A Systematic Approach to Discussing Active Surveillance with Patients with Low-risk Prostate Cancer

Abstract

Background

Physicians report difficulty convincing patients with prostate cancer about the merits of active surveillance (AS); as a result, a majority of patients unnecessarily choose to undergo radical treatment.

Objective

To develop and evaluate a systematic approach for physicians to counsel patients with low-risk prostate cancer to increase acceptance of AS.

Design, setting, and participants

A systematic counseling approach was developed and piloted in one clinic. Then five surgeons participated in a 1-h training session in which they learned about the approach. A total of 1003 patients with Gleason 3 + 3 prostate cancer were included in the study. We compared AS rates for 761 patients who were counseled over a 24-mo period before the training intervention with AS rates for 242 patients who were counseled over a 12-mo period afterwards, controlling for temporal trends and case mix.

Intervention

A systematic approach for communicating the merits of AS using appropriate framing techniques derived from principles studied by negotiation scholars.

Outcome measurements and statistical analysis

The rate of AS acceptance by patients for management of low-risk prostate cancer.

Results and limitations

In the pilot phase, 81 of 86 patients (94%) accepted AS after counseling by the physician who developed the counseling approach. In the subsequent study, the cohort for the training intervention comprised 1003 consecutive patients, 80% of whom met the Epstein criteria for very low-risk disease. The proportion of patients who selected AS increased from 69% before the training intervention to 81% afterwards. After adjusting for time trends and case mix, the rate of AS after the intervention was 9.1% higher (95% confidence interval −0.4% to 19.4%) than expected, a relative reduction of approximately 30% in the risk of unnecessary curative treatment.

Conclusions

A systematic approach to counseling can be taught to physicians in a 1-h lecture. We found evidence that even this minimal intervention can decrease overtreatment. Our novel approach offers a framework to help address cancer screening–related overtreatment that occurs across medicine.

Patient summary

In this study, we evaluated the impact of teaching physicians how to better communicate the benefits and risks of prostate cancer treatments on the willingness of patients to choose active surveillance. Decisions related to cancer are often guided by emotions and biases that lead most patients to seek radical treatment; however, we demonstrated that if discussions are framed differently, these biases can be overcome and more patients will choose active surveillance.

Introduction

The adoption of widespread prostate-specific antigen (PSA) screening has been accompanied by overdetection and subsequent overtreatment of select prostate cancers that are unlikely to lead to morbidity or mortality [1]. Active surveillance (AS) as a treatment modality attempts to reduce overtreatment of low-risk prostate cancer and involves careful, frequent monitoring, with subsequent curative treatment if evidence of cancer progression is found. Despite the desire to avoid potential morbidity associated with radical treatment (including erectile dysfunction and urinary or bowel incontinence) most men eligible for AS instead undergo curative treatment [2]. Fewer than 40% of all men with low-risk prostate cancer are currently managed with AS, and between 25% and 80% of patients undergo radical treatment for prostate cancer unnecessarily.

Such overtreatment is commonly attributed to the misaligned incentives for physicians [3]. However, even those who support AS as a management approach report considerable difficulty in convincing patients of its merits [4]. Patients generally believe that cancer is inherently life-threatening, and so the perception that they would not be receiving curative treatment for their cancer causes significant anxiety [5]. Physicians receive very little, if any, training to effectively counsel patients about AS and may lack the communication skills necessary to address biases against a noncurative approach to management. As a result, patients rarely report discussing all the treatment options with physicians and often perceive AS as “doing nothing” [6]. These observations not only raise the possibility of achieving better patient outcomes but also suggest potential to reduce health care costs. One study estimated that if 50% of patients recently diagnosed with low-risk prostate cancer were to choose AS, the health care savings would surpass $1 billion in the USA annually [7].

Scholars in the field of negotiation have studied various methods for achieving better agreements between individuals who have different perspectives or seemingly divergent interests [8], [9]. Furthermore, considerable research among social psychologists and behavioral economists reveals that decision-making is impacted by how options are “framed”, such as whether consequences are described in terms of lower costs or greater benefits. When physicians provide options and education about low-risk prostate cancer, they are inevitably making several (potentially unconscious) choices on how these are framed, including the order in which treatment options are communicated and whether consequences are described in terms of gains (eg, “survival rates are higher”) or losses (eg, “death rates are lower”) [10], [11]. These framing choices, whether made deliberately or not, can impact patient choice.

Other well-studied principles in behavioral science that can impact patient decisions include “social proof” (how the choices made by similar individuals in similar situations influence our own choices) and “reference point effects” that shift the context within which a decision-maker evaluates an option [10], [12]. For example, educating patients about the relatively long latent natural history of prostate cancer before describing the follow-up schedule for AS can overcome the perception that the schedule is not aggressive enough, or that the cancer can metastasize in the time between serial examinations. Studies have demonstrated that these framing effects impact medical decision-making [13], [14].

An important unmet need is to help physicians engage patients about all treatment options for low-risk prostate cancer in a way that is ethically responsible, and takes into account biases that might encourage immediate intervention even in situations for which there is little if any mortality benefit but potentially significant costs in terms of morbidity.

Our systematic approach to counseling men first evokes, as advised by negotiation scholars, all of the patient's own interests—that is, their reasons for considering the various treatment options. For example, a patient who is interested only in reducing mortality risk is less likely to consider noncurative treatments than one who acknowledges an interest in reduced mortality and morbidity. Once a patient has articulated his interests, appropriate framing principles can help the physician to effectively communicate how AS can be a viable treatment option for the perceived life-threatening malignancy. This represents a novel approach with the potential to help patients with low-risk prostate cancer avoid unnecessary radical treatment.

The approach was adopted by one of our urologists (B.E.) in his clinic, and led to a seemingly large increase in the number of patients accepting AS. Accordingly, we sought to determine whether this experience could be generalized to other physicians. As a first step, we decided to test a minimal intervention in which negotiation theory (which focuses on the importance of identifying and addressing underlying interests) and social psychology principles (to effectively frame options) were taught in a single 1-h lecture. Here, we report the rate of AS acceptance by patients who were counseled by physicians before and after the minimal teaching intervention.