Decisional regret and quality of life after participating in medical decision-making for early-stage prostate cancer

Hepatocellular carcinoma surveillance may be associated with potential psychological harms in patients with cirrhosis

BACKGROUND AND AIMS

The value of HCC surveillance is determined by the balance between benefits and harms; however, no studies have enumerated psychological harms.

APPROACH AND RESULTS

We fielded surveys measuring psychological harms to patients with cirrhosis in a multicenter randomized trial of HCC surveillance outreach. All patients with positive or indeterminate surveillance results and matched patients with negative results were invited to complete surveys measuring (1) depression through the Patient Health Questionnaire-ninth version, (2) anxiety through State-Trait Anxiety Inventory, (3) HCC-specific worry through Psychological Consequences Questionnaire, and (4) decisional regret. Patients were classified into 4 groups: true positive (TP), false positive (FP), indeterminate, and true negative (TN). Multivariable longitudinal regression analysis using the generalized estimating equation method was performed to compare the means of measures across groups. We conducted 89 semistructured interviews in a subset of patients stratified by health system and test results. Of 2872 patients in the trial, 311 completed 1+ follow-up survey (63 FP, 77 indeterminate, 38 TP, and 133 TN). Moderate depression decreased in TN patients, increased in TP, and had intermittent but mild increases in those with FP and indeterminate results. High anxiety temporarily increased in patients with TP results but resolved over time and was stable in those with FP and indeterminate results. Decisional regret was low and did not differ across groups. In semistructured interviews, patients reported apprehension, anxiety, emotional distress, and coping related to HCC surveillance.

CONCLUSIONS

Psychological harms of HCC surveillance appear mild but differ by test result. Future research should determine the impact of psychological harms on the value of HCC surveillance programs.

Decisional regret, symptom burden, and quality of life following transoral robotic surgery for oropharyngeal cancer

BACKGROUND

Transoral robotic surgery (TORS) has equivalent oncologic control to radiotherapy with potential for improved quality of life (QOL) and lower patient-reported decisional regret.

METHODS

Cross-sectional study between 2016 and 2021 of TORS patients with early-stage oropharyngeal squamous cell carcinoma who completed the Decision Regret Scale (DRS), M. D. Anderson Dysphagia Inventory (MDADI), and University of Washington Quality of Life (UW-QOL). The median time from treatment to questionnaire completion was 1.8 years (IQR 1.4-3.3, range 1.0-5.6).

RESULTS

Of 65 patients, 84.6% expressed no or mild decisional regret. Regret was not associated with clinical parameters or adjuvant treatment but was correlated with MDADI (τavg = -0.23, p < 0.001) and UW-QOL (τavg = -0.27, p < 0.001). Worse MDADI was associated with older age and worse UW-QOL was associated with multi-site operation and shorter time to survey.

CONCLUSIONS

Overall, the TORS cohort expressed very limited decisional regret. DRS scores were unaffected by clinicodemographics or additional adjuvant therapies, but decision regret was correlated with worse QOL and worse swallowing.

Decision Regret in Patients with Localised Prostate Cancer: A Systematic Review and Meta-analysis

CONTEXT

Treatment choice for localised prostate cancer remains a significant challenge for patients and clinicians, with uncertainty over decisions potentially leading to conflict and regret. There is a need to further understand the prevalence and prognostic factors of decision regret to improve patient quality of life.

OBJECTIVE

To generate the best estimates for the prevalence of significant decision regret localised prostate cancer patients, and to investigate prognostic patient, oncological, and treatment factors associated with regret.

EVIDENCE ACQUISITION

We performed a systematic search of MEDLINE, Embase, and PsychINFO databases including studies evaluating the prevalence or patient, treatment, or oncological prognostic factors in localised prostate cancer patients. A pooled prevalence of significant regret was calculated with the formal prognostic factor evaluation conducted per factor identified.

EVIDENCE SYNTHESIS

Significant decision regret was present in a pooled 20% (95% confidence interval 16-23) of patients across 14 studies and 17883 patients. This was lower in active surveillance (13%), with little difference between those who underwent radiotherapy (19%) and those who underwent prostatectomy (18%). Evaluation of individual prognostic factors demonstrated higher regret in those with poorer post-treatment bowel, sexual, and urinary function; decreased involvement in the decision-making process; and Black ethnicity. However, evidence remains conflicting, with low or moderate certainty of findings.

CONCLUSIONS

A significant proportion of men experience decision regret after a localised prostate cancer diagnosis. Monitoring those with increased functional symptoms and improving patient involvement in the decision-making process through education and decision aids may reduce regret.

PATIENT SUMMARY

We looked at how common regret in treatment decisions is after treatment for early-stage prostate cancer and factors linked with this. We found that one in five regret their decision, with those who had experienced side effects or were less involved in the decision-making process more likely to have regret. By addressing these, clinicians could reduce regret and improve quality of life.

Trajectory of Depression among Prostate Cancer Patients: A Secondary Analysis of a Randomized Controlled Trial

Background: While psychological difficulties, such as depression, among prostate cancer patients are known, their longitudinal burden remains understudied. We assessed the burden of depression across low-, intermediate- and high-risk prostate cancer groups, and the association between regret and long-term depression. Methods: Secondary analysis of data from a multi-centered randomized controlled study among localized prostate cancer patients was carried out. Assessments were performed at baseline, and at 3-, 6-, 12- and 24-month follow-up. Depression was assessed using the Center for Epidemiologic Studies Depression (CES-D) scale. A CES-D score ≥ 16 indicates high depression. Regret was measured using the regret scale of the Memorial Anxiety Scale for Prostate Cancer (MAX-PC). The proportion of patients with high depression was compared over time, for each risk category. Logistic regression was used to assess the association between regret, and long-term depression after adjusting for age, race, insurance, smoking status, marital status, income, education, employment, treatment, number of people in the household and study site. Results: The study had 743 localized prostate cancer patients. Median depression scores at 6, 12 and 24 months were significantly larger than the baseline median score, overall and for the three prostate cancer risk groups. The proportion of participants with high depression increased over time for all risk groups. Higher regret at 24-month follow-up was significantly associated with high depression at 24-month follow-up, after adjusting for covariates. Conclusions: A substantial proportion of localized prostate cancer patients continued to experience long-term depression. Patient-centered survivorship care strategies can help reduce depression and regret, and improve outcomes in prostate cancer care.

Comprehensive Implementation of Shared Decision Making in a Neuromedical Center Using the SHARE TO CARE Program

PURPOSE

SHARE TO CARE (S2C) is a comprehensive, multi-module implementation program for shared decision making (SDM). It is currently applied at the University Hospital Schleswig-Holstein in Kiel, Germany, and among general practitioners at the Federal State of Bremen. This study examines the results of the full implementation of S2C in terms of effectiveness within the Kiel Neuromedical Center comprising the departments of neurology and neurosurgery.

