2011 and May 2016 were invited to participate through mailed questionnaires. A total of 207 patients formed our cohort. The questionnaires included European Organization for Research and Treatment of Cancer Quality of Life of Cancer patients 30 and PR25 modules, sexual health inventory in men and Likert decisional regret scale. A Decisional Regret Scale score of >15 was used to define an outcome of high decision regret.

RESULTS

The mean patient age was 63 years and the mean duration of follow up was 36 months. Of the 106 responders, 51 (48%) were fully satisfied with the decision to undergo RARP and 32 (30%) recorded high regret. The mean Decisional Regret Scale score was 11.3. High decision regret associated with the length of time from RARP to questionnaire administration, higher prostate specific quality of life symptom scores and lower sexual and erectile function scores.

CONCLUSION

Our study represents the first contemporary United Kingdom series assessing decision regret following the management of localised prostate cancer with RARP. Higher regret was seen in one third of patients and was associated with worse disease-specific quality of life, sexual and erectile function measures. To minimize regret, collaborative and detailed discussion should take place pre-operatively when counselling patients about RARP. The potential longevity and impact on quality of life of these side effects should be made clear.

Decision regret, adverse outcomes, and treatment choice in men with localized prostate cancer: Results from a multi-site randomized trial

INTRODUCTION

Men diagnosed with localized prostate cancer must navigate a highly preference-sensitive decision between treatment options with varying adverse outcome profiles. We evaluated whether use of a decision support tool previously shown to decrease decisional conflict also impacted the secondary outcome of post-treatment decision regret.

METHODS

Participants were randomized to receive personalized decision support via the Personal Patient Profile-Prostate or usual care prior to a final treatment decision. Symptoms were measured just before randomization and 6 months later; decision regret was measured at 6 months along with records review to ascertain treatment choices. Regression modeling explored associations between baseline variables including race and D`Amico risk, study group, and 6-month variables regret, choice, and symptoms.

RESULTS

At 6 months, 287 of 392 (73%) men returned questionnaires of which 257 (89%) had made a treatment choice. Of that group, 201 of 257 (78%) completely answered the regret scale. Regret was not significantly different between participants randomized to the P3P intervention compared to the control group (P = 0.360). In univariate analyses, we found that Black men, men with hormonal symptoms, and men with bowel symptoms reported significantly higher decision regret (all P < 0.01). Significant interactions were detected between race and study group (intervention vs. usual care) in the multivariable model; use of the Personal Patient Profile-Prostate was associated with significantly decreased decisional regret among Black men (P = 0.037). Interactions between regret, symptoms and treatment revealed that (1) men choosing definitive treatment and reporting no hormonal symptoms reported lower regret compared to all others; and (2) men choosing active surveillance and reporting bowel symptoms had higher regret compared to all others.

CONCLUSION

The Personal Patient Profile-Prostate decision support tool may be most beneficial in minimizing decisional regret for Black men considering treatment options for newly-diagnosed prostate cancer.

TRIAL REGISTRATION

NCT01844999.

Study structure may compromise understanding of longitudinal decision regret stability: A systematic review

OBJECTIVES

To perform a systematic review of decision regret studies in cancer patients to determine if regret is longitudinally stable, and whether these study structures account for late-emerging treatment effects.

METHODS

Online databases including the George Mason Libraries, Global Health, Nursing and Allied Health, and PubMed were searched to identify decision regret studies with longitudinal components in patients with cancer.

RESULTS

A total of 845 unique citations were identified; 20 studies met inclusion criteria. Data was also collected on the time horizon for 90 studies; 47 % of studies evaluated regret at time points of one year or less, although this has increased significantly in prostate cancer citations since 2010. Regret was infrequent, affecting less than 20 % of patients, and often stable. Effect sizes in studies where decision regret changed over time were small to negligible.

CONCLUSION

Longitudinal effects can influence the expression of decision regret, yet many studies are not designed to collect long-term data; prostate cancer studies may be particularly disadvantaged. The degree of this influence in current studies is small, though this outcome must be interpreted with caution.

PRACTICE IMPLICATIONS

Providers should be aware of the risk of late-emerging regret and counsel patients appropriately.

Change in Functional Status After Prostate Cancer Treatment Among Medicare Advantage Beneficiaries

OBJECTIVE

To examine the relationship between treatment and subsequent functional status among prostate cancer patients.

METHODS

Using Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey data, we identified men 65 years or older diagnosed with prostate cancer between 1998 and 2009 (follow-up through 2010) who were treated with conservative management, surgery, or radiation. Our primary outcome was functional status as measured by activities of daily living. Secondary outcomes included physical component summary and mental component summary scores, which are both calculated from the Short Form 36 (SF-36) and the Veterans RAND 12-item health survey (VR-12) questionnaires. We included patients who completed 2 surveys and performed propensity score analyses to match patients 1:5 with noncancer controls. We used generalized linear mixed effects models, accounting for clustering due to insurance plan.

