A prospective cohort study of treatment decision-making for prostate cancer following participation in a multidisciplinary clinic

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.

Perspectives on prostate cancer: advances and pending challenges for a multidisciplinary oncological approach in South America

Prostate cancer is one of the tumors with the highest incidence and mortality among men worldwide, and this situation is no different in South America. However, epidemiological data are highly variable for each country and even more so than in North America. These data may be influenced by the very low rate of early detection of disease, availability of diagnostic methods, proper data collection, and limited access to specialized multidisciplinary treatment. For many South American countries, academic referral centers can only offer state-of-the-art diagnostics and multidisciplinary cancer treatment for patients who live in or can travel to large cities, so most patients are cared for by non-expert urologists with limited resources, which can have a negative impact on their prognosis and worsen oncologic outcomes. We aimed to show the clinical management of prostate cancer patients, the current advances in management, limitations present in South America, and how a multidisciplinary approach in referral cancer centers conformed of specialized urologists, medical oncologists, and mental health professionals can maximize patient outcomes.

Novel hormone therapy and coordination of care in high-risk biochemically recurrent prostate cancer

Biochemical recurrence (BCR) occurs in 20-50% of patients with prostate cancer (PCa) undergoing primary definitive treatment. Patients with high-risk BCR have an increased risk of metastatic progression and subsequent PCa-specific mortality, and thus could benefit from treatment intensification. Given the increasing complexity of diagnostic and therapeutic modalities, multidisciplinary care (MDC) can play a crucial role in the individualized management of this patient population. This review explores the role for MDC when evaluating the clinical evidence for the evolving definition of high-risk BCR and the emerging therapeutic strategies, especially with novel hormone therapies (NHTs), for patients with either high-risk BCR or oligometastatic PCa. Clinical studies have used different characteristics to define high-risk BCR and there is no consensus regarding the definition of high-risk BCR nor for management strategies. Next-generation imaging and multigene panels offer potential enhanced patient identification and precision-based decision-making, respectively. Treatment intensification with NHTs, either alone or combined with radiotherapy or metastasis-directed therapy, has been promising in clinical trials in patients with high-risk BCR or oligometastases. As novel risk-stratification and treatment options as well as evidence-based literature evolve, it is important to involve a multidisciplinary team to identify patients with high-risk features at an earlier stage, and make informed decisions on the treatments that could optimize their care and long-term outcomes. Nevertheless, MDC data are scarce in the BCR or oligometastatic setting. Efforts to integrate MDC into the standard management of this patient population are needed, and will likely improve outcomes across this heterogeneous PCa patient population.

Do all prostate cancer patients want, and experience shared decision making prior to curative treatment?

OBJECTIVE

In comparable men with non-metastatic prostate cancer, radical prostatectomy (RP), radiotherapy (RAD) and active surveillance (AS) are treatment options with similar survival rates, but different side-effects. Healthcare professionals consider pretreatment shared decision making (SDM) to be an essential part of medical care, though the patients' view about SDM is less known. In this article, we explore prostate cancer (PCa) patients' SDM wish (SDMwish), and experiences (SDMexp).  Material and methods: This is a registry-based survey performed by the Cancer Registry of Norway (2017-2019). One year after diagnosis, 5,063 curatively treated PCa patients responded to questions about their pre-treatment wish and experience regarding SDM. Multivariable analyses identified factors associated with SDM. Statistical significance level: p < 0.05.  Results: Overall, 78% of the patients wished to be involved in SDM and 83% of these had experienced SDM. SDMwish and SDMexp was significantly associated with decreasing age, increasing education, and living with a partner. Compared with the RP group, the probability of SDMwish and SDMexp was reduced by about 40% in the RAD and the AS groups.  Conclusion: Three of four curatively treated PCa wanted to participate in SDM, and this wish was met in four of five men. Younger PCa patients with higher education in a relationship, and opting for RP, wanted an active role in SDM, and experienced being involved. Effective SDM requires the responsible physicians' attention to the individual patients' characteristics and needs.

Patterns of multispecialty care for low- and intermediate-risk prostate cancer in the use of active surveillance

BACKGROUND

Multidisciplinary models of care have been advocated for prostate cancer (PC) to promote shared decision-making and facilitate quality care. Yet, how this model applies to low-risk disease where the preferred management is expectant remains unclear. Accordingly, we examined recent practice patterns in specialty visits for low/intermediate-risk PC and resultant use of active surveillance (AS).

METHODS

Using SEER-Medicare, we ascertained whether patients saw urology and radiation oncology (i.e., multispecialty care) versus urology alone, based on self-designated specialty codes, for newly diagnosed PC from 2010 to 2017. We also examined the association with AS, defined as the absence of treatment within 12 months of diagnosis. Time trends were analyzed using Cochran-Armitage test. Chi-squared and logistic regression analyses were applied to compare sociodemographic and clinicopathologic characteristics between these models of care.

