Is 'watchful waiting' a real choice for men with prostate cancer? A qualitative study

Factors Influencing Patient Decision-Making in the Treatment of Muscle-Invasive Bladder Cancer

BACKGROUND

In 2023, an estimated 82,290 individuals were diagnosed with bladder cancer in the United States. For muscle-invasive bladder cancer (MIBC), the American Urological Association recommends offering radical cystectomy with cisplatin-based neoadjuvant chemotherapy. However, patients are increasingly requesting alternative treatments.

OBJECTIVE

To describe factors influencing selection of radical cystectomy with cisplatin-based neoadjuvant chemotherapy (NAC + RC), radical cystectomy monotherapy (RC), or tri-modality therapy (TMT) among patients with MIBC.

METHODS

Individual, semi-structured phone interviews were conducted with 18 adults who underwent MIBC treatment at the University of North Carolina, recruiting six patients each from three treatment groups: 1) NAC + RC, 2) RC, and 3) TMT. Interview transcriptions were qualitatively analyzed using QSR NVivo, with major themes and sub-themes extracted. Patients also completed the Shared Decision-Making Questionnaire (SDM-Q-9; range 0-100).

RESULTS

Concern for survival and risks, quality of life, and varied patient preferences for involvement influenced the decision-making process. Concern surrounding sexual function, bladder preservation, and urostomy bags drove patients towards TMT. High levels of shared decision-making were observed overall, with a median SDM-Q-9 score of 95 (IQR 89-100). Patients undergoing TMT reported the highest median SDM-Q-9 score (97, IQR 94-100), while those receiving radical cystectomy alone had the lowest (66, IQR 37-96).

CONCLUSIONS

Patients with MIBC described a multifaceted treatment decision-making process, highlighting key influences, concerns, and unmet needs. Understanding this process can help address misconceptions and align treatment choices with patient goals. Physicians can use these insights to engage in shared decision-making, ultimately improving patient experiences and outcomes.

Differences between physician and patient preferences for cancer treatments: a systematic review

BACKGROUND

Shared decision-making is useful to facilitate cancer treatment decisions. However, it is difficult to make treatment decisions when physician and patient preferences are different. This review aimed to summarize and compare the preferences for cancer treatments between physicians and patients.

METHODS

A systematic literature search was conducted on PubMed, Embase, PsycINFO, CINAHL and Scopus. Studies elicited and compared preferences for cancer treatments between physicians and patients were included. Information about the study design and preference measuring attributes or questions were extracted. The available relative rank of every attribute in discrete choice experiment (DCE) studies and answers to preference measuring questions in non-DCE studies were summarized followed by a narrative synthesis to reflect the preference differences.

RESULTS

Of 12,959 studies identified, 8290 were included in the title and abstract screening and 48 were included in the full text screening. Included 37 studies measured the preferences from six treatment-related aspects: health benefit, adverse effects, treatment process, cost, impact on quality of life, and provider qualification. The trade-off between health benefit and adverse effects was the main focus of the included studies. DCE studies showed patients gave a higher rank on health benefit and treatment process, while physicians gave a higher rank on adverse effects. Non-DCE studies suggested that patients were willing to take a higher risk of adverse effects or lower health benefit than physicians when accepting a treatment.

CONCLUSIONS

Physicians and patients had important preference differences for cancer treatment. More sufficient communication is needed in cancer treatment decision-making.

Factors that influence treatment decisions: A qualitative study of racially and ethnically diverse patients with low- and very-low risk prostate cancer

BACKGROUND

Factors that influence prostate cancer treatment decisions are complex, multifaceted, and personal, and may vary by race/ethnicity. Although research has been published to quantify factors involved in decision-making, these studies have been limited to primarily white, and to a lesser extent, Black patients, and quantitative studies are limited for discerning the cultural and contextual processes that shape decision-making.

METHODS

We conducted 43 semi-structured interviews with a racially and ethnically diverse sample of patients diagnosed with low- and very-low risk prostate cancer who had undergone treatment for their prostate cancer. Interviews were transcribed, independently coded, and analyzed to identify themes salient for decision-making, with attention to sociocultural differences.

RESULTS

We found racial and ethnic differences in three areas. First, we found differences in how socialized masculinity influenced patient's feelings about different treatment options. Second, we found that for some men, religion and spirituality alleviated anxiety associated with the active surveillance protocol. Finally, for racially and ethnically minoritized patients, we found descriptions of how historic and social experiences within the healthcare system influenced decision-making.

CONCLUSIONS

Our study adds to the current literature by expounding on racial and ethnic differences in the multidimensional, nuanced factors related to decision-making. Our findings suggest that factors associated with prostate cancer decision-making can manifest differently across racial and ethnic groups, and provide some guidance for future research.

How do cancer patients refuse treatment? A grounded theory study

BACKGROUND

All cancer patients, except for a small fraction, seek treatment after becoming aware of the disease. That small fraction do not seek any treatment due to various reasons, and this phenomenon is unknown to us. Therefore, the present study aimed to discover the reasons for treatment refusal in cancer patients.

METHODS

This qualitative grounded theory study was conducted on 22 participants including patients, caregivers, physicians, and nurses. Purposive theoretical sampling was employed. Data were collected through in-depth interviews. All interviews were gradually transcribed and analyzed. Data analysis was carried out through the three-step method of open, axial, and selective coding and was continued until theoretical saturation. Straussian Grounded Theory was used for data analysis.

RESULTS

A total of 4 themes and 20 sub-themes were extracted in this study. The core variable extracted from the interviews was "resilience" Other related themes included encounter with cancer, fighting cancer, and coping with cancer. The findings showed that in the context of fighting cancer, patients lost their resilience through various processes and refused treatment.

CONCLUSION

Cancer patients abandon the treatment in silence, oncologists and even family members being unaware of the matter. In other words, refusal of treatment is like an iceberg and the majority of the patients who have abandoned treatment are unknown to the health system. The model obtained in this study can increase the knowledge of the process that leads patients to lose their resilience against cancer and abandon treatment, which can increase the possibility of recognizing and predicting treatment refusal for oncologists.

Worsening Quality of Life in Indolent Non-Hodgkin Lymphoma and Chronic Lymphocytic Leukemia Patients in Active Surveillance: A 12-Month Longitudinal Study

INTRODUCTION

Newly diagnosed indolent non-Hodgkin lymphoma and chronic lymphocytic leukemia (NHL/CLL) patients are often monitored for disease progression to delay the impact of cancer-directed therapy on patients' quality of life. However, research on quality of life in patients under active surveillance versus in cancer-directed treatment has yielded mixed results. This study examined distress and quality of life in indolent NHL/CLL patients in active surveillance or cancer-directed treatment over the first-year post-diagnosis.

PATIENTS AND METHODS

Adult patients (≥21 years) with newly diagnosed indolent NHL/CLL completed electronic self-report measure of distress and quality of life every 4 months over the course of a year for a total of 4 surveys. Fisher's exact test and t-tests were used to examine demographic and disease differences between patients receiving different treatments. Mixed-effect models were also used to compare overall differences between treatment status over time, accounting for missing values.

RESULTS

The sample consisted of 64 patients with known baseline treatment status who did not change treatments over the course of the study. Total quality of life and physical, social and functional quality of life improved over time in patients receiving cancer-directed treatment and decreased over time in patients under active surveillance. Relative to patients in active treatment, overall, social, and functional quality of life in patients under surveillance changed more slowly over time.

DISCUSSION

Active surveillance may have negative implications for patient quality of life, despite that a common goal of active surveillance is to delay the impact of treatment (e.g., appointments, toxicities) on quality of life.

Patient reported factors influencing the decision-making process of men with localised prostate cancer when considering Active Surveillance-A systematic review and thematic synthesis

OBJECTIVES

Outcomes for men with localised prostate cancer managed with Active Surveillance (AS) are similar to outcomes for men who have received Active Treatment. This review explore men's perceptions of the factors that influence their decision-making process when considering AS.

METHOD

A systematic review of studies was conducted up to May 2021, including qualitative studies which explored the decision making of men with localised prostate cancer when considering AS. Evidence was analysed using thematic synthesis.

RESULTS

Thirteen papers, including 426 men, met inclusion criteria and were analysed in the review. Approximately half of the men had chosen AS and half had chosen Active Treatment. The choice of AS was not a one-off decision but rather an ongoing behaviour. Four themes were identified and considered within a temporal model: pre-diagnosis representations of cancer and treatment; experience of testing and diagnosis; patient decision making; and emotional adjustment to AS. Key barriers and facilitators to men choosing AS were identified. In deciding whether or not to choose AS, men balanced a desire for quality of life against fear of cancer progression.