METHOD AND DESIGN

The S2C program consists of four combined intervention modules: 1) multimodal training of physicians; 2) a patient activation campaign including the ASK-3 method; 3) digital evidence-based patient decision aids; and 4) SDM support by nurses, e.g., as decision coaches. The SDM level before and immediately after implementation was retrospectively assessed in consecutively selected patients on the subscale "Patient Decision Making" of the Perceived Involvement in Care Scale (PICS_PDM). Mean scores were compared with t-tests.

RESULTS

Eighty-nine percent of all physicians (N = 56) completed the SDM training. We developed a total of 12 evidence-based digital decision aids in the center, educated two decision coaches to support patients' decision processes by using decision aids. Physicians adjusted patients' pathways to incorporate the use of decision aids. Patients (n = 261) reported a significant increase in participation (p<0.001; Hedges' g = 0.49) in medical decision making.

CONCLUSION

The S2C program has been successfully implemented within the entire Neuromedical Center. Patients reported a medium to small increase of perceived involvement in decision making demonstrating the effectiveness of the implementation. For future research, it might be interesting to investigate the sustainability of the effects of S2C. In addition, it seems useful to complement the patient-based evaluation with observer-based data.

Sustainability of large-scale implementation of shared decision making with the SHARE TO CARE program

Introduction

SHARE TO CARE (S2C) is a comprehensive implementation program for shared decision making (SDM). It is run at the University Hospital Schleswig-Holstein (UKSH) in Kiel, Germany, and consists of four combined intervention modules addressing healthcare professionals and patients: (1) multimodal training of physicians (2) patient activation campaign including the ASK3 method, (3) online evidence-based patient decision aids (4) SDM support by nurses. This study examines the sustainability of the hospital wide SDM implementation by means of the Neuromedical Center comprising the Departments of Neurology and Neurosurgery.

Methods

Between 2018 and 2020, the S2C program was applied initially within the Neuromedical Center: We implemented the patient activation campaign, trained 89% of physicians (N = 56), developed 12 patient decision aids and educated two decision coaches. Physicians adjusted the patients' pathways to facilitate the use of decision aids. To maintain the initial implementation, the departments took care that new staff members received training and decision aids were updated. The patient activation campaign was continued. To determine the sustainability of the initial intervention, the SDM level after a maintenance phase of 6-18 months was compared to the baseline level before implementation. Therefore, in- and outpatients received a questionnaire via mail after discharge. The primary endpoint was the "Patient Decision Making" subscale of the Perceived Involvement in Care Scale (PICS_PDM). Secondary endpoints were an additional scale measuring SDM (CollaboRATE), and the PrepDM scale, which determines patients' perceived health literacy while preparing for decision making. Mean scale scores were compared using t-tests.

Results

Patients reported a significantly increased SDM level (PICS_PDM p = 0.02; Hedges' g = 0.33; CollaboRATE p = 0.05; Hedges' g = 0.26) and improved preparation for decision making (PrepDM p = 0.001; Hedges' g = 0.34) 6-18 months after initial implementation of S2C.

Discussion

The S2C program demonstrated its sustainability within the Neuromedical Center at UKSH Kiel in terms of increased SDM and health literacy. Maintaining the SDM implementation required a fraction of the initial intensity. The departments took on the responsibility for maintenance. Meanwhile, an additional health insurance-based reimbursement for S2C secures the continued application of the program.

Conclusion

SHARE TO CARE promises to be suitable for long-lasting implementation of SDM in hospitals.

Treatment Regret, Mental and Physical Health Indicators of Psychosocial Well-Being among Prostate Cancer Survivors

Prostate cancer (PCa) patients and survivors are at high risk of mental health illness. Here, we examined the contribution of treatment regret, mental and physical health indicators to the social/family, emotional, functional and spiritual well-being of PCa survivors. The study assessed 367 men with a history of PCa residing in the Maritimes Canada who were surveyed between 2017 and 2021. The outcomes were social/family, emotional, functional and spiritual well-being (FACT-P,FACIT-Sp). Predictor variables included urinary, bowel and sexual function (UCLA-PCI), physical and mental health (SF-12), and treatment regret. Logistic regression analyses were controlled for age, income, and survivorship time. Poor social/family, emotional, functional and spiritual well-being was identified among 54.4%, 26.5%, 49.9% and 63.8% of the men in the sample. Men who reported treatment regret had 3.62, 5.58, or 4.63 higher odds of poor social/family, emotional, and functional well-being, respectively. Men with low household income had 3.77 times higher odds for poor social/well-being. Good mental health was a protective factor for poor social/family, emotional, functional, or spiritual well-being. Better physical and sexual health were protective factors for poor functional well-being. Seeking to promote PCa patients' autonomy in treatment decisions and recognizing this process' vulnerability in health care contexts is warranted.

Development of a Patient Reported Measure of Experimental Transplants with HIV and Ethics in the United States (PROMETHEUS)

BACKGROUND

Transplantation of HIV-positive (HIV+) donor organs for HIV+ recipients (HIV D+/R+) is now being performed as research in the United States, but raises ethical concerns. While patient-reported outcome measures are increasingly used to evaluate clinical interventions, there is no published measure to aptly capture patients' experiences in the unique context of experimental HIV D+/R+ transplantation. Therefore, we developed PROMETHEUS (patient-reported measure of experimental transplants with HIV and ethics in the United States). To do so, we created a conceptual framework, drafted a pilot battery using existing and new measures related to this context, and refined it based on cognitive and pilot testing. PROMETHEUS was administered 6-months post-transplant in a clinical trial evaluating these transplants. We analyzed data from the first 20 patient-participants for reliability and validity by calculating Cronbach's alpha and reviewing item performance characteristics.

RESULTS

PROMETHEUS 1.0 consisted of 29 items with 5 putative subscales: Emotions; Trust; Decision Making; Transplant; and Decision Satisfaction. Overall, responses were positive. Cronbach's alpha was > 0.8 for all subscales except Transplant, which was 0.38. Two Transplant subscale items were removed due to poor reliability and construct validity.

CONCLUSIONS

We developed PROMETHEUS to systematically capture patient-reported experiences with this novel experimental transplantation program, nested it in an actual clinical trial, and obtained preliminary data regarding its performance.

The Relationship Between Decisional Regret and Well-Being in Patients With and Without Depressive Disorders: Mediating Role of Shared Decision-Making

Background: The objectives of this study were two-fold: (1) to assess the relationship between patients' decisional regret and their well-being and (2) to examine the mediated effect of shared decision-making (SDM) on this relationship. Methods: A cross-sectional survey was conducted in five cities in Southern China. Patients were asked to fill out questionnaires assessing their decisional regret, SDM, subjective well-being, and depressive status. Mediation analysis was used to investigate the effect of SDM on the relationship between patients' decisional regret and their subjective well-being. Results: The findings showed significant direct negative effects of decisional regret on subjective well-being and SDM. For non-depressive patients, SDM exerted a significant and indirect effect on reducing the negative influence of decisional regret on subjective well-being. Conclusions: Findings suggest that implementation of SDM can decrease patients' decisional regret and improve their well-being; however, there is a need to examine their depressive status as part of routine healthcare.