RESULTS

The proportion of patients seeing both specialists was 35.5% and 46.5% for low- and intermediate-risk patients respectively. Trend analysis showed a decline in multispecialty care in low-risk patients (44.1% to 25.3% years 2010-2017; P < 0.001). Between 2010 and 2017, the use of AS increased 40.9% to 68.6% (P < 0.001) and 13.1% to 24.6% (P < 0.001) for patients seeing urology and those seeing both specialists respectively. Age, urban residence, higher education, SEER region, co-morbidities, frailty, Gleason score, predicted receipt of multispecialty care (all P < 0.02).

CONCLUSIONS

Uptake of AS among men with low-risk PC has occurred primarily under the purview of urologists. While selection is certainly at play, these data suggest that multispecialty care may not be required to promote the utilization of AS for men with low-risk PC.

The Treatment Decision-making Preferences of Patients with Prostate Cancer Should Be Recorded in Research and Clinical Routine: a Pooled Analysis of Four Survey Studies with 7169 Patients

Different patients want to take different roles in the treatment decision-making process; these roles can be classified as passive, collaborative, and active. The aim of this study was to investigate the correlation between decision-making preferences among patients with prostate cancer and personal, disease-related, and structural factors. In four survey studies, we asked 7169 prostate cancer patients about their decision-making preferences using the Control Preferences Scale (CPS) and collected clinical, psychological, and quality-of-life measures. Most patients (62.2%) preferred collaborative decision-making, while 2322 (32.4%) preferred an active role, and only 391 (5.5%) preferred a passive role. Age (p < 0.001), data collection mode (p < 0.001), peer-to-peer support (p = 0.018), treatment status (p < 0.001), performed or planned radical prostatectomy (p < 0.001), metastatic disease (p = 0.001), and quality of life (p < 0.001) showed significant associations with patients' preferred decision-making roles. Oncologic risk group, anxiety, and depression were not significant in the model. In particular, younger prostate cancer patients with higher quality of life completing an online survey want to play a more active role in treatment decision-making. Before treatment has started, patients tend to prefer collaborative decision-making. Few prostate cancer patients in Germany prefer a passive role. These patients are mostly older patients, patients with a metastatic disease, and patients who have opted for prostatectomy. Whether this finding reflects a generational effect or a tendency by age group and disease phase should be investigated. Further research is also needed to describe the causalities of these relationships. The CPS offers valuable information for personal counselling and should be applied in clinical routine. In a large group of patients with prostate cancer, we found that there is a strong desire for joint decision-making with the physician before the actual treatment. Especially younger men, men with active online behaviour, and men with a high quality of life want to be actively involved in therapy decision-making processes.

Dynamic multidisciplinary team discussions can improve the prognosis of metastatic castration-resistant prostate cancer patients

BACKGROUND

Multidisciplinary team (MDT) management is a popular treatment paradigm in managing cancer patients, which provides fully-discussed, interdisciplinary treatment recommendations for patients. However, there has been a lack of data on its actual impact on the overall survival (OS) of metastatic castration-resistant prostate cancer (mCRPC) patients. mCRPC is the end stage of prostate cancer, facing a treatment dilemma of overwhelming options; therefore, we hypothesize dynamic MDT discussions can be helpful in comprehensively managing these patients.

METHODS

We retrospectively collected 422 mCRPC patients' clinical information from 2013 to 2020 from our institute. Patients can voluntarily choose whether to enroll in the dynamic MDT group, which includes discussions at CRPC diagnosis and subsequent disease progression. All patients were followed up regularly, and OS from CRPC diagnosis to death was set as the endpoint of this study.

RESULTS

Participating in MDT discussions is a favorable independent indicator of longer overall survival (median OS: MDT (+): 39.7 months; MDT (-): 27.0 months, hazard ratio: 0.549, p = .001). Moreover, this survival benefit of MDT remained in subgroups with first-line therapy [median OS: MDT (+): not reached; MDT (-): 27.0 months, p = .001) and with multi-line therapy until the end of follow-up (median OS: MDT (+): 36.7 months; MDT (-): 25.6 months, p = .044).

CONCLUSION

Therefore, regular MDT discussions are valuable in the management of mCRPC patients. Clinicians are encouraged to tailor MDT discussions dynamically to provide mCRPC patients with a better and more individualized treatment plan and more prolonged survival. Take-home messages ● The MDT model is defined as dynamic MDT discussions at the time of mCRPC diagnosis and each time they progressed later on throughout the disease management. ● Prostate cancer MDT usually includes specialists in urologic oncology, pathology, chemotherapy, radiotherapy, ultrasound, imaging and nuclear medicine. ● MDT model can benefit mCRPC patients in terms of overall survival.

