Patients’ Survival Expectations With and Without Their Chosen Treatment for Prostate Cancer

Jinping Xu; James Janisse; Julie J. Ruterbusch; Joel Ager; Joe Liu; Margaret Holmes-Rovner; Kendra L. Schwartz

doi:10.1370/afm.1926

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Medical Students' Commentary on Patients' Survival Expectations With and Without Their Chosen Treatment for Prostate Cancer
Akash Patel

Published on: 30 August 2016
Re:Educating Men Diagnosed with Localized Prostate Cancer About Treatment Options: It Is More Than Life Expectancy
Patricia Baumann

Published on: 15 August 2016
Author response to "Educating Men Diagnosed with Localized Prostate Cancer About Treatment Options: It Is More Than Life Expectancy"
Jinping Xu

Published on: 11 August 2016
Educating Men Diagnosed with Localized Prostate Cancer About Treatment Options: It Is More Than Life Expectancy
Lisa M. Lowenstein

Published on: 26 July 2016

Published on: (30 August 2016)
Page navigation anchor for Medical Students' Commentary on Patients' Survival Expectations With and Without Their Chosen Treatment for Prostate Cancer
Medical Students' Commentary on Patients' Survival Expectations With and Without Their Chosen Treatment for Prostate Cancer
Akash Patel, Medical student
Other Contributors:
The article reviewed attempted to describe the risks and benefits of various treatment options in the care of individuals with prostate cancer. This study was designed to compare the feelings and expectations of years to live with the actual number of years lived for a sample of men from one city in the United States diagnosed with localized prostate cancer (LPC) after different treatments.
In their introduction...
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The article reviewed attempted to describe the risks and benefits of various treatment options in the care of individuals with prostate cancer. This study was designed to compare the feelings and expectations of years to live with the actual number of years lived for a sample of men from one city in the United States diagnosed with localized prostate cancer (LPC) after different treatments.
In their introduction, the authors stated there had not been a study before taking examining race, socioeconomic status, and education alongside treatment choices and how these variables affect the expectations of outcome. The authors provided a study from the journal Cancer stating the differences in treatment choice might be due to racial differences ("Why do men choose one treatment over another?"). However, the authors from the study referenced suggest that treatment choice is more strongly tied to patient education by physicians and the differences in treatment could be explained by physicians providing different groups of people different information. That article suggested future studies to research this potential physician bias to explain these differences in choice, not the differences between racial groups in and of themselves. The authors reference the Prostate Cancer Intervention Versus Observation Trial (PIVOT) as a baseline for the decisions made by many men with this disease. Only one study prior had examined treatment success of LPC.
Overall there are limited studies examining individuals' expectations about their prostate cancer, making this study unique and adding to the current literature. The study focused on a sample of men living in the Detroit metropolitan area younger than 75 years of age who were either white/Caucasian or black/African American. We believe the choice of this sample can be explained in a couple different ways. First, choosing men younger than 75 allows for patients to better estimate their life expectancy based on treatment than men who are older. For example, a man around 60 who has a very favorable outlook of intensive surgical intervention might be more willing to estimate their life expectancy higher than if they chose the option of watchful waiting and active surveillance. Conversely, a man around the age of 90 may more likely have other health issues limiting his perceived life expectancy than prostate cancer. Second, including only two racial groups might have been done because these two groups likely represent the population accessible and/or more likely to be representative of men diagnosed with LPC.
The decision to use the Dillman method of recruiting and maintaining contact with study participants is supported by previous literature. The Dillman method guarantee 80% returns and this study showed a 70% return for subjects which was considered by the group a positive return rate. Group members discussed recruitment of patients and were concerned with physician bias. We would have liked more explanation for this decision. The survey sent to patients in this study asked for the treatment choice, the reason for that choice, what other treatments were offered, how long they expected to live with this treatment, and how long they expected to live without getting this treatment. It was difficult to know when in the course of the disease the patient was given the survey. The stage of disease may have significantly affected the treatment decision while also creating distrust in the effectiveness of other options. The study also did not present information about what treatment options were given to patients. We would have liked to see this type of information included in future studies as it could help to guide our clinical practice.