Unrealistic parental expectations for cure in poor-prognosis childhood cancer

BACKGROUND

Many parents of children with advanced cancer pursue curative goals when cure is no longer possible. To the authors' knowledge, no pediatric studies to date have prospectively evaluated prognosis communication or influences on decision making in poor-prognosis childhood cancer.

METHODS

The authors conducted a prospective cohort study at 9 pediatric cancer centers that enrolled 95 parents of children with recurrent or refractory, high-risk neuroblastoma (63% of those who were approached), a condition for which cure rarely is achieved. Parents were surveyed regarding the child's likelihood of cure; their primary goal of care; the child's symptoms, suffering, and quality of life; and regret concerning the last treatment decision. Medical records identified care and treatment decisions.

RESULTS

Only 26% of parents recognized that the chance of cure was <25%. When asked to choose a single most important goal of care, approximately 72% chose cure, 10% chose longer life, and 18% chose quality of life. Parents were more likely to prioritize quality of life when they recognized the child's poor prognosis (P = .002). Approximately 41% of parents expressed regret about the most recent treatment decision. Parents were more likely to experience regret if the child had received higher intensity medical care (odds ratio [OR], 3.14; 95% CI, 1.31-7.51), experienced suffering with limited benefit from the most recent treatment (OR, 4.78; 95% CI, 1.16-19.72), or experienced suffering from symptoms (OR, 2.91; 95% CI, 1.18-7.16).

CONCLUSIONS

Parents of children with poor-prognosis cancer frequently make decisions based on unrealistic expectations. New strategies for effective prognosis communication are needed.

Prevalence and predictors of probable depression in prostate cancer survivors

BACKGROUND

The early diagnosis and treatment of depression are cancer care priorities. These priorities are critical for prostate cancer survivors because men rarely seek mental health care. However, little is known about the epidemiology of depression in this patient population. The goal of this study was to describe the prevalence and predictors of probable depression in prostate cancer survivors.

METHODS

The data were from a population-based cohort of North Carolinian prostate cancer survivors who were enrolled from 2004 to 2007 in the North Carolina-Louisiana Prostate Cancer Project (n = 1031) and were prospectively followed annually from 2008 to 2011 in the Health Care Access and Prostate Cancer Treatment in North Carolina study (n = 805). Generalized estimating equations were used to evaluate an indicator of probable depression (Short Form 12 mental composite score ≤48.9; measured at enrollment and during the annual follow-up) as a function of individual-level characteristics within the longitudinal data set.

RESULTS

The prevalence of probable depression fell from 38% in the year of the cancer diagnosis to 20% 6 to 7 years later. Risk factors for probable depression throughout the study were African American race, unemployment, low annual income, younger age, recency of cancer diagnosis, past depression, comorbidities, treatment decisional regret, and nonadherence to exercise recommendations.

CONCLUSIONS

Depression is a major challenge for prostate cancer survivors, particularly in the first 5 years after the cancer diagnosis. To the authors' knowledge, this is the first study to demonstrate an association between treatment decisional regret and probable depression.

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.

"I'm Not Sure We Had A Choice": Decision Quality and The Use of Cardiac Implantable Electronic Devices In Older Adults With Cognitive Impairment

Background

The decision to implant a cardiac device in a person with Alzheimer’s disease or related dementia requires considering the possible trade-offs of quality of life (QOL) and quantity of life. This study measured the decision-making experience of patients with and without cognitive impairment (CI) who received a cardiac device and their family members who were involved in the decision.

Methods and Results

Semi-structured interviews and questionnaires were administered with 15 patient-family member dyads. Interviews revealed few conversations between physicians, patients and family members about the patient’s cognitive status or about the benefits, risks, and long-term implications of the device for someone with CI. Participants largely stated that the decision to get the device was based on the patient’s functional status at the time of the implant, and not on expectations about future functioning. Patients with CI had more regret, measured with the Decision Regret Scale (DRS), (p=0.037) and family members of patients without CI reported more decisional conflict, measured with the Decisional Conflict Scale (p=0.057).

Conclusions

Although CI impacts life expectancy and QOL, cognitive status was largely not discussed prior to device implant. Few differences were found between the experiences of dyads that included patients with or without CI.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Incongruence in treatment decision making is associated with lower health-related quality of life among prostate cancer survivors: results from the PiCTure study

PURPOSE

We investigated associations between treatment decision making (TDM) and global health-related-quality-of-life (gHRQoL) among prostate cancer (PCa) survivors.

METHODS

Postal questionnaires were sent to 6559 PCa survivors 2-18 years post-diagnosis, identified through population-based cancer registries in Ireland. The Control Preference Scale was used to investigate respondents' 'actual' and 'preferred' role in TDM. The TDM experience was considered 'congruent' when actual and preferred roles matched and 'incongruent' otherwise. The EORTC QLQ-C30 was used to measure gHRQoL. Multivariate linear regression was employed to investigate associations between (i) actual role in TDM, (ii) congruence in TDM, and gHRQoL.

RESULTS

The response rate was 54% (n = 3348). The percentages of men whose actual role in TDM was active, shared or passive were 36, 33 and 31%, respectively. Congruence between actual and preferred roles in TDM was 58%. Actual role in TDM was not associated with gHRQoL. In multivariate analysis, after adjusting for socio-demographic and clinical factors, survivors whose TDM experience was incongruent had significantly lower gHRQoL than those who had a congruent experience (- 2.25 95%CI - 4.09, - 0.42; p = 0.008). This effect was most pronounced among survivors who had more involvement in the TDM than they preferred (- 2.69 95%CI - 4.74, - 0.63; p = 0.010).

CONCLUSIONS

Less than 6 in 10 PCa survivors experienced congruence between their actual and preferred roles in TDM. Having an incongruent TDM experience was associated with lower gHRQoL among survivors. These findings suggest that involving patients in TDM to the degree to which they want to be involved may help improve PCa survivors' gHRQoL.

"What if…": decisional regret in patients who discontinued active surveillance

PURPOSE

To investigate the presence of regret in patients about having followed an active surveillance (AS) protocol. The secondary aim was to identify variables that influence regret.

METHODS

From February 2006 to May 2014, 204 patients discontinued the AS protocols and were invited to enter the study. Sociodemographic variables were collected at AS enrollment, together with health-related quality of life (Functional Assessment of Cancer Therapy-Prostate version [FACT-P]) and coping (Mini-Mental Adjustment to Cancer). Patients were asked to complete a Treatment Regret Scale as well as the FACT-P questionnaire. Clinical data were gathered, as well as time of stay within the AS protocol, reason for discontinuing AS, kind of post-AS treatment, and time elapsed since AS discontinuation. Questionnaires were completed by 105 patients (51.5% of those who had been invited to enter the study).