Low conflict and high satisfaction: Decisional outcomes after attending a combined clinic to choose between robotic prostatectomy and radiotherapy for prostate cancer

BACKGROUND

Decisional conflict and post-treatment decisional regret have been documented in men with localised prostate cancer (LPC). However, there is limited evidence regarding decisional outcomes associated with the choice between robotic-assisted radical prostatectomy (RARP) and radiotherapy, when both treatment options are available in the public health system. There is increasing support for multidisciplinary approaches to guide men with LPC in their decision-making process. This study assessed decisional outcomes in men deciding between RARP or radiotherapy treatment before and after attending a LPC combined clinic (CC).

METHODS

Quantitative longitudinal data were collected from 52 men who attended a LPC CC, where they saw both a urologist and radiation oncologist. Patients completed questionnaires assessing involvement in decision-making, decisional conflict, satisfaction and regret before and after the CC, three months, six months and 12 months post-treatment. Urologists and radiation oncologists also reported their perceptions regarding patients' suitability for, openness to, perceived preferences and appropriateness for each treatment. Data was analysed using paired/independent samples t-tests and McNemar's tests.

RESULTS

Most participants (n = 37, 71%) opted for RARP over radiotherapy (n = 14, 27%); one participant deferred treatment (2%). Urologists and radiation oncologists reported low agreement (κ = 0.26) regarding the most appropriate treatment for each patient. Participants reported a desire for high levels of control over their decision-making process (77.5% patient-led, 22.5% shared) and high levels of decisional satisfaction (M = 4.4, SD = 0.47) after the CC. Decisional conflict levels were significantly reduced (baseline: M = 29.3, SD = 16.9, post-CC: M = 16.3, SD = 11.5; t = 5.37, P < 0.001) after the CC. Mean decisional regret scores were 'mild' at three-months (M = 16.0, SD = 17.5), six-months (M = 18.8, SD = 18.7) and 12-months (M = 18.2, SD = 15.1) post-treatment completion.

CONCLUSION

This is the first Australian study to assess decisional outcomes when patients are offered the choice between RARP and radiotherapy in the public health system. A CC seems to support decision-making in men with LPC and positively impact some decisional outcomes. However, larger-scale controlled studies are needed to confirm these findings.

Overview of potential determinants of radical prostatectomy versus radiation therapy in management of clinically localized prostate cancer: results from an Italian, prospective, observational study (the Pros-IT CNR study)

BACKGROUND

We assessed patients and tumor characteristics, as well as health-related quality of life (HRQoL) items, associated with curative intent treatment decision-making in clinically localized prostate cancer (PCa) patients.

METHODS

Clinically localized PCa treated with either radical prostatectomy (RP) or radiation therapy (RT) within 12 months from diagnosis were abstracted from The PROState cancer monitoring in ITaly, from the National Research Council (Pros-IT CNR) database. Multivariable logistic regression (MLR) models predicting RT vs. RP were fitted, after adjustment for HRQoL items, patients and tumor characteristics.

RESULTS

Of 1041 patients, 631 (60.2%) were treated with RP and 410 (39.8%) with RT. Relative to RT, RP patients were younger age (mean age 64.5±6.6 vs. 71.4±4.9, P<0.001) and had higher rates of D'Amico low-intermediate risk groups (31.8 vs. 21.9% low, 46.3% vs. 43.5% intermediate and 21.9% vs. 34.6% high risk, P<0.001). Overall, 93.2% of RP patients were enrolled by urologists and 82.7% of RT patients by radiation oncologists. RP patients had generally higher means values of HRQoL items. In MLR models, higher RT rates were independently associated with more advanced age (odds ratio [OR] 6.14, P<0.001) and BMI≥30 kg/m2 (OR 1.78, P<0.001). Conversely, lower rates of RT were independently associated with married (OR 0.55, P=0.01) and worker status (OR 0.52, P=0.004), enrollment in academic centers (OR 0.59, P=0.005) and higher physical composite score (OR 0.88, P=0.03) and baseline sexual function items (OR 0.92, P<0.001).

CONCLUSIONS

Most patients with clinically localized prostate cancer undergoing definitive treatment at Italian institutions receive RP instead of RT. Moreover, those who are younger, married, working, as well as those with better physical and sexual function are more likely to undergo surgery.

Health-Related Quality of Life and Survival in Prostate Cancer Patients in a Real-World Setting

OBJECTIVE

To analyze the health-related quality of life (HRQoL) and survival of real-world prostate cancer (PC) patients and to calculate quality-adjusted life-years (QALYs) experienced under different treatment strategies.

MATERIALS AND METHODS

PC patients undergoing active surveillance (n = 226), radiation treatment (n = 280), surgery (n = 299), or hormonal treatment (n = 62) responded to the generic 15-dimensional (15D) HRQoL questionnaire at the time of the diagnosis and were followed up 3, 6, 12, and 24 months later. QALYs experienced during the follow-up were calculated for each treatment group, and variables associated with survival were analyzed using Cox proportional hazards models.

