Factors influencing treatment decisions and decision support needs for patients diagnosed with localised prostate cancer

Review date March 2019

Citation Smith, A.B., Rincones, O., Sidhom, M. et al. Robot or radiation? A qualitative study of the decision support needs of men with localised prostate cancer choosing between robotic prostatectomy and radiotherapy treatment. Patient Educ Couns. 2019. S0738-3991(19)30067-9

Background

In 2017, over 16,500 Australian men were estimated to receive a diagnosis of prostate cancer, making this the most commonly diagnosed cancer in men over 50. Localised prostate cancer is treated in several ways, including: active surveillance, open or robotic prostatectomy (surgery), or radiotherapy. Large clinical studies have found no significant difference between treatment choice for localised prostate cancer and the rate of cure (1). Both surgery and radiotherapy treatments can negatively impact quality of life scores but the specific side-effects vary; urinary incontinence and erectile dysfunction is more likely with surgery, and bowel dysfunction is more likely with radiotherapy (2).

While shared treatment decision-making is advocated, there is no singular pathway that Australian men with low-risk prostate cancer or their doctors are required to take. A small research study carried out by an impartial research team at a public hospital in NSW examined the decision making process for men with localised prostate cancer, where robotic surgery or radiotherapy would be equally appropriate treatment options.

Aim

The Prostatectomy versus Radiotherapy for Early-stage PRostatE cancer (PREPaRE) study aimed to understand how men treated at the Liverpool Hospital (Sydney) come to decisions about their prostate cancer treatment, and the best ways to support men in choosing a treatment that most suits them.

Methods

The qualitative study was conducted in 2017 at Liverpool Hospital. Patients diagnosed with localised prostate cancer underwent a combined clinic, meeting with a urologist and a radiation oncologist, to facilitate informed decision making around their treatment plan. The information provided to the patient was guided by the clinician delivering the consultation. Patients who participated in the study (n=25) had localised prostate cancer and were suitable for either radiotherapy or robotic surgery treatments. Patients had appointments with a urologist at least twice (for biopsy and diagnosis) before attending the combined clinic.

The study participants completed surveys and interviews before and/or after the combined clinic appointment to assess: the men’s understanding of the robotic prostatectomy and radiotherapy treatments; what their preferences were and their reasons for selecting a specific treatment; and what information and decision aids they found helpful.

Results

Men’s initial treatment preferences and subsequent treatment decisions after the combined clinic are shown in the Table.

Major themes (see subthemes in notes)

• Specialists were the primary driver of treatment decision making. Patients put great trust in their clinicians, the information provided by the doctor strongly guided their treatment decision. However, the patients agreed that they felt the decision was theirs to make.

• A second driver of decision-making included sourcing information from other prostate cancer patients, family/friends, online sources and information sheets. This was generally related to the perceived fit of the treatment such as practicalities (e.g. number of appointments, cost), and age and physical condition of the patient (e.g. younger, fitter men more likely to opt for surgery).  

• The side-effects of the treatment types were not a major driver of treatment choice; these were seen as inevitable. The patient assigned more importance to the perceived curative rate of the treatment.

• Patients were highly varied in their preference for receiving information about their cancer. They wanted overall information on the different treatments and side effects, treatment length and time in hospital, survival rate, and recovery length. Information challenges included information overload, concerns about reliability, difficulties remembering verbal information but also processing paper-based information, and a specific lack of information about radiotherapy for prostate cancer. Some participants preferred detailed information resources such as booklet to read, whereas other patients only wanted to receive information from their doctor.

Conclusions

The authors conclude that men with localised prostate cancer should see both a urologist and a radiation oncologist to make a fully informed decision about their treatment, and that this should be done earlier in the patient’s care (i.e. at diagnosis).

The authors recommended more education to improve patients’ understanding about the difference between radical prostatectomy and radiotherapy and about their specific side effects. Tailored strategies to best support and inform men about treatments for prostate cancer are needed.

Points to Note

• Some men were unaware the radiotherapy was an option before attending the combined clinic appointment (they had seen a urologist twice prior).
• Some men had already decided before the combined clinic that they would opt for surgery or radiotherapy. For those that had not, the combined appointment enabled them to make an informed decision.
• Many men incorrectly thought that robotic prostatectomy was more likely to improve survival and reduce the chance of reoccurrence i.e. surgery would be a ‘once off’ treatment. They thought that if they had radiotherapy then they might need surgery down the track anyway.
• Men who chose radiotherapy said it was because they perceived it as less invasive, would have a lower impact on their body and fewer side-effects than surgery. These patients were more likely to be undecided before the combined clinic.
• Men who chose radical prostatectomy experienced less conflict in regards to decision-making opposed to patients choosing radiotherapy. Patients choosing radiotherapy may experience more doubt due to initial consultations that indicate benefits of surgery.

1. Hamdy FC, Donovan JL, Lane JA, et al. (2016) 10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer. N Engl J Med. 375(15):1415-1424.

2. Donovan JL, Hamdy FC, Lane JA, et al. (2016) Patient-Reported Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer. N Engl J Med. 375(15):1425-1437.

Website: https://www.ncbi.nlm.nih.gov/pubmed/30803903