RESULTS

Most of the patients had a low or null degree of regret on the Treatment Regret Scale from 0 to 100 (82/105 patients [78.1%] obtained a score &lt;30, and about 30% of the sample had a score equal to zero). Only 5 patients (4.7%) scored 60 or more, indicating some degree of regret. None of the statistical tests between regret scores and a number of analyzed variables reached significance.

CONCLUSIONS

These results show that the degree of regret about following an AS protocol and after its discontinuation because of entering active treatment was very low. The regret after AS was not related to sociodemographic or clinical factors.

Spirituality is associated with less treatment regret in men with localized prostate cancer

BACKGROUND

Some patients with prostate cancer regret their treatment choice. Treatment regret is associated with lower physical and mental quality of life. We investigated whether, in men with prostate cancer, spirituality is associated with lower decisional regret 6 months after treatment and whether this is, in part, because men with stronger spiritual beliefs experience lower decisional conflict when they are deciding how to treat their cancer.

METHODS

One thousand ninety three patients with prostate cancer (84% white, 10% black, and 6% Hispanic; mean age = 63.18; SD = 7.75) completed measures of spiritual beliefs and decisional conflict after diagnosis and decisional regret 6 months after treatment. We used multivariable linear regression to test whether there is an association between spirituality and decisional regret and structural equation modeling to test whether decisional conflict mediated this relationship.

RESULTS

Stronger spiritual beliefs were associated with less decisional regret (b = -0.39, 95% CI = -0.53, -0.26, P < .001, partial η²  = 0.024, confidence interval = -0.55, 39%, P < .001, partial η²  = 0.03), after controlling for covariates. Decisional conflict partially (38%) mediated the effect of spirituality on regret (indirect effect: b = -0.16, 95% CI = -0.21, -0.12, P < .001).

CONCLUSIONS

Spirituality may help men feel less conflicted about their cancer treatment decisions and ultimately experience less decisional regret. Psychosocial support post-diagnosis could include clarification of spiritual values and opportunities to reappraise the treatment decision-making challenge in light of these beliefs.

Factors Associated with Men's Assessment of Prostate Cancer Treatment Choice

The objective of this study is to examine factors among a group of African American and White men in North Carolina and their assessment of prostate cancer treatment choice or belief that treatment chosen was best. A sample of men (N = 877) with a history of prostate cancer diagnosis was recruited from the North Carolina Cancer Registry during 2007-2008 and asked to participate in a telephone interview covering several measures about their initial prostate cancer treatment. Logistic regression was used to assess demographic, psychosocial, and clinical factors on whether they felt that they had chosen the best treatment for the disease. Respondents were majority White (52.7 %), married (75.9 %), and had surgery (67.9 %) as their initial treatment. At the bivariate level, factors associated with the belief that the treatment chosen was best were as follows: White race/ethnicity, higher levels of education, a more recent treatment date, having health insurance coverage, type of treatment received, higher levels of bother from side effects, greater contentment with their quality of life, and doctor discussions of the various treatment options. Similarly, the multivariate analysis showed increased odds of belief that the treatment chosen was the best among demographic (i.e., race/ethnicity, level of education, and health insurance coverage) as well as psychosocial and clinical variables (i.e., greater bother from side effects, greater contentment with their quality of life, and initial treatment received). Results suggest that demographic, psychosocial, and clinical factors play an important role for men in assessing their treatment choices for prostate cancer.

When do cancer patients regret their treatment decision? A path analysis of the influence of clinicians' communication styles and the match of decision-making styles on decision regret

OBJECTIVE

To test the influence of physician empathy (PE), shared decision making (SDM), and the match between patients' preferred and perceived decision-making styles on patients' decision regret.

METHODS

Patients with breast or colon cancer (n=71) completed questionnaires immediately following (T1) and three months after a consultation (T2). Path analysis was used to examine the relationships among patient demographics, patient reports of PE, SDM, the match between preferred and perceived decision-making styles, and patient decision regret at T2.

RESULTS

After controlling for clinician clusters, higher PE was directly associated with more SDM (β=0.43, p<0.01) and lower decision regret (β=-0.28, p<0.01). The match between patients' preferred and perceived roles was negatively associated with decision regret (β=-0.33, p<0.01). Patients who participated less than desired reported more decision regret at T2. There was no significant association between SDM and decision regret (β=0.03, p=0.74).

CONCLUSION

PE and the match between patients' preferred and perceived roles in medical decision making are essential for patient-centered cancer consultations and treatment decisions.

PRACTICE IMPLICATIONS

Ways to enhance PE and matching the consultation style to patients' expectations should be encouraged.

Effects of Design Features of Explicit Values Clarification Methods

Background. Diverse values clarification methods exist. It is important to understand which, if any, of their design features help people clarify values relevant to a health decision. Purpose. To explore the effects of design features of explicit values clarification methods on outcomes including decisional conflict, values congruence, and decisional regret. Data Sources. MEDLINE, all EBM Reviews, CINAHL, EMBASE, Google Scholar, manual search of reference lists, and expert contacts. Study Selection. Articles were included if they described the evaluation of 1 or more explicit values clarification methods. Data Extraction. We extracted details about the evaluation, whether it was conducted in the context of actual or hypothetical decisions, and the results of the evaluation. We combined these data with data from a previous review about each values clarification method’s design features. Data Synthesis. We identified 20 evaluations of values clarification methods within 19 articles. Reported outcomes were heterogeneous. Few studies reported values congruence or postdecision outcomes. The most promising design feature identified was explicitly showing people the implications of their values, for example, by displaying the extent to which each of their decision options aligns with what matters to them. Limitations. Because of the heterogeneity of outcomes, we were unable to perform a meta-analysis. Results should be interpreted with caution. Conclusions. Few values clarification methods have been evaluated experimentally. More research is needed to determine effects of different design features of values clarification methods and to establish best practices in values clarification. When feasible, evaluations should assess values congruence and postdecision measures of longer-term outcomes.

Extent and Predictors of Decision Regret about Health Care Decisions: A Systematic Review

BACKGROUND

People often face difficult decisions about their health and may later regret the choice that they made. However, little is known about the extent of decision regret in health care or its predictors. We systematically reviewed evidence about the extent of decision regret and its risk factors among individuals making health decisions.

METHODS

The data sources were Medline, Embase, and reverse citation searches in Google Scholar and Web of Science. Studies using the Decision Regret Scale (DRS) to measure decision regret among individuals making nonhypothetical health decisions were included. There were no restrictions on study design, setting, or language. We extracted characteristics of included studies, measures of central tendency for DRS scores (0 = no regret, 100 = high regret), and all risk factors from published analyses. Quality appraisal was conducted using the Mixed Methods Appraisal Tool. A narrative synthesis was performed owing to the heterogeneity of studies.