RESULTS

HRQoL was stable during the first 2 years after diagnosis in all other treatment groups, except in patients treated with hormonal therapy. The overall survival within 6.5-year follow-up time was 84.4%. The number of QALYs experienced during the 2-year follow-up was similar in patients in active surveillance (1.790), surgery (1.784), and radiation groups (1.767), but significantly lower in the hormonal therapy group (1.665).

CONCLUSIONS

Patients receiving hormonal treatment had significantly impaired HRQoL and survival compared with other treatments. Although the number of QALYs experienced was similar in the 3 other treatment lines, there were marked differences between treatment lines on some 15D dimensions.

Treatment decision-making in men with localized prostate cancer living in a remote area: A cross-sectional, observational study

INTRODUCTION

For the management of localized prostate cancer, patient treatment choice is poorly documented among people living in remote areas, where access to certain treatments offered in large centers involves travelling several hundred kilometres. This study aimed to describe and identify the determinants of treatment decision-making in men with localized prostate cancer living in remote areas.

METHODS

In this cross-sectional study, patients with prostate cancer were recruited from Rouyn-Noranda's urology clinic (Quebec, Canada) between 2017 and 2019.

RESULTS

A total of 127 men (mean age 68.34±7.23 years) constituted the study sample. Radiotherapy, a treatment not available locally, was chosen most frequently (67.7%), followed by options available locally, such as surgery (22.8%) and active surveillance (9.4%). Most patients preferred to play an active role in this choice (53.5%) and agreed with the statement, "I chose that treatment because it gives the best chance for a cure" (86.6%). Multiple logistic regression analysis revealed that cancer stage (odds ratio [OR] 10.15; 95% confidence interval [CI] 3.18-32.40) was the only factor associated with radiotherapy choice (patients with lower stage cancer were more likely to choose radiotherapy). The socioeconomic status was not associated with treatment choice.

CONCLUSIONS

While radiotherapy was not available locally, it was the most frequently chosen treatment, even though the available literature suggests that no one treatment option is superior in terms of cancer control. The choice of radiotherapy is not associated with patient income, but rather the cancer stage. This result could be explained by the patients' desire to avoid surgery and its adverse effects.

A systematic scoping review of multidisciplinary cancer team and decision-making in the management of men with advanced prostate cancer

PURPOSE

The early diagnosis of prostate cancer and subsequent access to the treatment options helps to achieve optimal cancer outcomes. As the treatment options for patients with advanced prostate cancer continues to evolve, patients need to access a multidisciplinary team (MDT) meeting to receive best-practice care.

METHODS

In this paper a MEDLINE review was performed to assess clinical decision making in the context of MDT discussions for patients with advanced prostate cancer.

RESULTS

From 441 returned articles and abstracts, 50 articles were assessed for eligibility and 16 articles included for analysis. Sixteen articles were identified, 9 of the 16 articles used quantitative methodology including three retrospective analysis of clinical registry data, patient medical records and/or MDT meeting notes and three cross-sectional surveys. Other study designs included one observation study and one study using a combination of qualitative and quantitative methodologies and one mini-review. There were also four editorials included in the review and two consensus statements.

CONCLUSION

This paper highlights the important role the inter-disciplinary MDT has on shared decision making for men with advanced prostate cancer. The application of MDT care is a rapidly growing trend in uro-oncology and an efficient MDT service requires further research to assess its efficiency so that it may expand through all aspect of uro-oncology.

The role of cystoprostatectomy in management of locally advanced prostate cancer: a systematic review

Background

The role of cystoprostatectomy for the treatment of locally advanced prostate cancer (LAPC) was evaluated by a comprehensive review of contemporary literatures.

Methods

A systematic search of English language literatures using PubMed, EMBASE, Web of Science, and Cochrane library, from 1990 to 2018, was performed. Two independent authors reviewed abstracts as well as full-text articles and extracted data from the selected manuscripts.

Results

After the literature research, seven articles with a total of 211 patients were identified. Both 120 cases who received cystoprostatectomy for the primary treatment of LAPC and 91 cases for the salvage surgery after local recurrence were finally included. Overall incidence of positive surgical margins ranged from 25 to 78%. The incidence of major complications caused by the surgery during the follow-up time was limited. It had been reported that among LAPC patients who received cystoprostatectomy combined with adjuvant therapies, 5-year cancer-specific survival rate and 5-year biochemical progression-free survival was up to 87.1% and 62.2%. Moreover, symptoms such as hematuria and other urination dysfunctions, as well as patients’ quality of life were significantly improved after cystoprostatectomy in LAPC patients with the bladder invasion.