CONCLUSIONS

Both cognitive representations and emotional arousal influence how men decided whether or not to opt for AS. Interventions tailored to elicit and address emotional appraisals of risk, and increase trust in AS protocols, may be of value in helping men to make decisions around treatment for localised prostate cancer.

Inpatient admissions and outpatient appointments in the first year post cancer diagnosis: A population based study from England

BACKGROUND

Time spent in hospital (length of stay) is an important component of patient experience and the financial cost of cancer care. This study documents the length of stay across English cancer diagnoses at a national level and reports on variation by patient demographics and tumour characteristics.

METHODS

Data on all diagnoses of malignant neoplasms from the English National Cancer Registration and Analysis Service for 252,202 patients first diagnosed in 2015 was linked with NHS Digital's Admitted Patient Care and Outpatient Hospital Episode Statistics datasets to quantify length of stay within one year following diagnosis. Length of stay was modelled using linear regression adjusted for sex, age, tumour type, stage, time spent alive during the study period, vital status at end of study period, region, deprivation and ethnicity.

RESULTS

Patients spend a mean of 25 days (median = 17 days; IQR = 8-34 days) in hospital in their first year. Tumour type, stage, age and vital status corrections had the strongest effects in the model adjusting for other independent variables. Younger patients tended towards longer stays.

CONCLUSION

Length of stay varies among patients by tumour type, age and stage. Estimating future health service demands should account for changes in incident tumour characteristics.

Risks and Benefits of Web-Based Patient Narratives: Systematic Review

Background

Patient narratives are illustrative, individual accounts of patients’ experiences with certain health conditions. Web-based patient narratives have become widely available on the internet and in social media, as part of electronically available patient decision aids or Web-based databases. In recent years, the role of patient narratives as a source of information, insight, and support for both health care users and providers has increasingly been emphasized. Although the potential impact of patient stories has high immediate plausibility, it is of interest to know if this impact can be captured in quantitative studies.

Objective

This review aimed to evaluate whether research-generated Web-based patient narratives have quantifiable risks or benefits for (potential) patients, relatives, or health care professionals.

Methods

We searched the following databases from August 2017 to March 2019: Medical Literature Analysis and Retrieval System Online, PsycInfo, Sociological Abstracts, Web of Science, and EMBASE. Titles and abstracts of the retrieved studies were reviewed and assessed for the inclusion and exclusion criteria. Papers were included if they studied the following: (1) (potential) patients, relatives, or health care professionals; (2) the effects of Web-based patient narratives that were generated scientifically (eg, through qualitative research methods); and (3) were quantitative studies. Furthermore, 2 authors independently performed an assessment of the quality of the included studies using a validated checklist.

Results

Of 4226 documents, 17 studies met the inclusion criteria. The studies investigated 10 different sources of Web-based patient narratives. Sample sizes ranged from 23 to 2458. The mean score of the quality assessment was 82.6 (range 61-100). Effects regarding five different purposes were identified as follows: provide information, engage, model behavior, persuade, and comfort. We found positive effects in every category and negative effects in one category (persuade). Several of the reported effects are rather small or were identified under specific experimental conditions.

Conclusions

Patient narratives seem to be a promising means to support users in improving their understanding of certain health conditions and possibly to provide emotional support and have an impact on behavioral changes. There is limited evidence for beneficial effects on some outcomes. However, narratives are characterized by considerable heterogeneity and the investigated outcomes are hardly comparable with each other, which makes the overall judgment difficult. As there are numerous possible measures and purposes of narratives, quantifying the impact of Web-based patient narratives remains a challenge. Future research is needed to define the optimal standards for quantitative approaches to narrative-based interventions.

Identifying the exercise-based support needs and exercise programme preferences among men with prostate cancer during active surveillance: A qualitative study

PURPOSE

This study aims to investigate the attitudes and preferences men on active surveillance for prostate cancer have regarding exercise and exercise-based support. Exercise outcomes align with traditionally masculine values, can improve mental and physical health, and may even slow early stage prostate cancer progression. However, attitudes and preferences towards exercise and exercise support are unexplored in men on active surveillance.

METHODS

Semi-structured qualitative interviews were conducted with participants (13 males with a history of active surveillance for prostate cancer; 5 female partners). Interviews were conducted either by telephone or in person and audiotaped, transcribed verbatim, and thematically analysed.

RESULTS

Several key themes were identified relating to the two research aims: 'Attitudes and Preferences towards Exercise, and 'Attitudes and Preferences towards Exercise Support'. Despite all men engaging in exercise, the majority did not meet the recommended guidelines for cancer survivors. The majority of men either were interested in receiving exercise support or had previously received it, often recommending this for all men on active surveillance. There were varied preferences regarding delivery modality (i.e., online or face to face), the inclusion of partners, and group versus individual formats.

CONCLUSIONS

This study provides a novel insight into the attitudes and preferences of men on active surveillance regarding exercise and support. This research will help the development of acceptable and accessible person-centred support for men on active surveillance. However, further research is needed to evaluate the efficacy of different delivery modalities in this population.

Resisting recommended treatment for prostate cancer: a qualitative analysis of the lived experience of possible overdiagnosis

OBJECTIVE

To describe the lived experience of a possible prostate cancer overdiagnosis in men who resisted recommended treatment.

DESIGN

Qualitative interview study SETTING: Australia PARTICIPANTS: 11 men (aged 59-78 years) who resisted recommended prostate cancer treatment because of concerns about overdiagnosis and overtreatment.

OUTCOMES

Reported experience of screening, diagnosis and treatment decision making, and its impact on psychosocial well-being, life and personal circumstances.

RESULTS

Men's accounts revealed profound consequences of both prostate cancer diagnosis and resisting medical advice for treatment, with effects on their psychological well-being, family, employment circumstances, identity and life choices. Some of these men were tested for prostate-specific antigen without their knowledge or informed consent. The men felt uninformed about their management options and unsupported through treatment decision making. This often led them to develop a sense of disillusionment and distrust towards the medical profession and conventional medicine. The findings show how some men who were told they would soon die without treatment (a prognosis which ultimately did not eventuate) reconciled issues of overdiagnosis and potential overtreatment with their own diagnosis and situation over the ensuing 1 to 20+ years.

CONCLUSIONS

Men who choose not to have recommended treatment for prostate cancer may avoid treatment-associated harms like incontinence and impotence, however our findings showed that the impact of the diagnosis itself is immense and far-reaching. A high priority for improving clinical practice is to ensure men are adequately informed of these potential consequences before screening is considered.

Appraising risk in active surveillance of localized prostate cancer

Objectives

Men diagnosed with low‐risk prostate cancer are typically eligible for active surveillance of their cancer, involving monitoring for cancer progression and making judgements about the risks of prostate cancer against those of active intervention. Our study examined how risk for prostate cancer is perceived and experienced by patients undergoing active surveillance with their clinicians, how risk is communicated in clinical consultations, and the implications for treatment and care.

Method

Participants were nine patients and three clinicians from a university hospital urology clinic. A staged, qualitative, multi‐method data collection approach was undertaken, comprising: observations of consultations; patient and clinician interviews; and patient surveys. The three data sets were analysed separately using thematic analysis and then integrated to give a comprehensive view of patient and clinician views.

Results

Thirty data points (eight patient surveys; 10 observations of consultations between patients and clinicians; 10 patient interviews; and two clinician interviews) combined to create a detailed picture of how patients perceived and appraised risk, in three themes of “Making sense of risk”, “Talking about risk” and “Responding to risk”.

Conclusion

Effective risk communication needs to be finely tuned and timed to individual patient's priorities and information requirements. A structured information exchange process that identifies patients' priorities, and details key moments in risk assessment, so that complexities of risk are discussed in ways that are meaningful to patients, may benefit patient care. These findings could inform the development of patient‐centric risk assessment procedures and service delivery models in prostate cancer care more broadly.

Factors Influencing Men's Choice of and Adherence to Active Surveillance for Low-risk Prostate Cancer: A Mixed-method Systematic Review

CONTEXT

Despite support for active surveillance (AS) as a first treatment choice for men with low-risk prostate cancer (PC), this strategy is largely underutilised.

OBJECTIVE

To systematically review barriers and facilitators to selecting and adhering to AS for low-risk PC.

EVIDENCE ACQUISITION

We searched PsychINFO, PubMed, Medline 2000-now, Embase, CINAHL, and Cochrane Central databases between 2002 and 2017 using the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. The Purpose, Respondents, Explanation, Findings and Significance (PREFS) and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) quality criteria were applied. Forty-seven studies were identified.

EVIDENCE SYNTHESIS

Key themes emerged as factors influencing both choice and adherence to AS: (1) patient and tumour factors (age, comorbidities, knowledge, education, socioeconomic status, family history, grade, tumour volume, and fear of progression/side effects); (2) family and social support; (3) provider (speciality, communication, and attitudes); (4) healthcare organisation (geography and type of practice); and (5) health policy (guidelines, year, and awareness).