RESULTS

The initial search yielded 372 unique titles, and 59 studies were included. The overall mean DRS score across studies was 16.5, and the median of the mean scores was 14.3 (standard deviation range = 2.2-34.5) (n = 44 studies). The risk factors most frequently reported to be associated with decision regret in multivariate analyses included higher decisional conflict, lower satisfaction with the decision, adverse physical health outcomes, and greater anxiety levels.

CONCLUSIONS

The extent of decision regret as assessed with the DRS in nonhypothetical health decisions was often low but reached high levels for some decisions. Several risk factors related to the decision-making process significantly predicted decision regret. Additional research into the psychometrics of the DRS and the relevance of scores for clinicians and patients would increase the validity of decision regret as a patient-reported outcome.

The Health Effects of Masculine Self-Esteem Following Treatment for Localized Prostate Cancer Among Gay Men

PURPOSE

To identify factors associated with masculine self-esteem in gay men following treatment for localized prostate cancer (PCa) and to determine the association between masculine self-esteem, PCa-specific factors, and mental health factors in these patients.

METHODS

A national cross-sectional survey of gay PCa survivors was conducted in 2010-2011. To be eligible for the study, men needed to be age 50 or older, reside in the United States, self-identify as gay, able to read, write, and speak English, and to have been treated for PCa at least 1 year ago. One hundred eleven men returned surveys.

RESULTS

After simultaneously adjusting for the factors in our model, men aged 50-64 years and men aged 65-74 years reported lower masculine self-esteem scores than men aged 75 years or older. Lower scores were also reported by men who reported recent severe stigma. Men who reported feeling comfortable revealing their sexual orientation to their doctor reported higher masculine self-esteem scores than men who were not. The mental component score from the SF-12 was also positively correlated with masculine self-esteem.

CONCLUSION

PCa providers are in a position to reduce feelings of stigma and promote resiliency by being aware that they might have gay patients, creating a supportive environment where gay patients can discuss specific sexual concerns, and engaging patients in treatment decisions. These efforts could help not only in reducing stigma but also in increasing masculine self-esteem, thus greatly influencing gay patients' recovery, quality of life, and compliance with follow-up care.

The Impact of Patient Participation in Health Decisions Within Medical Encounters

Background: Although there are compelling moral arguments for patient participation in medical decisions, the link to health outcomes has not been systematically explored. Objective: Assess the extent to which patient participation in decision making within medical encounters is associated with measured patient outcomes. Methods: We conducted a primary search in PubMed—excluding non-English and animal studies—for articles on decision making in the context of the physician–patient relationship published through the end of February 2015, using the MeSH headings (Physician-Patient Relations [MeSH] OR Patient Participation [MeSH]) and the terms (decision OR decisions OR option OR options OR choice OR choices OR alternative OR alternatives) in the title or abstract. We also conducted a secondary search of references in all articles that met the inclusion criteria. Results: A thorough search process yielded 116 articles for final analysis. There was wide variation in study design, as well as measurement of patient participation and outcomes, among the studies. Eleven of the 116 studies were randomized controlled trials (RCTs). Interventions increased patient involvement in 10 (91%) of the 11 RCTs. At least one positive outcome was detected in 5 (50%) of the 10 RCTs reporting increased participation; the ratio of positive results among all outcome variables measured in these studies was much smaller. Although proportions differed, similar patterns were found across the 105 nonrandomized studies. Conclusions: Very few RCTs in the field have measures of participation in decision making and at least one health outcome. Moreover, extant studies exhibit little consistency in measurement of these variables, and results are mixed. There is a great need for well-designed, reproducible research on clinically relevant outcomes of patient participation in medical decisions.

Treatment decisional regret among men with prostate cancer: Racial differences and influential factors in the North Carolina Health Access and Prostate Cancer Treatment Project (HCaP-NC)

BACKGROUND

It has been demonstrated that treatment decisional regret affects quality of life in patients with prostate cancer (CaP); however, there are limited studies that identify factors associated with treatment decisional regret, particularly within a racially diverse patient population that has extended follow-up.

METHODS

Logistic regression analysis was used to determine associations between decisional regret and potential predictors in a population-based cohort of 348 African American men and 446 Caucasian American men approximately 3 years after CaP diagnosis.

RESULTS

Of 794 research participants, 12% experienced treatment decisional regret. Decisional regret was associated with androgen-deprivation therapy (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.1-4.0), recent urinary bother (OR, 3.4; 95% CI, 1.6-7.3), satisfaction with understanding potential treatment side effects (very unsatisfied: OR, 13.3; 95% CI, 5.5-32.2; somewhat unsatisfied: OR, 5.0; 95% CI, 2.3-11.2; neutral: OR, 3.8; 95% CI, 1.9-7.6), and CaP treatment effect on the spousal relationship (very affected: OR, 3.9; 95% CI, 2.0-7.6; somewhat affected: OR, 3.1; 95% CI, 1.4-7.3; neutral: OR, 2.4; 95% CI, 1.9-7.6). Younger African Americans were more likely to experience regret than older African Americans (OR, 3.0; 95% CI, 1.1-8.1), and older African Americans were less likely to experience regret than older Caucasian Americans (OR, 0.2; 95% CI, 0.1-0.7).

CONCLUSIONS

Treatment decisional regret remains an important issue in CaP survivors beyond initial treatment. Potential interventions should involve younger African Americans and patient spouses. Increased regret may reflect the unexpected influence of treatment side effects on the patient's everyday life; helping the patient relate potential side effects to his individual situation could improve patient satisfaction.

Consultation audio-recording reduces long-term decision regret after prostate cancer treatment: A non-randomised comparative cohort study

INTRODUCTION

The life expectancy of prostate patients is long and patients will spend many years carrying the burdens & benefits of the treatment decisions they have made, therefore, it is vital that decisions on treatments are shared between patient and physician. The objective was to determine if consultation audio-recording improves quality of life, reduces regret or improves patient satisfaction in comparison to standard counselling.

PATIENTS AND METHODS

In 2012 we initiated consultation audio-recordings, where patients are given a CD of their consultation to keep and replay at home. We conducted a prospective non-randomised study of patient satisfaction, quality of life (QOL) and decision regret at 12 months follow-up using posted validated questionnaires for the audio-recording (AR) patients and a control cohort. Qualitative and thematic analyses were used.

RESULTS

Forty of 59 patients in the AR group, and 27 of 45 patients in the control group returned the questionnaires. Patient demographics were similar in both groups with no statistically significant differences between the two groups. Decision regret was lower in the audio-recording group (11/100) vs control group (19/100) (p = 0.04). The risk ratio for not having any long-term decision regret was 5.539 (CI 1.643-18.674), with NNT to prevent regret being 4. Regression analysis showed that receiving audio-recording was strongest predictor for absence of regret even greater than potency and incontinence.

CONCLUSION

The study has shown that audio-recording clinic consultation reduces long-term decision regret, increases patient information recall, understanding and confidence in their decision. There is great potential for further expansion of this low-cost intervention.