Conclusions

Cystoprostatectomy can serve as an alternative to the surgical step of multimodal therapy for highly selected LAPC patients with the bladder invasion, which may improve patients’ symptoms and related quality of life. Therefore, cystoprostatectomy as an option for the treatment of LAPC with the bladder invasion may be feasible and safe with considerable survival outcomes.

Contemporary prostate cancer treatment choices in multidisciplinary clinics referenced to national trends

BACKGROUND

The purpose of this study was to assess treatment choices among men with prostate cancer who presented at The University of Texas MD Anderson Cancer Center multidisciplinary (MultiD) clinic compared with nationwide trends.

METHODS

In total, 4451 men with prostate cancer who presented at the MultiD clinic from 2004 to 2016 were analyzed. To assess nationwide trends, the authors analyzed 392,710 men with prostate cancer who were diagnosed between 2004 and 2015 from the Surveillance, Epidemiology, and End Results (SEER) database. The primary endpoint was treatment choice as a function of pretreatment demographics.

RESULTS

Univariate analyses revealed similar treatment trends in the MultiD and SEER cohorts. The use of procedural forms of definitive therapy decreased with age, including brachytherapy and prostatectomy (all P < .05). Later year of diagnosis/clinic visit was associated with decreased use of definitive treatments, whereas higher risk grouping was associated with increased use (all P < .001). Patients with low-risk disease treated at the MultiD clinic were more likely to receive nondefinitive therapy than patients in SEER, whereas the opposite trend was observed for patients with high-risk disease, with a substantial portion of high-risk patients in SEER not receiving definitive therapy. In the MultiD clinic, African American men with intermediate-risk and high-risk disease were more likely to receive definitive therapy than white men, but for SEER the opposite was true.

CONCLUSIONS

Presentation at a MultiD clinic facilitates the appropriate disposition of patients with low-risk disease to nondefinitive strategies of patients with high-risk disease to definitive treatment, and it may obviate the influence of race.

Does the Time Interval from Biopsy to Radical Prostatectomy Affect the Postoperative Oncologic Outcomes in Korean Men?

BACKGROUND

Prostate cancer (PC) is the second most common type of cancer in men worldwide and the fifth most common cancer among Korean men. Although most PCs grow slowly, it is unclear whether a longer time interval from diagnosis to treatment causes worse outcomes. This study aimed to investigate whether the time interval from diagnosis to radical prostatectomy (RP) in men with clinically localized PC affects postoperative oncologic outcomes.

METHODS

We retrospectively analyzed data of 427 men who underwent RP for localized PC between January 2005 and June 2016. The patients were divided into two groups based on the cutoff median time interval (100 days) from biopsy to surgery. The associations between time interval from biopsy to surgery (< 100 vs. ≥ 100 days) and adverse pathologic outcomes such as positive surgical margin, pathologic upgrading, and upstaging were evaluated. Biochemical recurrence (BCR)-free survival rates were analyzed and compared based on the time interval from biopsy to surgery.

RESULTS

Pathologic upgrading of Gleason score in surgical specimens was more frequent in the longer time interval group and showed marginal significance (38.8% vs. 30.0%; P = 0.057). Based on multivariable analysis, an association was observed between time interval from biopsy to surgery and pathologic upgrading (odds ratio, 2.211; 95% confidence interval [CI], 1.342-3.645; P = 0.002). BCR-free survival did not differ based on time interval from biopsy to surgery, and significant association was not observed between time interval from biopsy to surgery and BCR on multivariable analysis (hazard ratio, 1.285; 95% CI, 0.795-2.077; P = 0.305).

CONCLUSION

Time interval ≥ 100 days from biopsy to RP in clinically localized PC increased the risk of pathologic upgrading but did not affect long-term BCR-free survival rates in Korean men.

Multi-disciplinary and shared decision-making approach in the management of organ-confined prostate cancer

Decision-making in the management of organ-confined prostate cancer is complex as it is based on multi-factorial considerations. It is complicated by a multitude of issues, which are related to the patient, treatment, disease, availability of equipment(s), expertise, and physicians. Combination of all these factors play a major role in the decision-making process and provide for an interactive decision-making preferably in the multi-disciplinary team (MDT) meeting. MDT decisions are comprehensive and are often based on all factors including patients' biological status, disease and its aggressiveness, and physician and centres' expertise. However, one important and often under rated factor is patient-related factors. There is considerable evidence that patients and physicians have different goals for treatment and physicians' understanding of their own patients' preferences is not accurate. Several patient-related key factors have been identified such as age, religious beliefs, sexual health, educational background, and cognitive impairment. We have focused on these areas and highlight some key factors that need to be taken considered whilst counselling a patient and understanding his choice of treatment, which might not always be match with the clinicians' recommendation.

Factors underlying treatment decision-making for localized prostate cancer in the U.S. and Canada: A scoping review using principal component analysis

INTRODUCTION

The purpose of this research is to gather, collate, and identify key factors commonly studied in localized prostate cancer (LPC) treatment decision-making in Canada and the U.S.