CONCLUSIONS

Many factors influence men's choice and adherence to AS on multiple levels. It is important to learn from the experience of other chronic health conditions as well as from institutions/countries that are making significant headway in appropriately recruiting men to AS protocols, through standardised patient information, clinician education, and nationally agreed guidelines, to ultimately decrease heterogeneity in AS practice.

PATIENT SUMMARY

We reviewed the scientific literature for factors affecting men's choice and adherence to active surveillance (AS) for low-risk prostate cancer. Our findings suggest that the use of AS could be increased by addressing a variety of factors such as information, psychosocial support, clinician education, and standardised guidelines.

Molecular-integrated risk profile to determine adjuvant radiotherapy in endometrial cancer: Evaluation of the pilot phase of the PORTEC-4a trial

OBJECTIVE

The Post-Operative Radiation Therapy in Endometrial Carcinoma (PORTEC)-4a trial is a randomized trial for women with high-intermediate risk endometrial cancer (EC), comparing individualized adjuvant treatment based on a molecular-integrated risk profile to standard adjuvant treatment; vaginal brachytherapy. To evaluate patient acceptability and pathology logistics of determining the risk profile, a pilot phase was included in the study.

METHODS

PORTEC-4a is ongoing and the first 50 patients enrolled were included in the pilot phase. Primary endpoints of the pilot phase were patient acceptance, evaluated by analyzing the screening logs of the participating centers, and logistical feasibility of determination of the risk profile within 2 weeks, evaluated by analyzing the pathology database.

RESULTS

In the first year, 145 eligible women were informed about the trial at 13 centers, of whom 50 (35%) provided informed consent. Patient accrual ranged from 0 to 57% per center. Most common reasons for not participating were: not willing to participate in any trial (43.2%) and not willing to risk receiving no adjuvant treatment (32.6%). Analysis of the pathology database showed an average time between randomization and determination of the molecular-integrated risk profile of 10.2 days (1-23 days). In 5 of the 32 patients (15.6%), pathology review took >2 weeks.

CONCLUSIONS

The PORTEC-4a trial design was proven feasible with a satisfactory patient acceptance rate and an optimized workflow of the determination of the molecular-integrated risk profile. PORTEC-4a is the first randomized trial to investigate use of a molecular-integrated risk profile to determine adjuvant treatment in EC.

Patient Factors That Influence How Physicians Discuss Active Surveillance With Low-Risk Prostate Cancer Patients: A Qualitative Study

For men diagnosed with prostate cancer, making treatment decisions can be overwhelming. Navigating treatment options, along with potential treatment side effects, can be difficult, and patients often rely heavily on the advice of their physicians. This study was aimed at understanding more about the way urologists talk with their patients about one treatment option: active surveillance (AS), a recognized management strategy for men with low-risk prostate cancer that includes close observation and monitoring of the cancer. This study reports, through 22 interviews with urologists, that urologists believe patients are hesitant about AS for a number of reasons, including misperceptions about cancer severity, anxiety, aversion to repeated biopsies that accompany AS, or family member preferences. Because urologists play an influential role in educating patients about treatment options, the discussion around AS can be impacted by barriers that physicians believe matter for their patients. Improving awareness among urologists about what factors impact their patient education about low-risk prostate cancer is important. Identifying tools to improve shared decision making in this area could result in treatment decisions that are increasingly concordant with patients' values, concerns, and goals.

The experience of adults who choose watchful waiting or active surveillance as an approach to medical treatment: a qualitative systematic review

BACKGROUND

"Watchful waiting" or "active surveillance" is an alternative approach in the medical management of certain diseases. Most often considered appropriate as an approach to treatment for low-risk prostate cancer, it is also found in the literature in breast cancer surveillance, urinary lithiasis, lymphocytic leukemia, depression and small renal tumors.

OBJECTIVES

This systematic review sought to:Identify and synthesize the best available international evidence on the experience of adults who choose watchful waiting or active surveillance as an approach to medical treatment. To this end the questions addressed in this review were:1. How do patients who have chosen watchful waiting or active surveillance describe the process of coming to the decision?2. What were the factors that influenced their decision to choose?3. How do patients who have chosen watchful waiting or active surveillance describe the experience?

INCLUSION CRITERIA

Male or female patients, 18 years or older, who experience the phenomenon of choosing or not choosing watchful waiting or active surveillance as a treatment approach.The phenomena of interest were accounts of the experiences of adult patients who choose watchful waiting or active surveillance as an approach to medical treatment.This review considered studies that focused on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and critical theory. Mixed method studies with narrative description and patient voice were also considered. Grey literature such as research reports and dissertations were also included.

SEARCH STRATEGY

The search strategy aimed to find both published and unpublished studies through electronic databases, reference lists, and the World Wide Web. Extensive searches were undertaken of relevant databases to include CINAHL, PubMed, SCOPUS and PsycINFO. A three-step search strategy was used in each component of the review. Studies were limited to English language papers. The search considered papers from the year 2000 to January 2015.

METHODOLOGICAL QUALITY

Qualitative papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI). Any disagreements that arose between the reviewers were resolved through discussion, or with a third reviewer.

DATA EXTRACTION

Qualitative data were extracted from papers included in the review using the standardized data extraction tool from. The data extracted included specific details about the phenomena of interest that described the experiences pertinent to the review questions

DATA SYNTHESIS

The data were synthesized using the Joanna Briggs Institute approach to meta-synthesis by meta-aggregation using the JBI-QARI software and methods.

RESULTS

A total of 16 studies, critically appraised by two independent reviewers and deemed to be of high quality, were included in the final review. One study was excluded after appraisal. One hundred and fifty-five findings from the 16 studies were extracted into 10 categories and then into three synthesized findings. The synthesized findings explicated:

CONCLUSIONS

The synthesized findings of the review conclude that the process of making the decision to choose watchful waiting is complex. Through the process patients and their significant others experience an array of emotions that often lead to uncertainty and anxiety. Once the decision is made patients must cope with the knowledge that they have a troubling diagnosis and make the necessary adjustments. An empathic, reassuring relationship with a healthcare practitioner eases the burden of this process.Healthcare providers need to recognize that not all patients are "at peace" with the decision of choosing watchful waiting. Uncertainty and fear may intensify during this time as well as feelings of stress and anxiety. Patients and their significant others often attempt to adapt in the best way they know how but the effectiveness of their coping strategies needs to be assessed. In addition, healthcare providers need to also be aware that with the increased anxiety and stress associated with watchful waiting, patients' understanding of healthcare information and the ability to ask questions may be diminished. Both providers and patients benefit from open discussions related to the many aspects of uncertainty and fear related to making and living with the decision. Employing a shared decision making model with regard to the management of the array of issues that comes from both making the decision and living with it is recommended. It appears that patients are very sensitive to recognizing when the care they are receiving lacks empathy. Communication that is open, empathic, and non-judgmental is essential. A willingness to discuss sensitive issues such as sexual function needs to be conveyed. Lastly, providers and their staff need to remain attentive to the importance of articulating aspects of the situation that are hopeful and optimistic as many patients, during their visits, take their cues regarding their health status from non-verbal and verbal interactions.Future studies should investigate.

Experience of US Patients Who Self-identify as Having an Overdiagnosed Thyroid Cancer: A Qualitative Analysis

Importance

Overdiagnosis of cancer-the identification of cancers that are unlikely to progress-is a source of discomfort and challenge for patients, physicians, and health care systems. A major cause of this discomfort is the inability to know prospectively with certainty which cancers are overdiagnosed. In thyroid cancer, as patients have begun to understand this concept, some individuals are independently deciding not to intervene, despite this practice not yet being widely accepted.

Objective

To describe the current experience of people who independently self-identify as having an overdiagnosed cancer and elect not to intervene.

Design, Setting, and Participants

In this qualitative study, semistructured interviews were conducted between July 1 and December 31, 2015, with 22 community-dwelling adults aged 21 to 75 years who had an incidentally identified thyroid finding that was known or suspected to be malignant and who questioned the intervention recommended by their physicians. Verbatim transcripts were analyzed using constant comparative analysis.

Main Outcomes and Measures

The experience of individuals who self-identify as having an overdiagnosed cancer and elect not to intervene.