Treatment regret and quality of life following radical prostatectomy

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Quality of life, uncertainty, and perceived involvement in decision making in patients with head and neck cancer

PURPOSE/OBJECTIVES

To explore the relationship among perceived involvement in decision making, uncertainty, and quality of life (QOL) in patients with head and neck cancer in pre- and post-treatment periods using Mishel's Uncertainty in Illness Theory.

DESIGN

A prospective, correlational design.

SETTING

Six outpatient clinics at urban hospitals in New York, NY.

SAMPLE

A convenience sample of 52 adults newly diagnosed with head and neck cancer.

METHODS

Data were collected by a self-administered questionnaire containing a demographic datasheet, the Functional Assessment of Cancer Therapy-Head and Neck, Mishel Uncertainty in Illness Scale (Adult), and Perceived Involvement in Care Scale, at pretreatment (Time 1) and six weeks post-treatment (Time 2).

MAIN RESEARCH VARIABLES

QOL, uncertainty, perceived involvement in decision making.

FINDINGS

Post-treatment QOL was lower than pretreatment. QOL was associated with uncertainty and employment status at Time 1 and Time 2. Uncertainty and QOL at the time of pretreatment were predictors of post-treatment QOL after controlling for unemployment, chemoradiation, and physician. Perceived involvement in decision making was not associated with uncertainty or QOL.

CONCLUSIONS

The higher a patient's pretreatment QOL, the more likely QOL remains sound after treatment.

IMPLICATIONS FOR NURSING

Additional studies, including interventional evaluations to decrease uncertainty and to maintain employment and better income, are needed. Antecedents of Mishel's Uncertainty in Illness Theory may need to be refined for patients with head and neck cancer.

Who makes the decision regarding the treatment of clinically localized prostate cancer--the patient or physician?: results from a population-based study

BACKGROUND

The current study examined how patients' sociodemographic, cancer-related, and subjective affective factors impacted their role in treatment decision-making.

METHODS

The patient sample (N = 788) was taken from a prospective follow-up study of a population-based cohort. Participants included 343 African American and 445 Caucasian-American patients with clinically localized prostate cancer. Multinomial logistic regression was used to investigate relations between the explanatory variables and the nominal 3-level decision-making variable: patient-only, patient-physician shared, and physician-only.

RESULTS

Approximately 41% of patients reported patient-only decision-making, 45% reported shared decision-making, and 13% reported physician-only decision-making. The odds of patient-only over physician-only decision-making were greater for younger men (vs those aged ≥ 65 years) (odds ratio [OR], 1.68; 95% confidence interval [95% CI], 1.03-2.74), and were less for men with high (vs low) cancer aggressiveness (OR,0.29; 95% CI, 0.15-0.55). The odds of shared over physician-only decision-making were less for men with high (vs low) cancer aggressiveness (OR, 0.40; 95% CI, 0.22-0.73). Greater odds of patient-only and shared decision-making also were found to be associated with greater concerns about the physical impact of treatment and having enough time for decision-making and lower scores of receiving advice from others.

CONCLUSIONS

The findings of the current study indicate that, to facilitate a more patient-oriented decision-making process regarding treatment in those with clinically localized prostate cancer, clinicians need to tailor their interventions according to patient age and cancer aggressiveness, help reduce patient concerns and misconceptions regarding the physical impact of treatments, allow sufficient time for patients to consider treatment options, and assist patients in balancing advice and information received from different sources.

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.

Effect of intervention on decision making of treatment for disease progression, prostate-specific antigen biochemical failure and prostate cancer death

BACKGROUND

Patient preference for the choice of treatment modality for prostate cancer has increasingly gained attention.

OBJECTIVE

To assess the impact of client-oriented decision on long-term mortality, disease progression and biochemical failure compared with standard treatment protocol (TP).

METHODS

With data from a Finnish multicentre, randomized controlled trial with two arms [104 in the enhanced patient participation (EPP) arm and 106 in the TP arm], disease-specific and disease-free survival, biochemical failure with elevated prostate-specific antigen (PSA) level and disease progression were compared between the two arms using Wilcoxon test and also Cox proportional hazards regression model.

RESULTS

Patients in the EPP arm had a higher risk of death by 37% [HR, 1.37 (0.87-2.17)] compared with those in the TP arm. Patients in the EPP arm were at increased risk of having biochemical failure by 14% [HR, 1.14 (0.72-1.79)] and for having disease progression by 2% [HR, 1.02 (0.61-1.70)] compared with those in the TP arm. All the differences were non-significant.

CONCLUSIONS

Patients actively involved in the choice of treatment had higher risk of prostate cancer death but only slightly increased risk of biochemical failure and clinical disease progression. These findings would provide a good reference when patient autonomy for the choice of treatment modality is addressed.

The OPTION scale for the assessment of shared decision making (SDM): methodological issues

BACKGROUND

Promoting patient involvement in medical decision making has become a desirable goal in medical consultations. Reliable and valid measures are necessary to evaluate interventions designed to promote shared decision making and to understand determinants and associations. The OPTION ("observing patient involvement") scale is the most prominent observation instrument for assessing the extent to which clinicians actively involve patients in decision making.

OBJECTIVE

This paper discusses psychometric and methodological characteristics of the OPTION scale.

RESULTS

There is little support for the purported unidimensional structure. Although reliabilities are acceptable, results are highly heterogeneous across studies. There is also little evidence concerning validity. In particular, studies mainly failed to support convergent validity. Additional issues pertain to lack of item independence, restriction of range, and failure to consider dyadic aspects.

CONCLUSIONS

Given these findings, a number of methodological and conceptual issues still need to be addressed for the effective measurement of patient involvement. Directions for future research are discussed.

The Impact of Explicit Values Clarification Exercises in a Patient Decision Aid Emerges After the Decision Is Actually Made

Purpose

To determine if particular values clarification exercises included in a patient decision aid had discernible impact on postdecisional regret in patients with early-stage prostate cancer.

Methods

A multicenter randomized controlled trial compared 2 versions of a computerized patient decision aid: only structured information compared to the structured information plus values clarification exercises. Assessments were conducted during the decision aid visit; telephone follow-up interviews were conducted when patients made their decisions with their physician, 3 months after completing treatment, and >1 year later (per a mailing). Outcome measures included the Decisional Conflict Scale, the Preparation for Decision Making Scale, and the Decision Regret Scale.

Results

A total of 156 patients participated, 75 provided information only and 81 provided information plus values clarification exercises. The groups did not differ significantly on any outcome evaluated at the decision aid visit; in both groups, decisional conflict decreased immediately after using the decision aid. Between-group differences emerged after the decision was actually made. The values clarification exercises group reported higher Preparation for Decision Making Scale scores at the decision follow-up and at the >1-year follow-up. Regret did not differ significantly between groups at the 3-month follow-up but was lower for the values clarification exercises group than for the information group at the >1-year follow-up.

Conclusion

The results suggest that the values clarification exercises led to better preparation for decision making and to less regret. The impact, however, only emerged after the decision was made.