METHODS

This scoping review uses five databases (Medline, EMBASE, CINAHL, AMED, and PsycInfo) to identify relevant articles using a list of inclusion and exclusion criteria applied by two reviewers. A list of topics describing the themes of the articles was extracted and key factors were identified using principal component analysis (PCA). A word cloud of titles and abstracts of the relevant articles was created to identify complementary results to the PCA.

RESULTS

This review identified 77 relevant articles describing 32 topics related to LPC treatment decision-making. The PCA grouped these 32 topics into five key factors commonly studied in LPC treatment decision-making: 1) treatment type; 2) socioeconomic/demographic characteristics; 3) personal reasons for treatment choice; 4) psychology of treatment decision experience; and 5) level of involvement in the decision-making process. The word cloud identified common phrases that were complementary to the factors identified through the PCA.

CONCLUSIONS

This research identifies several possible factors impacting LPC treatment decision-making. Further research needs to be completed to determine the impact that these factors have in the LPC treatment decision-making experience.

Participation in a prostate cancer support group and health literacy

BACKGROUND

To cope with prostate cancer (PC) and its consequences and to be certain about therapeutic alternatives, some patients seek mutual help in prostate cancer support groups (PCSGs), where they share information and find social support. Our study was intended to assess whether group participation is associated with health literacy (HL).

METHODS

We compared PCSG members (n = 441) with PC patients without support group experiences (n = 135) in a cross-sectional design. For this purpose, HL was operationalized through PC-specific knowledge, noncancer-specific knowledge about health care, guideline awareness, and skills needed to apply health information to meet own needs. Binary logistic regression models were calculated. Socio-demographic data and disease-related characteristics were used as control variables.

RESULTS

Knowledge about PC (OR, 2.2; CI, 1.3-3.7), the fact of having heard of guidelines (OR, 3.7; CI, 2.1-6.8) and having read one (OR, 5.1; CI, 2.8-9.4), and competencies regarding health service navigation (OR, 1.8; CI, 1.0-3.1) are associated with PCSG membership. No statistically significant associations could be found between PCSG membership and further skills questioned, as well as between membership and knowledge about noncancer-specific health care.

CONCLUSION

PCSG membership is associated with HL in some areas only. In particular, the groups seem to provide an important platform for information exchange in the field of PC. The potentially conflicting results on PC knowledge and the application skills may arise from the different forms of measurement-knowledge was tested; skills were self-assessed.

Intermittent androgen deprivation therapy: recommendations to improve the management of patients with prostate cancer following the GRADE approach

PURPOSE

The purpose of this study was to provide evidence-based recommendations of intermittent androgen deprivation therapy (IADT) compared with continuous androgen deprivation therapy (CADT) for men with prostate cancer (PCA).

METHODS

We conducted a comprehensive search in MEDLINE, EMBASE, The Cochrane Library, CINAHL, and ECONLIT, from the database inception to December 2017. We adhered to the Grading of Recommendations, Assessment, Development and Evaluation framework to assess the quality of the evidence and to formulate recommendations.

RESULTS

We included one systematic review with 15 trials as well as three additional studies that assessed IADT versus CADT, all of them focused on PCA patients in advanced stages. The findings did not show differences for critical and important outcomes, including adverse events. Trials reported the benefits of IADT in terms of selected domains of health-related quality of life, although with high heterogeneity. Evidence quality was considered moderate or low for most of the assessed outcomes. We identified a patient preference study reporting a high preference for IADT, due to issues related to quality of life, general well-being, and side effects, among others. We did not identify economic studies comparing these regimes. We formulate four recommendations: one no-recommendation, one conditional recommendation, and two good practice points.

CONCLUSION

For men in early stages of PCA, it is not possible to make any recommendation about the preferable use of IADT or CADT due to the lack of available evidence. For men in advanced stages of the disease, an IADT should be considered as soon as clinically reasonable (weak recommendation and low certainty of the evidence). Clinicians should discuss the risks and benefits of IADT and CADT with their patients, taking into account their values and preferences.

Mind the gap: Physicians' assessment of patients' importance weights in localized prostate cancer

BACKGROUND

The management of localized prostate cancer is challenging because of the many therapeutic options available, none of which is generally acknowledged as superior to the others in every respect. The selection of the most appropriate treatment should therefore reflect patients' preferences.

OBJECTIVE

The purpose of the following study was to pilot a new approach for investigating whether urologists who had previously provided patients with therapeutic advice actually knew their patients' importance weights concerning the relevant aspects of the treatments at issue.