The results of the survey were described as being over- or underestimated from the "normal" life expectancy, but there was no operational definition for "normal" was calculated. For example, should a patient choose watchful waiting and live a certain number of years after the diagnosis, what would his life expectancy be with surgical intervention? We are told in the analysis of the information what he thinks his life expectancy will be with each decision, but there was no objective calculation to describe how the authors arrived at "normal." Limited by the local scope of this study, the authors note the difficulty with generalizing the results. They provide advice for clinical application that is universal: maintain contact with patients and educate them on realistic expectations of their disease course. Patients reflect the knowledge and advice of their providers, so we as physicians should be conscious of the information we give to our patients, knowing our words have great influence. This being said, we feel a future study would benefit from the inclusion of physician attitudes toward different treatment modalities, and exploration of their common practice of providing care to patients diagnosed with prostate cancer. Doctors are not simply gatekeepers to medicine but are advocates for patients, trusted individuals working for the best outcome of each individual.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (15 August 2016)
Page navigation anchor for Re:Educating Men Diagnosed with Localized Prostate Cancer About Treatment Options: It Is More Than Life Expectancy
Re:Educating Men Diagnosed with Localized Prostate Cancer About Treatment Options: It Is More Than Life Expectancy
Patricia Baumann, Medical Student
Other Contributors:
Screening for prostate cancer, specifically over-screening with the PSA test, has been a subject of many conversations and lectures thus far in our medical education. This study examined a different issue related to prostate cancer. They chose to examine the increasing overtreatment of prostate cancer once it has been diagnosed as it applied to the patients' view of his life expectancy. The study also sought to compare A...
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Screening for prostate cancer, specifically over-screening with the PSA test, has been a subject of many conversations and lectures thus far in our medical education. This study examined a different issue related to prostate cancer. They chose to examine the increasing overtreatment of prostate cancer once it has been diagnosed as it applied to the patients' view of his life expectancy. The study also sought to compare African American men with Caucasian men in their perception of their life expectancy.
This study had an impressive response rate of 68% from their mailed survey. We question the bias of a mailed survey as the response rate may vary with level of education and economic status. The data they collected from the survey was subjective even the specifics of their diagnosis including Gleason score, PSA value and stage. We questioned whether all of the patients surveyed could accurately report this medical information or if it was obtained in a different manner it was not clearly mentioned. They examined variables including age, education, and comorbidities but did not list or define the comorbidities they included. The patients' age was measured as a continuous variable while life expectancy was measured as a categorical variable.
Their analysis found that younger men chose surgery as their treatment option even though surgery is the treatment choice associated with the most side effects. They also found that race had no effect on treatment choice. The most surprising finding is that many patients perceived that they would have a longer life expectancy with treatment than without treatment; however, one of the treatment options was watchful waiting with active surveillance, which we argued could be considered as no treatment.
Overall this study brought to light the fact that participants were not well informed about their prognosis or treatment options. The study cited the limited amount of time a specialist is able to spend with patients as the reason for the misperception of participants' life expectancy with or without treatment. We agree that primary care physicians are more likely to know the patient, have more time, and have witnessed other health decisions that the patient has made in regards to their health. We also believe that it is not impossible for specialists to build a relationship with his or her patient in order to help them make a treatment decision that is in-line with his or her health goals. The specialist has a better understanding of the disease while the primary care physician has a better understanding of the patient. It is important that an interdisciplinary approach be taken in regards to the treatment of prostate cancer as in this study, but also in other diseases in which treatment options can be confusing or risky so that the best interest of the patient is served.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (11 August 2016)
Page navigation anchor for Author response to "Educating Men Diagnosed with Localized Prostate Cancer About Treatment Options: It Is More Than Life Expectancy"
Author response to "Educating Men Diagnosed with Localized Prostate Cancer About Treatment Options: It Is More Than Life Expectancy"
Jinping Xu, Physician
Other Contributors:
Letter to the Editor: In response to "Educating Men Diagnosed with Localized Prostate Cancer About Treatment Options: It Is More Than Life Expectancy" by Lisa M. Lowenstein, PhD, MPH, et al
Authors: Jinping Xu, MD, MS, Margaret Holmes-Rovner, PhD, Kendra Schwartz, MD, MSPH
We want to thank Dr. Lowenstein and her colleagues for their insightful comments on our recently published article "Patients' Survi...
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Letter to the Editor: In response to "Educating Men Diagnosed with Localized Prostate Cancer About Treatment Options: It Is More Than Life Expectancy" by Lisa M. Lowenstein, PhD, MPH, et al
Authors: Jinping Xu, MD, MS, Margaret Holmes-Rovner, PhD, Kendra Schwartz, MD, MSPH
We want to thank Dr. Lowenstein and her colleagues for their insightful comments on our recently published article "Patients' Survival Expectations With and Without Their Chosen Treatment for Prostate Cancer" regarding strategies to address the knowledge gap of life expectancy that men expected from surgery or radiation compared to no treatment.
We agree with the authors' point that accurate estimation of life expectancy is difficult for individual patients, especially for patients aged 65 years or older with multiple comorbidities. Clearly, a greater emphasis in clinical practice on the impact of treatment side effects on quality of life would be helpful to help men make more appropriate treatment decisions. However, our data suggested patients' expectation about greater length of life from active treatment, not quality of life, drives their decision to choose active treatment over active surveillance.(1) When men heard the word "cancer", the immediate and number one concern of most men was "how long do I have to live" as most of them believed that cancer was fatal if it was not being actively treated.(2) When survival was perceived to be threatened, the argument of treatment-related side effects on quality of life was not considered relevant.(2) In fact, men told us that they would "rather live than have sex" during the interviews.(3) Future efforts to educate men about the treatment options, either with decision aids or through patient-physician communication interventions, need to reassure men that most localized prostate cancer grows so slowly that most men will die from something else and that choosing active surveillance will provide them with time to maintain quality of life while catching the fast-growing tumors that require surgery or radiation.
It is a bit of a conundrum as to who should be doing the educating of patients on various treatment options and their impact on survival and quality of life. While we agree with Dr. Lowenstein et al that primary care physicians are not commonly involved in the patient-physician discussions about treatment options nor life expectancy discussion in current clinical practice in the US, we argue that it would be beneficial for primary care physicians to educate patients about the natural history of localized prostate cancers and the well-documented specialists' biases towards the options they themselves deliver.(4) Involving primary care physicians in addition to oncologists has the potential to fill men's knowledge gap identified in our study about life expectancy with and without treatment.(1) Similar to the recent "choosing wisely" campaign held in the medical community, physicians and patients both need to be educated on "more is not necessarily better" regarding medical intervention. This is especially true for clinically localized prostate cancer, since the general public has been conditioned to the message of "early detection and early treatment saves lives" during the last four decades.
There will not be a single solution and there is no magic bullet. Rather it will require a multitude of solutions for diverse patents and physicians operating in a range of contexts and health services. It may require more than the medical community's efforts to get the message out. We are pleased to see that our article attracted attention from the celebrity physician Dr. Oz as he cited our findings in his "Beyond active surveillance for early prostate cancer" effort to educate men on this issue.(5) By working together to educate men, their spouses and support networks, we can fill the knowledge gap and help men make more informed treatment decision that matched their preferences, values and treatment goals.
References
1. Xu J, Janisse J, Ruterbusch JJ, et al. Patients' Survival Expectations With and Without Their Chosen Treatment for Prostate Cancer. Annals of family medicine. 2016 May;14(3):208-14.
2. Xu J, Neale AV, Dailey RK, Eggly S, Schwartz KL. Patient perspective on watchful waiting/active surveillance for localized prostate cancer. Journal of the American Board of Family Medicine : JABFM. 2012 Nov-Dec;25(6):763-70.
3. Xu J, Dailey RK, Eggly S, Neale AV, Schwartz KL. Men's Perspectives on Selecting Their Prostate Cancer Treatment. Journal of National Medical Association. 2011;103(June):468-78.
4. Fowler FJ, Jr., McNaughton Collins M, Albertsen PC, Zietman A, Elliott DB, Barry MJ. Comparison of recommendations by urologists and radiation oncologists for treatment of clinically localized prostate cancer. Jama. 2000 Jun 28;283(24):3217-22.
5. Oz M, Roizen M. Beyond active surveillance for early prostate cancer. http://wwwidahostatesmancom/living/health-fitness/article91173832html. July 21, 2016.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (26 July 2016)