Results

Of the 22 people interviewed (16 females and 6 males; mean age, 48.5 years), 18 had elected not to intervene on their thyroid finding and had been living with the decision for a mean of 39 months (median, 40 months; range, 1-88 months). Twelve of the 18 participants reported that they experienced significant anxiety about cancer progression, but had considered reasons for choosing nonintervention: understanding issues of precision in diagnostic testing and the varied behavior of cancer, surgical risks, medication use, and low risk of death from the cancer. Twelve participants described their decisions as met with nonreassuring, unsupportive responses. Medical professionals, friends, and internet discussion groups told them they were "being stupid," "were wrong," or were "crazy" to not intervene. Although 14 individuals said they wished to connect with others about their experiences, only 3 reported success in doing so. Fifteen participants reported that they managed their overall experience through secret keeping. By the time of this study, 5 of the 18 individuals had discontinued surveillance, the recommended alternative to intervention. Despite this, only 7 participants "wished they did not know" about their thyroid finding.

Conclusions and Relevance

Isolation and anxiety characterize the current experience of patients with thyroid cancer who are living with the decision to not intervene. These patients are at risk of disengaging from health care. Successful de-escalation of intervention for patients who self-identify as having overdiagnosed cancers requires explicit social and health system support and education. We hypothesize that improved support would also promote quality of care by increasing the likelihood that patients could be kept engaged for recommended surveillance.

Influence of Men's Personality and Social Support on Treatment Decision-Making for Localized Prostate Cancer

Background

Optimal treatment for localized prostate cancer (LPC) is controversial. We assessed the effects of personality, specialists seen, and involvement of spouse, family, or friends on treatment decision/decision-making qualities.

Methods

We surveyed a population-based sample of men ≤ 75 years with newly diagnosed LPC about treatment choice, reasons for the choice, decision-making difficulty, satisfaction, and regret.

Results

Of 160 men (71 black, 89 white), with a mean age of 61 (±7.3) years, 59% chose surgery, 31% chose radiation, and 10% chose active surveillance (AS)/watchful waiting (WW). Adjusting for age, race, comorbidity, tumor risk level, and treatment status, men who consulted friends during decision-making were more likely to choose curative treatment (radiation or surgery) than WW/AS (OR = 11.1, p < 0.01; 8.7, p < 0.01). Men who saw a radiation oncologist in addition to a urologist were more likely to choose radiation than surgery (OR = 6.0, p = 0.04). Men who consulted family or friends (OR = 2.6, p < 0.01; 3.7, p < 0.01) experienced greater decision-making difficulty. No personality traits (pessimism, optimism, or faith) were associated with treatment choice/decision-making quality measures.

Conclusions

In addition to specialist seen, consulting friends increased men's likelihood of choosing curative treatment. Consulting family or friends increased decision-making difficulty.

Qualitative insights into how men with low-risk prostate cancer choosing active surveillance negotiate stress and uncertainty

Background

Active surveillance is a management strategy for men diagnosed with early-stage, low-risk prostate cancer in which their cancer is monitored and treatment is delayed. This study investigated the primary coping mechanisms for men following the active surveillance treatment plan, with a specific focus on how these men interact with their social network as they negotiate the stress and uncertainty of their diagnosis and treatment approach.

Methods

Thematic analysis of semi-structured interviews at two academic institutions located in the northeastern US. Participants include 15 men diagnosed with low-risk prostate cancer following active surveillance.

Results

The decision to follow active surveillance reflects the desire to avoid potentially life-altering side effects associated with active treatment options. Men on active surveillance cope with their prostate cancer diagnosis by both maintaining a sense of control over their daily lives, as well as relying on the support provided them by their social networks and the medical community. Social networks support men on active surveillance by encouraging lifestyle changes and serving as a resource to discuss and ease cancer-related stress.

Conclusions

Support systems for men with low-risk prostate cancer do not always interface directly with the medical community. Spousal and social support play important roles in helping men understand and accept their prostate cancer diagnosis and chosen care plan. It may be beneficial to highlight the role of social support in interventions targeting the psychosocial health of men on active surveillance.

Treatment decision making in early-stage papillary thyroid cancer

OBJECTIVE

The purpose of this study was to develop an in-depth understanding of papillary microcarcinoma (PMC) patients' decision-making process when offered options of surgery and active surveillance.

METHODS

Fifteen PMC patients and 6 caregivers participated in either a focus group or individual interview. Focus groups were segmented by patients' treatment choice. Primary themes were identified in transcripts using thematic text analysis.

RESULTS

Four themes emerged from the surgery subsample: (1) Decision to undergo thyroidectomy quickly and with a sense of urgency; (2) Perception of PMC as a potentially life-threatening disease; (3) Fear of disease progression and unremitting uncertainty with active surveillance; and (4) Surgery as a means of control and potential cure. Three themes emerged from the active surveillance subsample: (1) View of PMC as a common, indolent, and low-risk disease; (2) Concerns about adjusting to life without a thyroid and becoming reliant on hormone replacement medication; and (3) Openness to reconsidering surgery over the long run. Two themes were identified that were shared by participants from both subsamples: (1) Deep level of trust and confidence in physician and cancer center; and (2) Use of physician and internet as primary sources of disease and treatment-related information.

CONCLUSIONS

Several factors influenced participants' treatment choice, with similarities and differences noted between surgery and active surveillance subsamples. Many of the emergent themes are consistent with research on decision making among localized prostate cancer patients. Findings suggest that participants from both PMC treatment subsamples are motivated to reduce illness and treatment-related uncertainty.

Active surveillance for low-risk localized prostate cancer: what do men and their partners think?

BACKGROUND

Active surveillance (AS) is recognized as a reasonable treatment option for low-risk localized prostate cancer (LPC) but continues to be chosen by a minority of men. To date, limited data are available regarding reasons why men with low-risk LPC adopt AS.

PURPOSE

The aim of this study is to better understand conceptualizations, experiences and reasons why men with low-risk LPC and their partners adopt AS.

METHODS

We conducted five focus groups (FGs), three among men with low-risk LPC who had chosen AS and two with their partners. FGs were video/audio recorded, transcribed and analysed using qualitative thematic analysis.

RESULTS

A total of 12 men and 6 partners (all women) participated in FG discussions. The most common reasons for choosing AS were seeing the LPC as 'small' or 'low grade' without need for immediate treatment and trusting their physician's AS recommendation. The most common concerns about AS were perceived unreliability of prostate specific antigen, pain associated with prostate biopsies and potential cancer progression. Partners saw themselves as very involved in their husbands' treatment decision-making process, more than men acknowledged them to be. Multiple terms including 'watchful waiting' were used interchangeably with AS. There appeared to be a lack of understanding that AS is not simply 'doing nothing' but is actually a recognized management option for low-risk LPC.

CONCLUSIONS

Emphasizing the low risk of a man's LPC and enhancing physician trust may increase acceptability of AS. Standardizing terminology and presenting AS as a reasonable and recognized management option may also help increase its adoption.

Anxiety symptoms prior to a prostate cancer diagnosis: Associations with knowledge and openness to treatment

AIM

Research suggests that anxiety may be a common response to a cancer diagnosis, but research is needed to examine anxiety before diagnosis. Anxiety before diagnosis may relate to the comprehension of relevant health information or openness to potential treatments. This study examined anxiety and these outcomes in men who were waiting to learn of a prostate cancer diagnosis.

OBJECTIVES

One goal of this study was to determine whether anxiety would increase as men came closer to learning the results of their prostate cancer biopsy. Another goal was to test whether anxiety was associated with knowledge about prostate cancer or openness to different treatments.

METHODS

Men (N = 265) who were facing a prostate cancer diagnosis were surveyed at two time points. Time 1 occurred at the time of biopsy, and Time 2 occurred immediately before men received their biopsy result. At each time point, men reported their anxiety about prostate cancer and their biopsy result. At Time 2, they completed a knowledge test of information about prostate cancer and reported their openness to different potential treatments.

RESULTS

Anxiety symptoms increased as men came closer to learning their diagnosis. Also, higher anxiety was associated with lower knowledge and greater openness to particular treatments like surgery. Interactions showed that when anxiety increased from Time 1 to Time 2, having high or low knowledge mattered less to treatment openness.

CONCLUSION

Waiting for a cancer diagnosis is an important time period in which anxiety may increase and relate to information processing and openness to treatments. Statement of contribution What is already known on this subject? Men undergoing prostate cancer screening have been found to experience high and low levels of anxiety. Research has shown that negative emotions like anxiety are common following a cancer diagnosis, but little research has examined emotions right before diagnosis. Anxiety has been associated with information processing and motivation to engage in preventive behaviours. What does this study add? Applies and tests a theoretical idea related to how anxiety may change as one approaches personally relevant threatening health feedback. Shows relationships between changes in anxiety and knowledge in the context of waiting for actual health feedback. Associates increased anxiety in the prostate cancer context with knowledge and openness to different treatments.