RESULTS

We identified 408 patients of whom 143 (35%) underwent conservative management, 59 (14%) underwent surgery, and 206 (51%) underwent radiation. Among conservative management and radiation patients, changes in functional status mirrored that of their noncancer controls (all P > .05). Among surgery patients, changes in activities of daily living scores were not significant, but physical component summary (mean difference = 4.5, P < .001) and mental component summary (mean difference = 3.3, P = .01) scores declined slightly more than for their noncancer peers.

CONCLUSION

Surgery patients had a slight decline in their general functional status whereas conservative management and radiation patients had no differences in functional status compared with their noncancer peers. Although the functional status of surgery patients declined more than that of their noncancer peers, this difference may not be clinically significant.

Local Therapy Decisional Regret in Older Women With Breast Cancer: A Population-Based Study

PURPOSE

Older women with nonmetastatic breast cancer can often choose from several surgery and radiation treatment options. Little is known regarding how these choices contribute to decisional regret, which is a negative emotion reflecting the idea that another surgery or radiation decision might have been preferable. We sought to characterize the burden of and examine potential risk factors for local therapy decisional regret among a population-based cohort of older breast cancer survivors.

METHODS AND MATERIALS

National Medicare claims for age ≥67 female breast cancer incident in 2009 identified patients treated with lumpectomy plus whole-breast irradiation, brachytherapy, or endocrine therapy or mastectomy with or without radiation. We sampled 330 patients per treatment group (N = 1650), of whom 1253 agreed to receive a paper survey including the Decisional Regret Scale and EQ-5D-3L Health-Utility Scale. Local therapy regret was defined as neutral or worse response to questions regarding surgery- or radiation-related decisional regret. Local therapy regret risk factors were evaluated using a multivariable generalized linear model. Association of local therapy regret with health utility was modeled using multivariable linear regression.

RESULTS

The response rate was 30.2% (n = 498 of 1650); 421 surveys were included in this analysis. Median diagnosis age was 72 years, and surveys were completed 6 years after diagnosis. Overall, 23.8% of respondents (n = 100) reported experiencing local therapy decisional regret. Type of local therapy was not associated with local therapy regret. Predictors of increased regret included black race (risk ratio [RR], 2.09; 95% confidence interval [CI], 1.33-3.29), high school education or less (RR, 1.87; 95% CI, 1.27-2.75), and axillary nodal dissection (RR, 2.13; 95% CI, 1.33-3.41). Local therapy regret was not associated with health utility (P = .37).

CONCLUSIONS

Local therapy regret afflicts nearly one quarter of our cohort of older breast cancer survivors, and it is associated with black race, less education, and more extensive nodal dissection, but not breast surgery. Regret is distinct from health utility, suggesting that it is a unique psychosocial construct that merits further study and mitigation strategies.

Regret in Surgical Decision Making: A Systematic Review of Patient and Physician Perspectives

OBJECTIVE

Regret is a powerful motivating factor in medical decision making among patients and surgeons. Regret can be particularly important for surgical decisions, which often carry significant risk and may have uncertain outcomes. We performed a systematic review of the literature focused on patient and physician regret in the surgical setting.

METHODS

A search of the English literature between 1986 and 2016 that examined patient and physician self-reported decisional regret was carried out using the MEDLINE/PubMed and Web of Science databases. Clinical studies performed in patients and physicians participating in elective surgical treatment were included.

RESULTS

Of 889 studies identified, 73 patient studies and 6 physician studies met inclusion criteria. Among the 73 patient studies, 57.5% examined patients with a cancer diagnosis, with breast (26.0%) and prostate (28.8%) cancers being most common. Interestingly, self-reported patient regret was relatively uncommon with an average prevalence across studies of 14.4%. Factors most often associated with regret included type of surgery, disease-specific quality of life, and shared decision making. Only 6 studies were identified that focused on physician regret; 2 pertained to surgical decision making. These studies primarily measured regret of omission and commission using hypothetical case scenarios and used the results to develop decision curve analysis tools.

CONCLUSION

Self-reported decisional regret was present in about 1 in 7 surgical patients. Factors associated with regret were both patient- and procedure related. While most studies focused on patient regret, little data exist on how physician regret affects shared decision making.

Analysis of Factors Associated with Patient or Caregiver Regret following Surgery for Fecal Incontinence

PURPOSE

Malone antegrade continence enema has been a successful and widely used procedure for achieving fecal continence in children. We present data on the previously uninvestigated issue of patient and caregiver regret following surgery for intractable constipation and fecal incontinence.

