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.

Keywords: Active surveillance; Behavioral economics; Communication; Outcomes; Prostate cancer; Social psychology.

Conflict of interest statement

Financial disclosures: Behfar Ehdaie certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None.

Copyright © 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Figures

Fig. 1

Proportion of patients who enrolled in active surveillance (AS) by initial consultation date. The vertical line represents the date of the intervention.

Fig. 2

Mean initial clinic room time by initial consultation date. The vertical line represents the date of the intervention.