Factors associated with current and severe physical side-effects after prostate cancer treatment: What men report

We identified patient and disease characteristics associated with (1) "current" physical side-effects of any severity; and (2) "severe" physical side-effects "ever" experienced by 3,348 (54%) prostate cancer (PCa) survivors in Ireland diagnosed 2-18 years previously. Postal questionnaires collected symptoms at diagnosis, post-biopsy complications, comorbidities, primary treatments and physical side-effects post-treatment (urinary incontinence, erectile dysfunction, libido loss, bowel problems, breast changes, hot flushes, and fatigue, "ever" and "current" at time of questionnaire completion). Men were grouped by "early" (localised) and "late" (locally advanced/advanced) disease at diagnosis. Multivariable logistic regression analysis identified patient and disease-related factors associated with post-treatment side-effects. Complications post-biopsy were associated with higher risk of "current" libido loss and impotence. Radical prostatectomy was associated with higher risk of "current" and "severe" incontinence, libido loss and impotence in both early and late disease. In early disease, brachytherapy was associated with lower risk of "current" fatigue and "severe" impotence. Comorbidities were associated with higher risk of "current" experience of four side-effects (incontinence, libido loss, bowel problems, fatigue). Men on active surveillance/watchful-waiting reported lower risk of sexual dysfunction. These findings could inform development of tailored information on side-effects, which, in turn, could inform treatment decision-making and post-treatment monitoring.

Emotional Distress Increases the Likelihood of Undergoing Surgery among Men with Localized Prostate Cancer

PURPOSE

We determined whether among men with clinically localized prostate cancer, particularly men with low risk disease, greater emotional distress increases the likelihood of undergoing surgery vs radiation or active surveillance.

MATERIALS AND METHODS

Participants were 1,531 patients recruited from 2 academic and 3 community facilities (nonHispanic white 83%, nonHispanic black 11% and Hispanic 6%; low risk 36%, intermediate risk 49% and high risk 15%; choice of active surveillance 24%, radiation 27% and surgery 48%). Emotional distress was assessed shortly after diagnosis and after men made a treatment decision with the Distress Thermometer. We used multinomial logistic regression with robust standard errors to test if emotional distress at either point predicted treatment choice in the sample as a whole and after stratifying by D'Amico risk score.

RESULTS

In the sample as a whole the participants who were more emotionally distressed at diagnosis were more likely to choose surgery over active surveillance (RRR 1.07; 95% CI 1.01, 1.14; p=0.02). Men who were more distressed close to the time they made a treatment choice were more likely to have chosen surgery over active surveillance (RRR 1.16; 95% CI 1.09, 1.24; p <0.001) or surgery over radiation (RRR 1.12; 95% CI 1.05, 1.19; p=0.001). This pattern was also found in men with low risk disease.

CONCLUSIONS

Emotional distress may motivate men with low risk prostate cancer to choose more aggressive treatment. Addressing emotional distress before and during treatment decision making may reduce a barrier to the uptake of active surveillance.

Treatment Preferences for Active Surveillance versus Active Treatment among Men with Low-Risk Prostate Cancer

BACKGROUND

Due to the concerns about the overtreatment of low-risk prostate cancer, active surveillance (AS) is now a recommended alternative to the active treatments (AT) of surgery and radiotherapy. However, AS is not widely utilized, partially due to psychological and decision-making factors associated with treatment preferences.

METHODS

In a longitudinal cohort study, we conducted pretreatment telephone interviews (N = 1,140, 69.3% participation) with newly diagnosed, low-risk prostate cancer patients (PSA ≤ 10, Gleason ≤ 6) from Kaiser Permanente Northern California. We assessed psychological and decision-making variables, and treatment preference [AS, AT, and No Preference (NP)].

RESULTS

Men were 61.5 (SD, 7.3) years old, 24 days (median) after diagnosis, and 81.1% white. Treatment preferences were: 39.3% AS, 30.9% AT, and 29.7% NP. Multinomial logistic regression revealed that men preferring AS (vs. AT) were older (OR, 1.64; CI, 1.07-2.51), more educated (OR, 2.05; CI, 1.12-3.74), had greater prostate cancer knowledge (OR, 1.77; CI, 1.43-2.18) and greater awareness of having low-risk cancer (OR, 3.97; CI, 1.96-8.06), but also were less certain about their treatment preference (OR, 0.57; CI, 0.41-0.8), had greater prostate cancer anxiety (OR, 1.22; CI, 1.003-1.48), and preferred a shared treatment decision (OR, 2.34; CI, 1.37-3.99). Similarly, men preferring NP (vs. AT) were less certain about treatment preference, preferred a shared decision, and had greater knowledge.

CONCLUSIONS

Although a substantial proportion of men preferred AS, this was associated with anxiety and uncertainty, suggesting that this may be a difficult choice.

IMPACT

Increasing the appropriate use of AS for low-risk prostate cancer will require additional reassurance and information, and reaching men almost immediately after diagnosis while the decision-making is ongoing. Cancer Epidemiol Biomarkers Prev; 25(8); 1240-50. ©2016 AACR.

Deciding about (neo-)adjuvant rectal and breast cancer treatment: Missed opportunities for shared decision making

BACKGROUND

The first step in shared decision making (SDM) is creating choice awareness. This is particularly relevant in consultations concerning preference-sensitive treatment decisions, e.g. those addressing (neo-)adjuvant therapy. Awareness can be achieved by explicitly stating, as the 'reason for encounter', that a treatment decision needs to be made. It is unknown whether oncologists express such reason for encounter. This study aims to establish: 1) if 'making a treatment decision' is stated as a reason for the encounter and if not, what other reason for encounter is provided; and 2) whether mentioning that a treatment decision needs to be made is associated with enhanced patient involvement in decision making.

MATERIAL AND METHODS

Consecutive first consultations with: 1) radiation oncologists and rectal cancer patients; or 2) medical oncologists and breast cancer patients, facing a preference-sensitive treatment decision, were audiotaped. The tapes were transcribed and coded using an instrument developed for the study. Oncologists' involvement of patients in decision making was coded using the OPTION-scale.

RESULTS

Oncologists (N = 33) gave a reason for encounter in 70/100 consultations, usually (N = 52/70, 74%) at the start of the consultation. The reason for encounter stated was 'making a treatment decision' in 3/100 consultations, and 'explaining treatment details' in 44/100 consultations. The option of foregoing adjuvant treatment was not explicitly presented in any consultation. Oncologist' involvement of patients in decision making was below baseline (Md OPTION-score = 10). Given the small number of consultations in which the need to make a treatment decision was stated, we could not investigate the impact thereof on patient involvement.

CONCLUSION

This study suggests that oncologists rarely express that a treatment decision needs to be made in consultations concerning preference-sensitive treatment decisions. Therefore, patients might not realize that foregoing (neo-)adjuvant treatment is a viable choice. Oncologists miss a crucial opportunity to facilitate SDM.

Characteristics and experiences of patients with localized prostate cancer who left an active surveillance program

BACKGROUND

Understanding the experiences of men leaving active surveillance programs is critical to making such programs viable for men with localized prostate cancer.

OBJECTIVE

To generate hypotheses about the factors that influence patients' decisions to leave an active surveillance program.

METHODS

Using data from the Johns Hopkins active surveillance cohort, bivariate analyses and multinomial regression models examined characteristics of men who self-elected to leave, those who stayed in the program, and those who left because of disease reclassification. We interviewed patients who self-elected to leave.

RESULTS

Of 1,159 men in active surveillance, 9 % self-elected to leave. In interviews with a sample of 14 men who self-elected to leave, uncertainty involved in active surveillance participation, existence of personal criteria-distinct from providers' clinical criteria-and fear of cancer were important factors in decisions to leave.

CONCLUSION

Men leaving active surveillance were motivated by a number of factors, including patient-defined criteria, which might differ from clinical recommendations. To ensure active surveillance participation, it may be important to address cancer-related anxiety and personal criteria underlying patient decisions.

Factors that influence patient preferences for prostate cancer management options: A systematic review

PURPOSE

We performed a systematic review to evaluate evidence regarding factors that influence patient preferences for management options for localized prostate cancer.

METHODS

We followed a prespecified search protocol (PROSPERO identifier CRD42014009173) to identify studies that evaluated patient preferences for prostate cancer management options for localized prostate cancer. We queried PubMed, the Cochrane Database of Systematic Reviews, Embase, Cumulative Index to Nursing & Allied Health Literature (CINAHL) Plus, and Econ-Lit databases. Two separate reviewers completed the article selection process and review, including coding of study characteristics. Study quality was scored according to the PREFS checklist, which consists of five criteria: Purpose, Respondents, Explanation, Findings, and Significance. Reviewers summarized the primary findings of each article included in the analysis.

