Informed prostate cancer patients are less likely to regret treatment

Relation

Hoffman RM, Lo M, Clark JA, et al. Regret of treatment decision in long-term survivors of localized prostate cancer: Results from the Prostate Cancer Outcomes Study.J Clin Oncol.2017;35(20):2306-2314.

Draft

Follow-up survey data from a large, population-based cohort study known as the Prostate Cancer Outcomes Study, originally published inJournal of the National Cancer Institute.¹

Study population

934 men treated in various U.S. cities between October 1994 and 1995 who were part of a cohort who completed baseline and 15-year surveys. They were diagnosed with localized prostate cancer, with 59% classified as low-risk disease, diagnosed before age 75. Of the total 934 patients, 696 were treated with initial radical prostatectomy, 146 received initial radiotherapy, and 92 were treated with either observational wait-and-see (no treatment) or androgen deprivation therapy within 1 year of diagnosis.

Results measured

Multivariable logistic regression analyzes were used to identify factors associated with regret. A 15-year follow-up survey was used to determine several key factors including:

• Demografie
• Sozioökonomischen Status
• Bedauern der Behandlungsentscheidung
• Informierte Entscheidungsfindung
• Allgemeine und krankheitsspezifische Lebensqualität
• Gesundheitssorgen
• PSA-Bedenken
• Lebensaussichten

Key insights

The survey response rate over the 15-year follow-up period was 69.3%. Most respondents had undergone radical prostatectomy, with 10.8% of survey responses coming from patients treated conservatively with watchful waiting or androgen deprivation therapy. Overall, less than 15% expressed regret about the treatment decision, with the largest proportion (16.6%) of regret coming from those who underwent radiation therapy. Men who were older and felt they had made an informed treatment decision also had the least regrets. The men who reported having symptoms involving bowel function, sexual function and higher PSA levels had the most regrets.

Practice implications

Interestingly, the same researchers surveyed the same participants in the Prostate Cancer Outcomes Study 2 years after treatment, so there are now 2 sets of data points to consider: 2 years (2003 study)²and 15 years (2017 study). In the 2-year follow-up, 2,365 men were examined and 59.2% were enthusiastic or very satisfied with their treatment choice. At the time of 2-year follow-up, a large percentage of men were cancer-free (66.4%) and had no problems with urinary (64.2%), bowel (60.5%), or sexual dysfunction (65.9%). The second 15-year follow-up study added a validated instrument to measure regret more accurately. This showed that regret actually increased over time. In both studies, self-reported treatment regret was fairly low, which is good news. But that's not the only interesting data to come from this latest study.

Regret is highly associated with lack of knowledge about treatment side effects such as bowel, urinary, and sexual dysfunction, which can negatively impact quality of life after treatment.

This study, as well as previous research, shows that regret is highly associated with a lack of knowledge about adverse treatment effects such as bowel, urinary, and sexual dysfunction, which can negatively impact quality of life after treatment.^3.4In related studies, Davison et al. found that men who took a more active role in their treatment decisions felt less regret.⁵Hacking et al. showed that men who used a navigator to support the treatment decision-making process had significantly less regret 6 months after treatment than those who did not use navigation.⁶

In this study, men who treated their cancer more conservatively with watchful waiting, also known as active surveillance, and whose PSA levels had normalized without recurrence experienced the lowest levels of regret, possibly due to a lack of treatment side effects and quality of life issues. These researchers see this as an opportunity to fully inform men with localized prostate cancer about the option of active surveillance. In fact, research shows that active surveillance had similar outcomes and mortality compared to initial radiation therapy and surgery. Due to the lack of treatment side effects, active surveillance has emerged as a standard treatment option for men with very low- and low-risk prostate cancer.^7.8The researchers in this present study believe their findings are “timely for men with low-risk cancers who are encouraged to consider active surveillance.”

As a radiation oncologist, it is important to me to note that treatment toxicity can vary over time. For example, this cohort was treated before the advent of intensity-modulated radiation therapy (IMRT), which radically improved both short- and long-term side effect profiles of radiation therapy. Surgical advances have also been made over time, such as: B. robot-assisted prostatectomy. Furthermore, active surveillance as a discrete protocol did not formally exist in 1994-95. Regardless of these therapeutic improvements, it is important to know that the conventional treatments we administer can sometimes cause long-term quality of life problems, such as: B. Urinary incontinence or sexual and bowel dysfunction. It is also challenging to anticipate long-term effects that may not dissipate. I work with patients to determine their risk tolerance, personal and psychological values, and other quality of life considerations to help them find the right path. A correct path for a 50 year old healthy man is probably different than the path for an unhealthy 78 year old. We'll go through the options and discuss factors that are completely under their control - how they eat, move their body, and manage their stress. We discuss that there is good data that these controllable factors may influence prostate cancer progression rates.⁹

The clinical take-home message is that all men deserve to be well-informed about the complexities and nuances of each prostate cancer treatment option. Patients must be counseled to make decisions based on many factors, including treatment side effects, quality of life issues, risk of relapse, healthy lifestyle habits, and other aspects of care, to ensure that the final decision is consistent with the patient's values ​​and expectations.¹⁰By helping men diagnosed with prostate cancer view their treatment options through this lens, we can reduce regret in both the short and long term.