MATERIALS AND METHODS

We reviewed all patients undergoing antegrade continence enema or cecostomy creation at a single institution between 2006 and 2016. Patients and caregivers were assessed for decisional regret using the Decisional Regret Scale. Results were correlated with demographics, surgical outcomes and complications.

RESULTS

A total of 81 responses (49 caregivers and 32 patients) were obtained. Mean followup was 49 months. Decisional regret was noted in 43 subjects (53%), including mild regret in 38 (47%) and moderate to severe regret in 5 (6%). No statistical difference in regret was noted based on gender, complications or performance of concomitant procedures. On regression analysis incontinence was strongly associated with decisional regret (OR 4.4, 95% CI 1.1-18.1, p <0.001) and regret increased as age at surgery increased, particularly when patients were operated on at age 13 to 15 years (OR 2.6, 95% CI 1.0-6.4 for age 13 years; OR 2.9, 95% CI 1.1-7.8 for age 14 years; OR 3.1, 95% CI 1.1-8.8 for age 15 years).

CONCLUSIONS

This is the first known study describing decisional regret following surgery for fecal incontinence. Surgical factors aimed at achieving continence may be effective in decreasing postoperative regret. The finding of increased regret in teenage patients compared to younger children should be shared with families since it may impact the age at which surgery is pursued.

Longitudinal regret after treatment for low- and intermediate-risk prostate cancer

BACKGROUND

Prostate cancer patients diagnosed with low- and intermediate-risk disease have several treatment options. Decisional regret after treatment is a concern, especially when poor oncologic outcomes or declines in health-related quality of life (HRQoL) occur. This study assessed determinants of longitudinal decisional regret in prostate cancer patients attending a multidisciplinary clinic and treated with radical prostatectomy (RP), external beam radiation therapy (EBRT), brachytherapy (BT), or active surveillance (AS).

METHODS

Patients newly diagnosed with prostate cancer at the Walter Reed National Military Medical Center who attended a multidisciplinary clinic were enrolled into a prospective study from 2006 to 2014. The Decision Regret Scale was administered at 6, 12, 24, and 36 months posttreatment. HRQoL was also assessed at regular intervals using the Expanded Prostate Cancer Index Composite and 36-item RAND Medical Outcomes Study Short Form questionnaires. Adjusted probabilities of reporting regret were estimated via multivariable logistic regression fitted with generalized estimating equations.

RESULTS

A total of 652 patients met the inclusion criteria (395 RP, 141 EBRT, 41 BT, 75 AS). Decisional regret was consistently low after all of these treatments. In multivariable models, only African American race (odds ratio, 1.67; 95% confidence interval, 1.12-2.47) was associated with greater regret across time. Age and control preference were marginally associated with regret. Regret scores were similar between RP patients who did and did not experience biochemical recurrence. Declines in HRQoL were weakly correlated with greater decisional regret.

CONCLUSION

In the context of a multidisciplinary clinic, decisional regret did not differ significantly between treatment groups but was greater in African Americans and those reporting poorer HRQoL. Cancer 2017;123:4252-4258. © 2017 American Cancer Society.

Do men regret prostate biopsy: Results from the PiCTure study

Background

Understanding men’s experience of prostate biopsy is important as the procedure is common, invasive and carries potential risks. The psychological aspects of prostate biopsy have been somewhat neglected. The aim of this study was to explore the level of regret experienced by men after prostate biopsy and identify any associated factors.

Methods

Men attending four clinics in Republic of Ireland and two in Northern Ireland were given a questionnaire to explore their experience of prostate biopsy. Regret was measured on a Likert scale asking men how much they agreed with the statement “It [the biopsy] is something I regret.”

Results

Three hundred thirty-five men responded to the survey. The mean age was 63 years (SD ±7 years). Three quarters of respondents (76%) were married or co-habiting, and (75%) finished education at primary or secondary school level. For just over two thirds of men (70%) their recent biopsy represented their first ever prostate biopsy. Approximately one third of men reported a diagnosis of cancer, one third a negative biopsy result, and the remaining third did not know their result. Two thirds of men reported intermediate or high health anxiety. 5.1% of men agreed or strongly agreed that they regretted the biopsy.

Conclusions

Level of regret was low overall. Health anxiety was the only significant predictor of regret, with men with higher anxiety reporting higher levels of regret than men with low anxiety (OR = 3.04, 95% CI 1.58, 5.84).

Men with high health anxiety may especially benefit from careful counselling before and after prostate biopsy.

Electronic supplementary material

The online version of this article (doi:10.1186/s12894-016-0194-y) contains supplementary material, which is available to authorized users.