METHOD

Participants were patients recently diagnosed with localized prostate cancer (n = 20), urologists (n = 10), and non-medical professionals (architects, n = 10). These last served as a control group for the urologists and were matched to them for age and gender. Patients' importance weights were elicited by two standard methods (Direct Rating and Value Hierarchy). Each urologist was asked to estimate (with Direct Rating) his/her patient's importance weights. The same task was performed by a corresponding architect, who never met the patient and knew only the patient's age. Univariate and bivariate statistical analyses were performed to investigate the association between importance weights as elicited from patients and as estimated by urologists and architects, as well as to assess whether such agreement was attribute-dependent.

RESULTS

Participants found both elicitation methods easy to use. The correlation between patients' actual importance weights and urologists' estimates was poor and comparable to that obtained between patients and architects. This result did not depend on the attribute considered, with the sole exception of the attribute "Effectiveness in curing the cancer", which was evaluated as the most important attribute by the majority of participants.

CONCLUSION

These findings demonstrate the feasibility of the employed methodology and highlight the need to support preference-sensitive decisions in clinical practice by facilitating the elicitation of patients' importance weights, as well as their communication to physicians.

Systematic Review of Decision Aids for the Management of Men With Localized Prostate Cancer

A broader range of decisional tools should be investigated. This paper will update the decisional outcome data and assess the features of decisional tool. Literature search strictly followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Articles that cited Lin et al and Violette et al were searched. Features of decisional tools were analyzed using the International Patient Decision Aid Standards Instrument criteria. The scores of the 31 decisional tools ranged from 6 to 15, which did not correlate proportionally with the positive decisional outcomes. Personal importance appeared to be a significant component. Multidisciplinary clinics are superior in improving decisional outcomes as they promote more at shared decision making.

Patient and provider experiences with active surveillance: A scoping review

Objective

Active surveillance (AS) represents a fundamental shift in managing select cancer patients that initiates treatment only upon disease progression to avoid overtreatment. Given uncertain outcomes, patient engagement could support decision-making about AS. Little is known about how to optimize patient engagement for AS decision-making. This scoping review aimed to characterize research on patient and provider communication about AS, and associated determinants and outcomes.

Methods

MEDLINE, EMBASE, CINAHL, and The Cochrane Library were searched from 2006 to October 2016. English language studies that evaluated cancer patient or provider AS views, experiences or behavioural interventions were eligible. Screening and data extraction were done in duplicate. Summary statistics were used to describe study characteristics and findings.

Results

A total of 2,078 studies were identified, 1,587 were unique, and 1,243 were excluded based on titles/abstracts. Among 344 full-text articles, 73 studies were eligible: 2 ductal carcinoma in situ (DCIS), 4 chronic lymphocytic leukemia (CLL), 6 renal cell carcinoma (RCC) and 61 prostate cancer. The most influential determinant of initiating AS was physician recommendation. Others included higher socioeconomic status, smaller tumor size, comorbid disease, older age, and preference to avoid adverse treatment effects. AS patients desired more information about AS and reassurance about future treatment options, involvement in decision-making and assessment of illness uncertainty and supportive care needs during follow-up. Only three studies of prostate cancer evaluated interventions to improve AS communication or experience.

Conclusions

This study revealed a paucity of research on AS communication for DCIS, RCC and CLL, but generated insight on how to optimize AS discussions in the context of routine care or clinical trials from research on AS for prostate cancer. Further research is needed on AS for patients with DCIS, RCC and CLL, and to evaluate interventions aimed at patients and/or providers to improve AS communication, experience and associated outcomes.

Quality of life in active surveillance and the associations with decision-making-a literature review

Several studies have been conducted on the quality of life (QoL) in men with low risk prostate cancer (PCa) who choose active surveillance (AS). While recent reviews have shown a lack of consistency among the available QoL-studies, a few key points have been identified, including decision-making (DM)-related issues and their potential effect on QoL. The importance of this theme has also been recently highlighted by the international task force of the European School of Oncology. However, to our knowledge, there are no studies that have specifically marshalled scientific knowledge on the association between DM and QoL among men with low-risk PCa undergoing AS. We performed a literature review to fill this gap, taking a systematic approach to retrieving and selecting articles that included both DM and QoL measures. Among the 272 articles retrieved, we selected nine observational, quantitative articles with both DM and QoL measures. The most considered DM aspects within these studies were decisional conflict and preference for the patient’s role in the DM process, as well as health-related QoL aspects. The studies included 42 assessments of the relationship between an empirical measure of DM and an empirical measure of QoL. Among these assessments, 23 (55%) were both positive and significant. They mostly concerned the relationship between patient-related (decisional self-efficacy, decisional control and knowledge) and external (presence of social support, collaborative role within the DM process, and influence of different physicians) DM aspects, as well as the QoL after choice. The findings of these studies revealed key challenges to research and clinical practice related to DM and QoL in AS. These include adopting a person-centred perspective where clinicians, caregivers and their interactions are also included in evaluations and where the psychosocial existential experience of individuals within the DM and AS journey is considered. Much more attention needs to be paid to the DM process after diagnosis, as well as to all the other moments where patients may have to or want to review their decision. Healthcare professionals play a key role in enabling men to make informed decisions and to take care of their health and well-being during AS. There is still work that needs to be done in training healthcare professionals from different disciplines to work together in a model of shared DM and AS tailored to the needs of low-risk PCa patients and their family members.