Page navigation anchor for Educating Men Diagnosed with Localized Prostate Cancer About Treatment Options: It Is More Than Life Expectancy
Educating Men Diagnosed with Localized Prostate Cancer About Treatment Options: It Is More Than Life Expectancy
Lisa M. Lowenstein, Instructor
Other Contributors:
In their article "Patients' Survival Expectations With and Without Their Chosen Treatment for Prostate Cancer", Xu et al.,[1] examined White and African American men's, with a recent diagnosis of localized prostate cancer, life expectancy with and without their chosen treatment. Unsurprisingly, these men overestimated their survival benefit with treatment. Among men who chose surgery, their life expectancy was 20.03 yea...
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In their article "Patients' Survival Expectations With and Without Their Chosen Treatment for Prostate Cancer", Xu et al.,[1] examined White and African American men's, with a recent diagnosis of localized prostate cancer, life expectancy with and without their chosen treatment. Unsurprisingly, these men overestimated their survival benefit with treatment. Among men who chose surgery, their life expectancy was 20.03 years with treatment and 8.38 years without treatment. Similarly, among men who chose radiation, their life expectancy was 19.59 years with treatment and 7.66 years without treatment. The belief that the survival benefit with treatment is far greater than without treatment for localized prostate cancer is not consistent with current evidence or clinical guidelines which recommend active surveillance [2].
The authors made several suggestions to address this knowledge gap including a call for decision aids that incorporate considerations of men's life expectancy associated with the different treatment options. Although we agree with the authors point, life expectancy estimates need to consider other factors beyond chronological age, especially for patients aged 65 years or older. Neither age or traditional performance status assessments accurately characterize these older patients [3-6]. These older patients have a number of factors that can affect their life expectancy with and without treatment, such as history of falls, independence, and vulnerability [6].
To further complicate matters, men have varying expectations about the aggressiveness of their prostate cancer. Men who opt for active surveillance have a greater appreciation of the slow growing nature of low risk localized prostate cancer and a desire to avoid treatment-related side effects, while others expect a greater potential for cure through immediate treatment. Therefore, a greater emphasis on the impact of treatment side effects on quality of life may be more helpful. Future efforts to educate men about the treatment options, either with decision aids or through patient-physician communication interventions, need to reassure men that choosing active surveillance will provide them with time to choose surgery and/or radiation if the cancer progresses [7].
In their discussion, Xu et al., advocate for primary care physicians to be involved in the patient-physician interaction to educate men about the treatment options with regards to life expectancy. Although primary care physicians may be well positioned to have these discussions, some men may not be receptive to their primary care physicians being involved and helping them weigh the benefits and harms of different treatment options. In fact, it is possible that men with localized prostate cancer may feel that "cancer" is out of primary care physicians' scope of practice. However, the integration of multidisciplinary specialties may result in more thoughtful and patient centered treatment decisions.
Lisa M. Lowenstein, PhD, MPH; Ashley J. Housten, OTD, MSCI, MPA; Robert J. Volk
[1] Xu J, Janisse J, Ruterbusch JJ, et al. Patients' Survival Expectations With and Without Their Chosen Treatment for Prostate Cancer. Annals of family medicine. May 2016;14(3):208-214.
[2] Chou R, Dana T, Bougatsos C, et al. Treatments for Localized Prostate Cancer: Systematic Review to Update the 2002 U.S. Preventive Services Task Force Recommendation. Rockville MD2011.
[3] Jolly TA, Deal AM, Nyrop KA, et al. Geriatric assessment- identified deficits in older cancer patients with normal performance status. The oncologist. Apr 2015;20(4):379-385.
[4] Repetto L, Fratino L, Audisio RA, et al. Comprehensive geriatric assessment adds information to Eastern Cooperative Oncology Group performance status in elderly cancer patients: an Italian Group for Geriatric Oncology Study. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. Jan 15 2002;20(2):494-502.
[5] O'Donovan A, Mohile SG, Leech M. Expert consensus panel guidelines on geriatric assessment in oncology. European journal of cancer care. Jul 2015;24(4):574-589.
[6] Reisinger KW, van Vugt JL, Tegels JJ, et al. Functional compromise reflected by sarcopenia, frailty, and nutritional depletion predicts adverse postoperative outcome after colorectal cancer surgery. Annals of surgery. Feb 2015;261(2):345-352.
[7] Volk RJ, McFall SL, Cantor SB, Byrd TL, Le YL, Kuban DA, Mullen PD. 'It's not like you just had a heart attack': decision-making about active surveillance by men with localized prostate cancer. Psycho- Oncology. April 2014;23(4):467-472.
Competing interests: None declared
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Competing Interests: None declared.