RESULTS

Of the 606 citations identified in the literature search, there were a total of 21 articles that met all selection criteria, reporting results for a total of 4,131 subjects. Themes identified in the studies included: the importance of patient perceptions of treatment efficacy and side effects; the influence of physician recommendations on patient decision-making; and the prioritization of concerns regarding treatment side effects among those men who prefer radiation therapy or active surveillance. The articles had an average PREFS score of 3.4 (standard deviation [SD] 1.0), which is similar to a recent study for breast cancer treatment preferences.

CONCLUSION

This systematic review of factors that influence patient preferences for prostate cancer management options identified a small, but high quality, group of articles that satisfied the selection criteria. The available evidence suggests that interventions aimed at informing patients regarding the comparative effectiveness of prostate cancer management alternatives should include the influence of physician recommendations and family members' desires on patient decision-making.

A systematic review of factors influencing older adults' decision to accept or decline cancer treatment

BACKGROUND

Cancer is a disease that affects mostly older adults. Older adults often have other chronic health conditions in addition to cancer and may have different health priorities, both of which can impact cancer treatment decision-making. However, no systematic review of factors that influence an older cancer patient's decision to accept or decline cancer treatment has been conducted.

MATERIALS AND METHODS

Systematic review of the literature published between inception of the databases and February 2013. Dutch, English, French or German articles reporting on qualitative studies, cross-sectional, longitudinal observational or intervention studies describing factors why older adults accepted or declined cancer treatment examining actual treatment decisions were included. Ten databases were used. Two independent reviewers reviewed manuscripts and performed data abstraction using a standardized form and the quality of studies was assessed with the Mixed Methods Appraisal Tool.

RESULTS

Of 17,343 abstracts reviewed, a total of 38 studies were included. The majority focused on breast and prostate cancer treatment decisions and most studies used a qualitative design. Important factors for accepting treatment were convenience and success rate of treatment, seeing necessity of treatment, trust in the physician and following the physician's recommendation. Factors important for declining cancer treatment included concerns about the discomfort of the treatments, fear of side effects and transportation difficulties.

CONCLUSION

Although the reasons why older adults with cancer accepted or declined treatment varied considerably, the most consistent determinant was physician recommendation. Further studies using large, representative samples and exploring decision-making incorporating health literacy and comorbidity are needed.

African-American Men with Low-Risk Prostate Cancer: Modern Treatment and Outcome Trends

OBJECTIVE

To investigate the clinical characteristics and treatment patterns for African-American (AA) men with low-risk prostate cancer (PCa) using a national, population-based dataset.

METHODS

We conducted a retrospective review of the Surveillance Epidemiology and End Results database 2004-2008. AA men aged ≥40 years with low-risk PCa were identified. For comparison, white men were selected using the same selection criteria. We reviewed all recorded treatment modalities. Definitive treatment (DT) was defined as undergoing radiotherapy or prostatectomy.

RESULTS

Overall, 7246 AA men and 47,154 white men met the criteria. Most of the patients had PSA level between 4.1 and 6.9 ng/mL (56.2 %) and received DT (76 %). Black men were younger (mean age: 62(±8) vs. 65(±10) years), less likely to receive DT (adjusted odds ratio (AOR), 0.71 [0.67-0.76]), and of those receiving DT, less likely to undergo prostatectomy (AOR, 0.58 [0.54-0.62]). Patients receiving DT had lower crude cancer-specific and overall mortality (0.17 vs. 0.41 % and 2.9 vs. 7.8 %, p value < 0.001, respectively, among blacks). The difference in overall mortality was largest among ≥ 75 years (5.6 vs. 18.2 %). Across age groups, blacks had higher all-cause mortality (AOR, 1.45 [1.13-1.87] and 1.56[1.31-1.86] for <65 and ≥ 65 years, respectively).

CONCLUSION

Our study of a large modern cohort of men with low-risk PCa demonstrates significant lower receipt of DT, lower receipt of prostatectomy among those receiving DT, and lower survival for black men compared to their white counterparts. Older men were less likely to receive DT. Patients who received DT had better survival. The survival difference was most striking among the elderly.

Treatment preferences and involvement in treatment decision making of patients with endometrial cancer and clinicians

BACKGROUND

Vaginal brachytherapy (VBT) in high-intermediate-risk endometrial cancer (EC) provides a significant reduction in the risk of local cancer recurrence, but without survival benefit and with increased mucosal atrophy. Five-year local control is estimated to be similar for VBT and a watchful waiting policy (WWP), in which patients receive VBT combined with external radiation in case of a recurrence. Our aim was to assess treatment preferences of EC patients and clinicians regarding VBT and WWP, and to evaluate their preferred and perceived involvement in treatment decision making.

METHODS

Interviews were held with 95 treated EC patients. The treatment trade-off method was used to assess the minimally desired benefit from VBT in local control. Patients' preferred and perceived involvement in decision making were assessed using a questionnaire. Seventy-seven clinicians completed a questionnaire assessing their minimally desired benefit and preferred involvement in decision making.

RESULTS

Minimally desired benefit of VBT was significantly lower for patients than for clinicians (median=0 vs 8%, P<0.001), for irradiated than for non-irradiated patients (median=0 vs 6.5%, P<0.001), and for radiation oncologists than for gynaecologists (median=4 vs 13%, P<0.001). Substantial variation existed within the groups of patients and clinicians. Participants preferred the patient and clinician to share in the decision about VBT. However, irradiated patients indicated low perceived involvement in actual treatment decision making.

CONCLUSIONS

We found variations between and within patients and clinicians in minimally desired benefit from VBT. However, the recurrence risk at which patients preferred VBT was low. Our results showed that patients consider active participation in decision making essential.

'It's not like you just had a heart attack': decision-making about active surveillance by men with localized prostate cancer

BACKGROUND

Growing recognition that active surveillance (AS) is a reasonable management option for many men diagnosed with localized prostate cancer led us to describe patients' conceptualizations of AS and reasons for their treatment decisions.

METHODS

Men were patients of a multidisciplinary prostate cancer clinic at a large tertiary cancer center where patients are routinely briefed on treatment options, including AS. We conducted a thematic analysis of interviews with 15 men who had chosen AS and 15 men who received radiation or surgery.

RESULTS

Men who chose AS described it as an organized process with a rigorous and reassuring protocol of periodic testing, with potential for subsequent and timely decision-making about treatment. AS was seen as prolonging their current good health and function with treatment still possible later. Rationales for choosing AS included trusting their physician's monitoring, 'buying time' without experiencing adverse effects of treatment, waiting for better treatments, and seeing their cancer as very low risk. Men recognized the need to justify their choice to others because it seemed contrary to the impulse to immediately treat cancer. Descriptions of AS by men who chose surgery or radiation were less specific about the testing regimen. Getting rid of the cancer and having a cure were paramount for them.

CONCLUSIONS

Men fully informed of their treatment options for localized prostate cancer have a comprehensive understanding of the purpose of AS. Slowing the decision-making process may enhance the acceptability of AS.

Quality of life in men undergoing active surveillance for localized prostate cancer

Active surveillance is an important arrow in the quiver of physicians advising men with prostate cancer. Quality-of-life considerations are paramount for patient-centered decision making. Although the overall deleterious impact on health is less dramatic than for those who pursue curative treatment, men on active surveillance also suffer sexual dysfunction and distress. Five-year outcomes revealed more erectile dysfunction (80% vs 45%) and urinary leakage (49% vs 21%) but less urinary obstruction (28% vs 44%) in men undergoing prostatectomy. Bowel function, anxiety, depression, well-being, and overall health-related quality of life (HRQOL) were similar after 5 years, but at 6-8 years, other domains of HRQOL, such as anxiety and depression, deteriorated significantly for those who chose watchful waiting. Further research is needed to compare prospectively HRQOL outcomes in men choosing active surveillance and those never diagnosed with prostate cancer, in part to help weigh the potential benefits and harms of prostate cancer screening.

Factors influencing patients' acceptance and adherence to active surveillance

Clinical decision making in localized prostate cancer is a complicated, multidimensional process in which men often consider their own personal preferences, the advice of their healthcare providers, the opinions of their family and friends, and outside information sources. They synthesize all of this within the framework of their own unique socioeconomic situation, their social support network, and their preconceived impressions of their health and the health-care system. This is particularly germane when considering factors that influence a patient's acceptance of and adherence to active surveillance (AS). We propose a conceptual framework based on a previously described systematic-heuristic theoretical model of decision making in this setting. We identify a number of factors that patients systematically prioritize when considering AS. These include desire for cancer control or cure, age at diagnosis, and concern regarding side effects of treatment. The way patients value these factors and effectively decide on treatment is influenced by more heuristic factors, including physician recommendation, opinion of friends and family members, and overall decision uncertainty. These heuristic factors also play an important role in adherence when a patient elects AS. Finally, some of the factors, particularly the heuristic ones, are potentially modifiable and may serve as targets for future interventions to increase acceptance of and adherence to AS.