Urinary Incontinence, Patient Satisfaction, and Decisional Regret after Prostate Cancer Treatment: A French National Study

BACKGROUND

Complications of prostate cancer treatments have a substantial impact on the patient's quality of life. We evaluated the prevalence of urinary consequences and factors affecting patient satisfaction and decisional regret after treatment.

METHODS

A retrospective self-administered questionnaire was sent to all members of the National Association of Prostate Cancer Patients in France.

RESULTS

From the 226 completed questionnaires received, the following information was obtained: 110 patients underwent surgery only, 29 received radiotherapy plus hormone therapy, 28 received radiotherapy only, and 49 received other combination treatments. The median follow-up period was 58.1 months. After treatment, the presence of urinary incontinence was reported by 34.5% of patients treated by radical prostatectomy, by 10.3% treated by radiotherapy plus hormone therapy, by 17.8% treated by curitherapy or radiotherapy only, and by 38.7% treated by other combination therapy (p = 0.01). The main reasons for decisional regret were the fact that patients received incomplete information about prostate cancer (40%) and consequences of treatment that affected the urinary system (34%). The information received about cancer was considered complete in 32.3% of the satisfied group and 14.3% of the decisional regret group (p = 0.003) and with regard to urinary incontinence the information received was considered complete in 41.4 and 17.4% respectively (p < 0.01).

CONCLUSIONS

Urinary consequences of prostate cancer treatment are common and impact the quality of life. Patients need clear information to be able to participate in therapeutic decision-making and to avoid subsequent decisional regret.

Canadian Men's perspectives about active surveillance in prostate cancer: need for guidance and resources

Background

In prostate cancer, men diagnosed with low risk disease may be monitored through an active surveillance. This research explored the perspectives of men with prostate cancer regarding their decision-making process for active surveillance to identify factors that influence their decision and assist health professionals in having conversations about this option.

Methods

Focus group interviews (n = 7) were held in several Canadian cities with men (N = 52) diagnosed with prostate cancer and eligible for active surveillance. The men’s viewpoints were captured regarding their understanding of active surveillance, the factors that influenced their decision, and their experience with the approach. A content and theme analysis was performed on the verbatim transcripts from the sessions.

Results

Patients described their concerns of living with their disease without intervention, but were reassured by the close monitoring under AS while avoiding harmful side effects associated with treatments. Conversations with their doctor and how AS was described were cited as key influences in their decision, in addition to availability of information on treatment options, distrust in the health system, personality, experiences and opinions of others, and personal perspectives on quality of life.

Conclusions

Men require a thorough explanation on AS as a safe and valid option, as well as guidance towards supportive resources in their decision-making.

Health Literacy Is an Independent Predictor of Cancer Patients' Hospitalizations

Background

Lower levels of health literacy predict higher hospitalization rates. Hospitalization is expensive and many admissions are potentially avoidable. Research examining the relationship between health literacy and health outcomes for cancer patients is limited, and no published studies to date have focused on hospitalization and health literacy in cancer patients.

Objective

This study examined the ability of health literacy to predict hospitalization of cancer patients.

Methods

This secondary data analysis investigated the relationship between health literacy and hospitalization rates of adult cancer patients in the first 5 years after their diagnosis. The sample included a diverse selection of cancer diagnoses and all stages of cancer were represented. Health literacy was assessed using the Cancer Health Literacy Test 30 (CHLT-30), a psychometrically sound measure of health literacy validated in a cancer patient population. Health literacy's ability to predict the number of times hospitalized, total days spent hospitalized, and number of 30-day readmissions was examined using multivariate negative binomial multiple regression to control for the outcomes and potentially confounding variables.

Key Results

When controlling for potentially confounding variables, a negative relationship was found between health literacy and the number of inpatient hospitalizations (β = -0.041, p = .009) and the total number of days spent hospitalized (β = -0.028, p = .023) independently, whereas the relationship between health literacy and the number of 30-day readmissions failed to reach significance (β = -0.002, p = .903).

Conclusions

Patients with lower health literacy need additional assistance to avoid unplanned hospitalizations. [Health Literacy Research and Practice. 2017;1(4):e153-e162.].

Plain Language Summary

Results from this study found that as cancer patients' health literacy scores decreased, the number of times hospitalized and the total number of days spent in the hospital increased. This relationship was significant when controlling for diagnosis, stage at diagnosis, receipt of chemotherapy, number of comorbidities, death, education, and race. Cancer patients with low health literacy are at a higher risk of being hospitalized.

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.