Patient Decision-Making Factors in Aggressive Treatment of Low-Risk Prostate Cancer

Abstract

Background Active surveillance (AS) is under-utilized for low-risk prostate cancer. This study examines decision-making factors associated with AS vs aggressive treatment in a population-based cohort of low-risk patients. Methods Newly-diagnosed patients were enrolled through the North Carolina Central Cancer Registry from 2011–2013 (n = 599), and surveyed regarding 5 factors which may impact treatment decision-making: perceived cancer aggressiveness, aggressiveness of treatment intent, most important goal (eg, cure, quality of life), primary information source, and primary decision-maker. We examined the association between treatment decision-making factors with patient choice for AS vs aggressive treatment using multivariale logistic regression analysis. Results This is a sociodemographically diverse cohort reflective of the population-based design, with 37.6% overall (47.6% among very low-risk patients) choosing AS. Aggressive treatment intent (odds ratio [OR] = 7.09, 95% confidence interval [CI] = 4.57–11.01), perceived cancer aggressiveness (OR = 4.93, 95% CI = 2.71–8.97), most important goal (cure vs other, OR = 1.72, 95% CI = 1.12–2.63) and primary information source (personal/family vs physician, OR = 1.76, 95% CI = 1.10–2.82) were associated with aggressive treatment. Overall, 88.4% of patients (92.2% among very low-risk) who indicated an intent to treat the cancer “not very aggressively” chose AS. Conclusions These data from the patient’s perspective shed new light on potentially modifiable factors that can help further increase AS uptake among low-risk patients. Helping more low-risk patients feel comfortable with a “not very aggressive” treatment approach may be especially important, which can be facilitated throughpatient education interventions to improveunderstanding of the cancer diagnosis and AS having a curative intent.

Determinants of active surveillance uptake in a diverse population‐based cohort of men with low‐risk prostate cancer: The Treatment Options in Prostate Cancer Study (TOPCS)

“…Although all study participants had LRPC, more than one‐third of those who chose definitive treatment believed their cancer was “serious” or “very serious”; this view was significantly associated with aggressive DT receipt. Men who underwent DT were also more likely to report that the desire to “cure” their cancer, a finding that is similar to the results of an earlier population‐based cohort study of 599 patients with LRPC 47 . Furthermore, nearly three‐quarters of patients who chose DT indicate that this treatment option will allow them live longer than if they had not undergone DT, despite a lack of evidence for survival benefit of DT among men with LRPC 3,48 .…”

“…25 Conversely, misperception of cancer seriousness may lead to an unnecessary aggressive treatment. 47,50 Urologists need to reassure low-risk patients that AS is an active, safe, and guideline-preferred alternative to avoid or delay more invasive treatments, 4,6 which do not improve survival for most low-risk patients while causing significant long-term side effects that reduce patients' quality of life. 3,48,51 We also found that shared collecting data on patient-reported treatment status and quality of life in a longitudinal cohort, TOPCS is poised to answer some of the critical unanswered questions related to LRPC management.…”

“…When physicians, especially urologists, appropriately describe LRPC as “small,” “low‐grade,” “not aggressive,” and with favorable prognosis, can result in a sense of relief for patients who then feel more comfortable with undergoing AS 25 . Conversely, misperception of cancer seriousness may lead to an unnecessary aggressive treatment 47,50 . Urologists need to reassure low‐risk patients that AS is an active, safe, and guideline‐preferred alternative to avoid or delay more invasive treatments, 4,6 which do not improve survival for most low‐risk patients while causing significant long‐term side effects that reduce patients’ quality of life 3,48,51 .…”