Demonstration of erectile management techniques to men scheduled for radical prostatectomy reduces long-term regret: a comparative cohort study

OBJECTIVE

To determine whether preoperative demonstrations of intracavernosal and vacuum therapies for erectile dysfunction (ED) influence the decision of treatment choice, reducing long-term regret.

PATIENTS AND METHODS

In all, 82 consecutive men with localized prostate cancer, scheduled for radical prostatectomy and reporting an International Index of Erectile Function score of >21, were prospectively enrolled at a single cancer centre. Following standard preoperative counselling, half of the men were invited to attend a further consultation for intracavernosal and vacuum therapy demonstrations. All patients were evaluated pretreatment and then 3 monthly using the five-point International Index of Erectile Function score and the 14-item Hospital Anxiety and Depression scale. At 12 months treatment choice changes were recorded and patients were assessed for treatment choice regret using Clark's validated two-item regret questionnaire. Statistical analysis was performed using the Mann-Whitney and Fisher's exact tests. Results were compared with a control population of 41 men who did not undergo additional ED counselling.

RESULTS

In all, 8/41 men (19%) changed their treatment choice, opting for brachytherapy rather than radical prostatectomy. Only 1/41 in the control population changed their decision before surgery. At 1 year, one patient (2%) in the intervention group expressed regret at his treatment choice (radical prostatectomy) compared with eight (20%) in the control group (P= 0.03, two-sided Fisher's exact test); ED was identified as the major cause of this regret.

CONCLUSION

Preoperative demonstrations of ED therapies can optimize decision making in prostate cancer and help reduce long-term regret.

Exploratory and Confirmatory Factor Analysis of the Decision Regret Scale in Recipients of Internal Cardioverter Defibrillators

The Decision Regret Scale (DRS) is a five-item instrument that captures an individual’s regret associated with a healthcare decision. Cross-sectional data were collected from 109 cardiac patients who decided to receive an internal cardioverter defibrillator (ICD). Exploratory and confirmatory factor analyses, assessments of the internal reliability consistency (α = .86), and discriminant validity established the DRS as a reliable and valid measure of decision regret in ICD recipients. The DRS, a psychometrically sound instrument, has relevance for clinicians and researchers vested in optimizing the decisional outcomes of ICD recipients. Future research is needed to examine the reliability and validity of the DRS in a larger and more diverse sample of ICD recipients.

Treatment decision regret and related factors following radical prostatectomy

BACKGROUND

Issues such as physical and psychological distress impact the quality of life of patients after a radical prostatectomy (RP). It is important to understand the regret that patients often report following a RP and the factors that influence their regret.

OBJECTIVE

The objective of the present study was to understand the regret that patients report following a RP and the influencing factors for their regret.

METHODS

Patients who had a diagnosis of prostate cancer and who underwent a RP between 2004 and 2010 were recruited for this study. The data gathered included a regret scale; the University of California, Los Angeles, Prostate Cancer Index; and demographic and disease-related information.

RESULTS

A total of 100 patients participated in our study. Of those who participated, 31% regretted that they had received an RP. Stepwise regression showed that the following 5 variables were predictors of patient regret after an RP: whether the patient would choose to have an RP again, understanding the treatment and complications, bothersome adverse sexual effects, age, and bothersome adverse bowel effects.

CONCLUSION

We found that 31% of the participants reported experiencing regret after receiving an RP. Our data suggest that urologists and nurses should carefully portray the risks and benefits of RPs during preoperative counseling to minimize patient regret and maximize patient satisfaction.

IMPLICATIONS FOR PRACTICE

Patient regret after an RP is common. Urological nurses should therefore counsel patients regarding the impacts of complications associated with RPs and seek appropriate nursing interventions to reduce patient regret following an RP.

Involvement in decision-making about treatment and ovarian cancer survivor quality of life

PURPOSE

This study sought to better understand the long-term effects on women's health related quality of life (HRQOL) of involvement in decision-making about their surgical and chemotherapeutic treatments for ovarian cancer treatment and about follow-up care after treatment.

METHODS

Using a cross-sectional survey design, a sample of 219 ovarian cancer patient/survivors from Western Washington who were between 3 months and ten years post-diagnosis were recruited via a mailed survey sent by their gynecological oncologist and interviewed about their ovarian cancer treatment, use of Complementary and Alternative Medicine (CAM), Health related quality of life, and their involvement in decision-making about their cancer treatment and follow-up care.

RESULTS

Multivariate regression analyses revealed age, but not stage of cancer to be a significant predictor of perceived involvement in decision-making about ovarian cancer treatment and follow-up. Age also predicted CAM use with older patients using herbal CAM, and younger patients using CAM activities and CAM providers (p<0.5). Controlling for demographic, disease, and treatment characteristics involvement in decision-making about surgery and follow-up care were associated with better mental health in survivorship (p<0.05). Involvement in decision-making about use of CAM and about lifestyle health changes was associated with greater vitality and better role-emotional health in survivorship (respectively; both; p<0.05).

CONCLUSIONS

As has been found in studies of breast cancer survivors, perceived involvement in decision-making about ovarian cancer treatment including surgery and follow-up care after treatment is associated with better quality of life for cancer survivors. Involvement in decision-making about the use of CAM and about changes in lifestyle health practices also appear to help survivor's emotional health related quality of life. Prospective studies are needed to determine the mechanisms by which perceived involvement in decision-making about treatment might influence survivor quality of life.

Effectiveness of multimedia interactive patient education on knowledge, uncertainty and decision-making in patients with end-stage renal disease

AIM

This study tested the efficacy of a multimedia interactive DVD as an education tool for patients with end-stage renal disease in terms of enhancing patient knowledge and decision-making skills and decreasing uncertainty.

BACKGROUND

End-stage renal case numbers in Taiwan are growing by approximately 6000 new patients per year. Helping patients choose an optimal treatment method to maximise quality of life is an important healthcare issue for this patient population.

DESIGN

This study adopted a quasi-experimental design and focused on subjects being treated at one medical centre in southern Taiwan. The study divided subjects into experimental and control groups.

METHODS

The experimental group received three multimedia interactive DVD nursing-guided interventions. The control group received only normal hospital health education. The study gathered data using several scales addressing knowledge, uncertainty perception and decision regret. Scales were implemented immediately before and after the multimedia interactive DVD nursing guidance intervention and at four and eight weeks postintervention. This study used an independent t-test, chi-square test and repeated measures analysis of variance.

RESULTS

This study found significant improvements in the experimental group in terms of knowledge, pre-dialysis uncertainty and decision regret. Experimental group subjects scored particularly less in terms of decision regret than those in the control group.

RELEVANCE TO CLINICAL PRACTICE

This study demonstrated the efficacy of the developed multimedia interactive DVD in significantly improving end-stage renal patient knowledge and reducing patient uncertainties and postdecision regret. Study findings can be used as a reference guide for clinical nursing education efforts in hospital and other healthcare settings.