Prevention and management of post prostatectomy erectile dysfunction

Sexual dysfunction is common in patients with prostate cancer (PC) following radical prostatectomy (RP). Review the available literature concerning prevention and management strategies for post-RP erectile function (EF) impairment in terms of preoperative patient characteristics, intra and postoperative factors that may influence EF recovery, and postoperative treatments for erectile dysfunction (ED). A literature search was performed using Google and PubMed database for English-language original and review articles, either published or e-published up to July 2013. The literature still demonstrates a great inconsistency in the definition of what is considered normal EF both before and after RP. Thus, using validated psychometric instruments with recognized cut-offs for normalcy and severity during the pre- and post-operative evaluation should be routinely considered. Therefore, a comprehensive discussion with the patient about the true prevalence of postoperative ED, the concept of spontaneous or pharmacologically-assisted erections, and the difference between “back to baseline” EF and “erections adequate enough to have successful intercourse” clearly emerge as key issues in the eventual understanding of post-RP ED prevention and promotion of satisfactory EF recovery. Patient factors (including age, baseline EF, comorbid conditions status), cancer selection (non- vs. uni- vs. bilateral nerve-sparing), type of surgery (i.e., intra vs. inter vs. extrafascial surgeries), surgical techniques (i.e., open, laparoscopic and robotically-assisted RP), and surgeon factors (i.e., surgical volume and surgical skill) represent the key significant contributors to EF recovery. A number of preclinical and clinical data show that rehabilitation and treatment in due time are undoubtedly better than leaving the erectile tissue to its unassisted postoperative fate. The role of postoperative ED treatment for those patients who received a non-nerve-sparing RP was also extensively discussed. Optimal outcomes are achieved mainly by the careful choice of the correct patient for the correct type of surgery. Despite a plethora of potential rehabilitative approaches, they should be only considered as “strategies”, since incontrovertible evidence of their effectiveness for improving natural EF recovery is limited. Conversely, numerous effective therapeutic options are available for treating post-RP ED.

Factors related to patient-perceived satisfaction after robot-assisted radical prostatectomy based on the expanded prostate cancer index composite survey

BACKGROUND

Few studies have analyzed factors that influence longitudinal changes in patient-perceived satisfaction during the recovery period following robot-assisted radical prostatectomy (RARP) for prostate cancer. We investigated variables that were associated with patient-perceived satisfaction after RARP using the expanded prostate cancer index composite (EPIC) survey.

METHODS

Of 175 men who underwent RARP between 2010 and 2011, 140 men completed the EPIC questionnaire preoperatively and 3, 6 and 12 months postoperatively. On the basis of the EPIC question no. 32 (item number 80), patients were divided into four groups according to the pattern of satisfaction change at postoperative 3 and 12 months: satisfied to satisfied (group 1); satisfied to dissatisfied (group 2); dissatisfied to satisfied (group 3); and dissatisfied to dissatisfied (group 4). Longitudinal changes in EPIC scores over time in each group and differences in EPIC scores of each domain subscale between groups at each follow-up were analyzed. A linear mixed model with generalized estimating equation approach was used to identify independent factors that influence overall satisfaction among repeated measures from same patients.

RESULTS

On the basis of the pattern of satisfaction change, groups 1, 2, 3 and 4 had 103 (74.3%), 21 (15.0%), 11 (7.9%) and 5 (2.9%) patients, respectively. The factor that was associated with overall satisfaction was urinary bother (UB) (β=0.283, 95% confidence interval (0.024, 0.543 ); P=0.033) adjusted for other factors under consideration.

CONCLUSIONS

UB was the independent factor influencing patient-perceived satisfaction after RARP. During post-RARP follow-up, physician should have the optimal management for the patient's UB.

Treatment regret and quality of life following radical prostatectomy

PURPOSE

Negative physical functioning outcomes including incontinence and erectile dysfunction are relatively common following radical prostatectomy (RP) and are associated with treatment regret and compromised quality of life (QOL). The role that treatment regret may have in influencing the association between prostate-specific QOL (i.e., sexual, urinary, bowl functioning) and general QOL following RP has not been examined.

METHOD

This study examined the associations of treatment regret, general QOL (36-item Short Form Health Survey physical and mental health (MCS) composite scores), and prostate-specific QOL (Prostate Cancer QOL sexual, urinary, bowl functioning, and cancer worry subscales) in 95 men who underwent RP for prostate cancer.

RESULTS

Multiple regression analyses indicated that poorer sexual and urinary functioning was associated with poorer MCS. Additionally, men with lower sexual and urinary functioning reported greater treatment regret. Treatment regret was also associated with lower MCS. Finally, treatment regret partially mediated the effects of both sexual and urinary functioning on MCS.

CONCLUSIONS

These findings suggest that regardless of a patient's prostate-specific QOL, reducing treatment regret may improve mental health following RP. Though there are limited options to alter patients' sexual or urinary functioning following RP, treatment regret may be a modifiable contributor to post-surgical adjustment and QOL.