Are decisions on treatment choices for prostate cancer shared by doctor and patient?

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

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

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

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

Discussing prostate cancer diagnoses and treatment options are part of a urologist's everyday work. Tikkinen's research team examined the impact of decision aids on the treatment decision through a systematic literature review and meta-analysis. They identified 14 randomized studies that had enrolled 3,377 patients. Their study was published in CA: A Cancer Journal for Clinicians (2015; doi:10.3322/caac.21272).

The most common form of decision aid provided to the patients was written information on the different treatment options. Fewer than half of the aids provided had been customized in some way to meet that specific patient's individual need for information.

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

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

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

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