Post-treatment regret among young breast cancer survivors

OBJECTIVE

The study addresses: (1) what women regret about their breast cancer treatment 5 years later, and (2) what characteristics of disease and treatment predict post-treatment regret.

METHOD

Interviews were conducted with breast cancer survivors in the San Francisco Bay Area. Participants were interviewed following diagnosis. Five years later, women were asked whether they had any regrets about their cancer treatment (N=449). Qualitative analysis was used to identify regret content, and logistic regression was used to determine what characteristics of treatment predicted regret.

RESULTS

Forty two point five percent women in the sample regretted some aspect of the treatment. The most common regrets were primary surgery (24.1%), chemotherapy and/or radiation (21.5%), reconstruction (17.8%), and problems with providers (13.1%). In addition, women regretted inactions (59.2%) (actions that they did not take) more than actions that they did take (30.4%). This represents a novel finding in the study of post-treatment regret, which has largely focused on regrets over actions. Quantitative analysis revealed that women who were anxious about the future (OR=1.32; p=0.03) or had problems communicating with physicians (OR=1.26; p=0.02) during treatment were more likely to express regret 5 years later. In addition, women with new or recurrent cancers 5 years later were significantly more likely to regret some aspect of their primary treatment (OR=5.81; p<0.001).

CONCLUSION

This research supports addressing the psychosocial aspects of cancer care and improving physician-patient communication. Evidence is also provided for addressing the unique emotional needs of women with recurrent cancers, who may experience an undue burden of regret.

The importance and complexity of regret in the measurement of 'good' decisions: a systematic review and a content analysis of existing assessment instruments

BACKGROUND OR CONTEXT: Regret is a common consequence of decisions, including those decisions related to individuals' health. Several assessment instruments have been developed that attempt to measure decision regret. However, recent research has highlighted the complexity of regret. Given its relevance to shared decision making, it is important to understand its conceptualization and the instruments used to measure it.

OBJECTIVES

To review current conceptions of regret. To systematically identify instruments used to measure decision regret and assess whether they capture recent conceptualizations of regret.

SEARCH STRATEGY

Five electronic databases were searched in 2008. Search strategies used a combination of MeSH terms (or database equivalent) and free text searching under the following key headings: 'Decision' and 'regret' and 'measurement'. Follow-up manual searches were also performed.

INCLUSION CRITERIA

Articles were included if they reported the development and psychometric testing of an instrument designed to measure decision regret, or the use of a previously developed and tested instrument.

MAIN RESULTS

Thirty-two articles were included: 10 report the development and validation of an instrument that measures decision regret and 22 report the use of a previously developed and tested instrument. Content analysis found that existing instruments for the measurement of regret do not capture current conceptualizations of regret and they do not enable the construct of regret to be measured comprehensively.

CONCLUSIONS

Existing instrumentation requires further development. There is also a need to clarify the purpose for using regret assessment instruments as this will, and should, focus their future application.

Assessing the acceptability and usability of an interactive serious game in aiding treatment decisions for patients with localized prostate cancer

BACKGROUND

Men diagnosed with localized prostate cancer face a potentially life-altering treatment decision that can be overwhelming. Enhancing patient knowledge through education can significantly reduce feelings of uncertainty while simultaneously increasing confidence in decision making. Serious games have been shown in other populations to increase health knowledge and assist with the health decision-making process. We developed an interactive serious game, Time After Time, which translates evidence-based treatment outcome data into an accessible and understandable format that men can utilize in their prostate cancer treatment decision-making process. The game specifically aims to raise men's awareness and understanding of the impact of health-related quality of life issues associated with the major treatment options and to enrich their conversations with their health care providers.

OBJECTIVE

This study determined the acceptability and usability of the alpha version of Time After Time, an interactive decision aid for men diagnosed with localized prostate cancer, in order to inform future iterations of the serious game.

METHODS

The study employed a mixed methods approach to assess the acceptability and usability of the Time After Time serious game using qualitative focus groups and a quantitative Likert scale survey.

RESULTS

A total of 13 men who had already completed treatment for localized prostate cancer completed the survey and participated in focus group meetings. The majority of the study participants rated Time After Time as an appropriate decision tool for localized prostate cancer and verified that it meets its goals of increasing focus on side effects and generating questions for the patient's health care team. However, participants also expressed concerns about game usability and the diversity of information covered regarding treatment options and potential treatment outcomes.

CONCLUSIONS

Serious games are a promising approach to health education and decision support for older men. Participants were receptive to the idea of a serious game as a decision aid in localized prostate cancer. However, usability issues are a major concern for this demographic, as is clarity and transparency of data sources.

Early prostate cancer--which treatment do men prefer and why?

STUDY TYPE

Preference (prospective cohort).

LEVEL OF EVIDENCE

1b. What's known on the subject? and What does the study add? In general the literature suggests that there is a need for improvement in aiding men diagnosed with early prostate cancer in their decision making about treatment options and that our understanding of this process is inadequate. There is limited data analyzing the reasons why these men decide between potentially curative or observational treatments and data evaluating patients' views before and after definitive therapy are scarce. This study begins the process of understanding the reasons underlying a patient's final treatment decision. Being a prospective study, it looks at the thought processes of these men before treatment during the time the decision is made. It also documents how satisfied patients are with their choice after their treatment and whether they would choose the same treatment again.

OBJECTIVE

To identify the reasons for patients with localised prostate cancer choosing between treatments and the relationship of procedure type to patient satisfaction post-treatment.

PATIENTS AND METHODS

768 men with prostate cancer (stage T1/2, Gleason≤7, PSA<20 ug/L) chose between four treatments: radical prostatectomy, brachytherapy, conformal radiotherapy and active surveillance. Prior to choosing, patients were counselled by a urological surgeon, clinical (radiation) oncologist and uro-oncology specialist nurse. Pre-treatment reasons for choice were recorded. Post-treatment satisfaction was examined via postal questionnaire.

RESULTS

Of the 768 patients, 305 (40%) chose surgery, 237 (31%) conformal beam radiotherapy, 165 (21%) brachytherapy and 61 (8%) active surveillance. Sixty percent of men who opted for radical prostatectomy were motivated by the need for physical removal of the cancer. Conformal radiotherapy was mainly chosen by patients who feared other treatments (n=63, 27%). Most men chose brachytherapy because it was more convenient for their lifestyle (n=64, 39%). Active surveillance was chosen by patients for more varied reasons. Post-treatment satisfaction was assessed in a subgroup who took part in the QOL aspect of this study. Of the respondents to the questionnaire, 212(87.6%) stated that they were satisfied/extremely satisfied with their choice and 171(92.9%) indicated they would choose the same treatment again.

CONCLUSION

Men with early prostate cancer have clear reasons for making decisions about treatment. Overall, patients were satisfied with the treatment and indicated that despite different reasons for choosing treatment, they would make the same choice again.