Variation in Communication of Competing Risks of Mortality in Prostate Cancer Treatment Consultations

Abstract

Purpose:Men with prostate cancer prefer patient-specific, quantitative assessments of longevity in shared decision making. We sought to characterize how physicians communicate the 3 components of competing risks—life expectancy (LE), cancer prognosis and treatment-related survival benefit—in treatment consultations.Materials and Methods:Conversation related to LE, cancer prognosis and treatment-related survival benefit was identified in transcripts from treatment consultations of 42 men with low- and intermediate-risk disease across 10 multidisciplinary providers. Consensus of qualitative coding by multiple reviewers noted the most detailed mode of communication used to describe each throughout the consultation.Results:Physicians frequently failed to provide patient-specific, quantitative estimates of LE and cancer mortality. LE was omitted in 17% of consultations, expressed as a generalization (eg “long”/”short”) in 17%, rough number of years in 31%, probability of mortality/survival at an arbitrary timepoint in 17% and in only 19% as a specific number of years. Cancer mortality was omitted in 24% of consultations, expressed as a generalization in 7%, years of expected life in 2%, probability at no/arbitrary timepoint in 40% and in only 26% as the probability at LE. Treatment-related survival benefit was often omitted; cancer mortality was reported without treatment in 38%, with treatment in 10% and in only 29% both with and without treatment. Physicians achieved “trifecta”—1) quantifying probability of cancer mortality 2) with and without treatment 3) at the patient’s LE—in only 14% of consultations.Conclusions:Physicians often fail to adequately quantify competing risks. We recommend the “trifecta” approach, reporting 1) probability of cancer mortality 2) with and without treatment 3) at the patient’s LE.

Use of Persuasive Language in Communication of Risk during Prostate Cancer Treatment Consultations

“…20,21,33,34 Despite this strong preference for quantification of risk, we found that life expectancy, cancer prognosis, and side effects are often not quantified and are described using either generalizations (“high/low”) or omitted entirely 34%, 31%, and 62% to 93% of the time, respectively, on a per consultation level. 18,19 In the absence of risk quantification, the persuasive language used to describe these risks becomes the sole source of information for the patient to gauge whether the risks are acceptable or not. While the patient’s health numeracy and literacy are important in determining how risk information should be optimally communicated (e.g., with visual depictions such as icon arrays better than probabilistic descriptions in low numerate individuals), 35 in these patients, persuasive language alone should not be considered an acceptable substitute for communication of risk.…”

“…10 We estimated that at least 20 patient consultations would allow for thematic saturation based on experience with our prior studies. 18,19 Patients were recruited until thematic saturation was reached, under which analysis of additional patients yielded no new codes (i.e., persuasive strategies). Of the total cumulative codes, 50%, 75%, and 90% of codes (persuasive strategies) were captured by subjects 3, 12, and 18, respectively (Supplementary Figure 1).…”

“…16,17 One possible explanation for this is that physicians may bias how patients perceive treatment tradeoffs, presumably through communication of risk during treatment consultations. Our previous work has shown that in prostate cancer consultations, the risks of cancer prognosis, life expectancy, and side effects are frequently described using either generalizations (“high/low”) or are omitted entirely, 18,19 which dampens patients’ risk perception 20,21 and allows physicians to control risk perception using persuasive language. Indeed, two previous meta-analyses showed that failure to quantify risk in consultations is associated with poorer patient risk perception.…”

Variation in communication of side effects in prostate cancer treatment consultations

“…Four coders independently analyzed these quotes using an inductive coding approach to characterize SE type, mode of communication, and whether a timeline was mentioned. Our coding approach was informed by our expertise in prostate cancer treatment and our previous work, in which we characterized patient preferences [7] and physician variation in communication [6] of competing risks of mortality.…”

“…We previously analyzed variation in communication of the survival benefit related to treatment-the "rewards" side of treatment tradeoffs-during treatment consultations and found substantial variation in the quality of risk communication [6]. In 40 consultations, physicians often failed to communicate the reduction in cancer mortality associated with treatment; cancer mortality was reported without treatment in 38%, with treatment in 10%, and in only 29% of consultations was cancer mortality reported both with and without treatment [6]. To our knowledge, there has been no similar analysis of how treatment-related SE are communicated by counseling physicians.…”