Patient perspective on watchful waiting/active surveillance for localized prostate cancer

OBJECTIVE

To describe prostate cancer treatment decision making, focusing on knowledge and attitudes toward observation, known as watchful waiting (WW) or active surveillance (AS), and reasons for not choosing WW/AS.

METHODS

Semistructured in-person interviews were conducted with 21 men (14 black; 7 white) with recently diagnosed localized prostate cancer.

RESULTS

All cancers were detected by prostate-specific antigen screening; 14 men had low-risk disease. Nineteen chose surgery or radiation treatment. The majority wanted to "get rid of" or "cure" the cancer by undergoing aggressive therapy, even with awareness of the potential for significant side effects. Most men seemed unaware of the uncertainty/controversies that aggressive treatment may not cure their cancer or improve their survival. Limited knowledge about WW/AS was common, and few remembered WW/AS being presented as a viable option. Rather, many men perceived it as "doing nothing." Some men, who initially were inclined toward WW/AS, yielded to pressure from family, physicians, or both to choose aggressive treatment. Lack of physician support was a significant barrier to WW/AS.

CONCLUSIONS

The observational strategy (WW/AS) was not viewed as a reasonable approach, even for those with low-risk cancer. The desire for aggressive therapy may reflect the complex psychology associated with receiving a diagnosis of cancer and the limited supportive counseling received. Further efforts to better understand and educate patients and physicians may help men make informed and appropriate treatment decisions to maximize quality of life without compromising survival.

Patient comprehension and attitudes toward maintenance chemotherapy for lung cancer

OBJECTIVE

Maintenance chemotherapy is a recently approved approach to the treatment of advanced non-small cell lung cancer (NSCLC). We sought to gain insight into patients' perceptions of maintenance chemotherapy using qualitative methods.

METHODS

We conducted thematic content analysis of focus groups at a freestanding cancer center and at an associated safety-net county hospital. Patients with advanced NSCLC who had started but not yet completed first-line platinum doublet chemotherapy were provided visual and written explanations of maintenance chemotherapy before being guided in group discussion.

RESULTS

Key themes to emerge for consideration of maintenance chemotherapy included: (1) survival benefits, disease control, and "buying time"; (2) the importance of "doing something"; (3) quality of life concerns; (4) the role of provider opinion/preference; and (5) the importance of logistics.

CONCLUSIONS

Patients undergoing first-line chemotherapy for advanced NSCLC were able to understand the concept of maintenance chemotherapy, distinguish it from traditional treatment paradigms, identify pros and cons of this approach, and convey reasons for considering it.

PRACTICE IMPLICATIONS

Advances in oncology care that alter therapy modalities and delivery may significantly impact patient perceptions and treatment experiences. Clinical team members may wish to elicit treatment preferences of first-line patients through clinical discussion that anticipate these considerations.

Psychological aspects of active surveillance

PURPOSE OF REVIEW

Active surveillance is emerging as a serious alternative to radical therapy for low-risk prostate cancer. In a situation in which the difference in effects on disease morbidity and mortality of different treatment options for these malignancies is likely to be small, the quality of life and psychological aspects may be decisive in treatment choice.

RECENT FINDINGS

The following three are the main issues being covered in the literature on psychological aspects of active surveillance. First, the process of consultation with the physician and treatment choice in men diagnosed with low-risk prostate cancer. Second, the effect of active surveillance on physical domains and resulting anxiety and distress, and on quality of life in general. And third, the possible supportive and educational interventions for patients on active surveillance. Observations are scarce and derived from nonrandomized studies with a limited follow-up after diagnosis.

SUMMARY

At the moment of treatment choice, fear of disease progression is the main reason to reject active surveillance. Active surveillance may spare physical domains and does not cause much anxiety or distress on short term in men who choose this strategy. Once men opt for active surveillance, only a minority of them switch to radical treatment due to psychological reasons. Supportive and educational interventions should be considered.

Current Challenges in Prostate Cancer Management and the Rationale behind Targeted Focal Therapy

Among men, prostate cancer has a high prevalence, with relatively lower cancer-specific mortality risk compared to lung and colon cancer. Prostate-specific antigen (PSA) screening has increased prostate cancer awareness since its implementation as a screening tool almost 25 years ago, but, due to the largely indolent course of this disease and the unspecific nature of the PSA test, increased incidence has largely been associated with cancers that would not go on to cause death (clinically insignificant), leading to an overdiagnosis challenge and an ensuing overtreatment consequences. The overtreatment problem is exacerbated by the high risk of side effects that current treatment techniques have, putting patients' quality of life at risk with little or no survival benefit. The goals of this paper are to evaluate the rise, prevalence, and impact of the overdiagnosis and ensuing overtreatment problems, as well as highlight potential solutions. In this effort, a review of major epidemiological and screening studies, cancer statistics from the advent of prostate-specific antigen screening to the present, and reports on patient concerns and treatment outcomes was conducted to present the dominant factors that underlie current challenges in prostate cancer treatment and illuminate potential solutions.

Social and clinical predictors of prostate cancer treatment decisions among men in South Carolina

OBJECTIVE

To assess social and clinical influences of prostate cancer treatment decisions among white and black men in the Midlands of South Carolina.

METHODS

We linked data collected on treatment decision making in men diagnosed with prostate cancer from 1996 through 2002 with clinical and sociodemographic factors collected routinely by the South Carolina Central Cancer Registry (SCCCR). Unconditional logistic regression was used to assess social and clinical influences on treatment decision.

RESULTS

A total of 435 men were evaluated. Men of both races who chose surgery (versus radiation) were more likely to be influenced by their physician and by family/friends. Black men who chose surgery also were ~5 times more likely to make independent decisions (i.e., rather than be influenced by their doctor). White men who chose surgery were twice as likely to be influenced by the desire for cure and less likely to consider the side effects of impotence (odds ratio (OR) = 0.40; 95% confidence interval (CI): 0.18, 0.88) and incontinence (OR = 0.27; 95% CI: 0.12, 0.63); by contrast, there was a suggestion of an opposite effect in black men, whose decision regarding surgery tended to be more strongly influenced by these side effects.

CONCLUSION

Results suggest that both clinical and social predictors play an important role for men in choosing a prostate cancer treatment, but these influences may differ by race.

Understanding Barrett's columnar lined oesophagus from the patients' perspective: qualitative analysis of semistructured interviews with patients

OBJECTIVES

To explore patients' views and perspectives on their experience of living with Barrett's columnar lined oesophagus (CLO) and being part of an endoscopic surveillance programme.

DESIGN

Qualitative semistructured interviews.

SETTING

District General Hospital.

SUBJECTS

22 men with diagnosis of Barrett's CLO between the ages of 50 and 70 years.

RESULTS

All subjects had received some information about Barrett's CLO and had a heightened awareness of the cancer risk. However, many had misinterpreted or poorly assimilated the information and overall health literacy levels were low. From their stories a 'Model of Uncertainty' in Barrett's surveillance was developed as a focus for healthcare professionals to ensure that the service users' perspective is considered in future service development.

CONCLUSION

Patients' assimilation of information should not be assumed by healthcare professionals but rather should be verified for individual patients. The model developed highlights the factors found to influence patients' knowledge and understanding of Barrett's CLO.

Beyond ballistics: expanding our conceptualization of men's health-related help seeking

Although the literature on men's help seeking offers important insights into health service engagement patterns within this population, there remain gaps in our understanding. In addition to insufficient attention to a range of male experiences and a restricted focus on sex-specific or associated diseases, much of the extant work is limited by insufficient attention to how men navigate needs and supports across illness and a narrow conceptualization of the core concept of help seeking. Specifically, as research focuses on masculinity as a determinant of the decision to seek medical help (emphasis on prediction), less is known about how men, as gendered beings, are experiencing help seeking over the course of illness (emphasis on understanding). In this article, it is argued that research on men's help seeking can benefit from the integration of a dynamic conceptualization of help seeking that is considerate of shifting needs and a diversity of supports and which emphasizes the subjective, interactive, and ongoing patterns in how men are perceiving, interpreting, and responding to the challenges of illness.

Patient acceptance of active surveillance as a treatment option for low-risk prostate cancer

What's known on the subject? and What does the study add? Active surveillance is a management strategy that offers patients the hope of avoiding the side effects associated with unnecessary treatment. This study identifies the resources required by men who choose to be on active surveillance to support them in their treatment decision.

OBJECTIVES

•  To examine the decision-making processes of men on active surveillance (AS). •  To identify the resources that men want to access to make, support and sustain them while on AS.

PATIENTS AND METHODS

•  Three-part survey developed for this study based on a qualitative study of 25 men on AS. •  Survey items explored: role men assumed with their physician in treatment decision-making, factors influencing decision to go on AS, and resources required while on AS. •  Surveys mailed out to cross-sectional sample of men on AS for less than 10 years.

RESULTS

•  27% of the 73 men reported assuming an active role in treatment decision-making with their urologist, 41% a shared role and 32% a passive role. •  82% of men reported being comfortable and 90% being satisfied with their decision to be on AS. •  55% reported not being anxious about the cancer progressing while on AS. •  Urologist's opinion, current age, and impact of treatment on urinary function were main factors influencing treatment decision. •  Information on future treatment options, non-traditional treatments and diet considered most important resources.

CONCLUSIONS

•  Results suggest that once men make a decision to go on AS, they are satisfied with their decision and few report being anxious about progression of cancer. •  Men are strongly influenced by the treating specialist in taking up AS. •  Additional information and psychological support resources are required for men on AS.

Interpersonal influences on patients' surgical decision making: the role of close others

Patients make medical decisions in consultation with their partner, family, and friends. However, little is known about the ways in which these close others influence their decisions, particularly with respect to discrete decisions such as those related to medical treatments. This cross-sectional study investigated their influence on the surgical decisions of inflammatory bowel disease patients referred for surgery to remove their colon (N = 91). Guided by research on social control and classic research on power and influence in close relationships, we identified four types of close other decision influence: persuasion, assistance with understanding, indirect influence, and negative influence. Linear logistic and regression analyses showed that patients were more likely to have surgery when their close other used persuasion, and they reported lower decisional conflict when their close other helped them understand the decision. Patients were less likely to have surgery and reported greater decisional conflict when their close other used negative influence tactics. Findings demonstrate the importance of considering social context when investigating patient decision making.

Provider and partner interactions in the treatment decision-making process for newly diagnosed localized prostate cancer

OBJECTIVE

• To evaluate the degree to which the partners of prostate cancer patients participate in the shared decision-making process with the patients' providers during the time between diagnosis and initiating treatment.

PATIENTS AND METHODS

• We recruited patients with newly diagnosed local-stage prostate cancer and their partners to complete take-home surveys after biopsy but before initiating treatment at urology practices in three states. • We asked partners to describe their roles in the decision-making process, including participation in clinic visits, and perceptions of encouragement from providers to participate in the treatment decision-making process. We also asked partners to rate their satisfaction with the patients' providers.

RESULTS

• Family members of 80% of newly diagnosed patients agreed to participate; most (93%) were partners (i.e. spouses or significant others). Most partners (93%) had direct contact with the patients' physicians. • Among the partners who had contact with providers, most (67%) were very satisfied with the patients' providers and 80% indicated that the doctor encouraged them to participate in the treatment decision. Overall, 91% of partners reported very frequent discussions with their loved one about the pending treatment decision, and 69% reported that their role was to help the patient make a decision. • In multivariate models, provider encouragement of partner participation was associated with higher partner satisfaction (odds ratio 3.4, 95% CI 1.4-8.4) and an increased likelihood of partners reporting very frequent discussions with their loved one (odds ratio 6.1, 95% CI 1.3-27.7).

CONCLUSIONS

• Partners often attended clinic visits and were very involved in discussions about treatment options with both loved ones and providers. • Provider encouragement of participation by partners greatly facilitates shared decision-making between patients and partners.

Do anxiety and distress increase during active surveillance for low risk prostate cancer?

PURPOSE

Anxiety and distress may be present in patients with low risk prostate cancer who are on active surveillance. This may be a reason to discontinue active surveillance.

MATERIALS AND METHODS

A total of 150 Dutch patients with prostate cancer on active surveillance in a prospective active surveillance study received questionnaires at study inclusion and 9 months after diagnosis. We assessed changes in scores on decisional conflict with the decisional conflict scale, depression with the Center for Epidemiologic Studies Depression Scale, generic anxiety with the State Trait Anxiety Inventory, prostate cancer specific anxiety with the Memorial Anxiety Scale for Prostate Cancer and the self-estimated risk of progression. We explored scores 9 months after diagnosis vs those at study inclusion for physical health (SF-12 physical component summary), personality (Eysenck Personality Questionnaire), shared decision making, prostate cancer knowledge, demographics, medical parameters and prostate specific antigen doubling time during followup.

RESULTS

Questionnaires at study inclusion and 9 months after diagnosis were completed by 129 of 150 (86%) and 108 of 120 participants (90%) a median of 2.4 and 9.2 months after diagnosis, respectively. Anxiety and distress at study inclusion were previously found to be generally favorable. Significant but clinically irrelevant decreases were seen in mean scores of the State Trait Anxiety Inventory (p = 0.016), Memorial Anxiety Scale for Prostate Cancer fear of progression subscale (p = 0.005) and the self-estimated risk of progression (p = 0.049). Anxiety and distress 9 months after diagnosis were mainly predicted by scores at study inclusion. Higher Eysenck Personality Questionnaire neuroticism score and an important role of the physician in the treatment decision had additionally unfavorable effects. Good physical health, palpable disease and older age had favorable effects. No association was seen for prostate specific antigen doubling time. Nine men discontinued active surveillance, including 2 due to nonmedical reasons.

CONCLUSIONS

Anxiety and distress generally remain favorably low during the first 9 months of surveillance.

Critical review: is watchful waiting a viable management option for older men with prostate cancer?

Prostate cancer is the most commonly diagnosed cancer and the second-leading cause of death from cancer in U.S. men. For older men with early-stage prostate cancer, watchful waiting (also referred to as surveillance, expectant management, deferred/delayed therapy, or active monitoring) is a reasonable approach to aggressive therapy. The purpose of this article is to critically review published studies on the watchful waiting management option for prostate cancer within the past 5 years. The review of documented reports on watchful waiting reveals that there are both negative and positive indications toward watchful waiting. Further research is needed to change the perception of watchful waiting as a "do nothing" approach to the management of prostate cancer or a "death sentence" and to develop interventions that assist men to manage the uncertainty associated with living with prostate cancer to improve health and advance quality of life.

Men's and carers' experiences of care for prostate cancer: a narrative literature review

OBJECTIVE

To review studies of patients' and carers' experience of prostate cancer care.

DESIGN

Narrative literature review.

METHODS

Search strategies were developed for the following databases: MEDLINE (1966-2006), EMBASE (1980-2006), CINAHL (1982-2006) and PsycINFO (1987-2006). A search of SIGLE (System for Information on Grey Literature in Europe) was also undertaken. Experience was defined as patients' and carers' reports of how care was organized and delivered to meet their needs. A narrative summary of the included papers was undertaken.

RESULTS

A total of 90 relevant studies were identified. Most studies reported on experiences of screening, diagnosis, the treatment decision, treatment and post-initial treatment. Few studies reported on experiences of the stages of referral, testing, and further treatment and palliative care, and no studies reported on monitoring or terminal care.

CONCLUSIONS

Although some phases of care have not been investigated in detail, there is evidence that: (i) many patients have a low level of knowledge of prostate cancer; (ii) patients with prostate cancer and their carers need information throughout the care pathway to enable them to understand the diagnosis, treatment options, self-care and support available; and (iii) increasing patient knowledge and understanding of prostate cancer (e.g. through interventions) are often associated with a more active role in decision making (e.g. screening, treatment decision).

Disease insight and treatment perception of men on active surveillance for early prostate cancer

STUDY TYPE

Survey (prospective cohort).

LEVEL OF EVIDENCE

1b.

OBJECTIVE

To investigate the levels of knowledge of prostate cancer and the perception of active surveillance (AS) in men on AS, as AS for early prostate cancer instead of radical treatment might partly solve the over-treatment dilemma in this disease, but might be experienced as a complex and contradictory strategy by patients.

PATIENTS AND METHODS

In all, 150 Dutch men recently diagnosed with early prostate cancer participating in a prospective protocol-based AS programme (PRIAS study) received questionnaires, including a 15-item measure on their general knowledge of prostate cancer, and open-ended questions on the most important disadvantages and advantages of AS, and on the specific perception of AS. We assessed knowledge scores and explored potentially associated factors, the stated (dis)advantages and specific perceptions.

RESULTS

The questionnaire response rate was 86% (129/150). Participants provided correct answers to a median (interquartile range) of 13 (12-14) of 15 (87%) knowledge items. Younger and higher educated men had higher knowledge scores. In line with a priori hypotheses, the most frequently reported advantage and disadvantage of AS were the delay of side-effects and the risk of disease progression, respectively. Specific negative experiences included the feeling of losing control over treatment decisions, distress at follow-up visits, and the desire for a more active participation in disease management. No conceptually wrong understandings or expectations of AS were identified.

CONCLUSIONS

We found adequate knowledge of prostate cancer levels and realistic perceptions of the AS strategy in patients with early prostate cancer and on AS. These findings suggest adequate counselling by the physician or patient self-education.