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Article of the Week: Decision-Making by PCa Physicians During AS

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Qualitative study on decision-making by prostate cancer physicians during active surveillance

Stacy Loeb*,,, Caitlin Curnyn, Angela Fagerlin¶,**, Ronald Scott Braithwaite
Mark D. Schwartz, Herbert Lepor*, Herbert Ballentine Carter†† and Erica Sedlander

 

Departments of *Urology, Population Health, Laura and Isaac Perlmutter Cancer Center, New York University, §Manhattan Veterans Affairs Medical Center, New York, NY, Department of Population Health Sciences, University of Utah, Salt Lake City, UT, **Informatics, Decision Enhancement, and Surveillance (IDEAS) Center, Salt Lake City VA, UT, and ††Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD, USA

 

How to Cite

Loeb, S., Curnyn, C., Fagerlin, A., Braithwaite, R. S., Schwartz, M. D., Lepor, H., Carter, H. B. and Sedlander, E. (2017), Qualitative study on decision-making by prostate cancer physicians during active surveillance. BJU International, 120: 32–39. doi: 10.1111/bju.13651

Abstract

Objective

To explore and identify factors that influence physicians’ decisions while monitoring patients with prostate cancer on active surveillance (AS).

Subjects and Methods

A purposive sampling strategy was used to identify physicians treating prostate cancer from diverse clinical backgrounds and geographic areas across the USA. We conducted 24 in-depth interviews from July to December 2015, until thematic saturation was reached. The Applied Thematic Analysis framework was used to guide data collection and analysis. Interview transcripts were reviewed and coded independently by two researchers. Matrix analysis and NVivo software were used for organization and further analysis.

Results

Eight key themes emerged to explain variation in AS monitoring: (i) physician comfort with AS; (ii) protocol selection; (iii) beliefs about the utility and quality of testing; (iv) years of experience and exposure to AS during training; (v) concerns about inflicting ‘harm’; (vi) patient characteristics; (vii) patient preferences; and (viii) financial incentives.

Conclusion

These qualitative data reveal which factors influence physicians who manage patients on AS. There is tension between providing standardized care while also considering individual patients’ needs and health status. Additional education on AS is needed during urology training and continuing medical education. Future research is needed to empirically understand whether any specific protocol is superior to tailored, individualized care.

Editorial: AS in PCa- New Efforts, New Voices, New Hope

In January 2016, in his final State of the Union address, US President Barack Obama tasked Vice President Joseph Biden with heading up a new national mission, the Cancer Moonshot, to expedite advances in cancer prevention, diagnosis and treatment. One of the blue-ribbon panel recommendations was to minimize the side effects of cancer treatment.

There is no better target for that goal than prostate cancer, the cancer that leads all others in the toll of Americans annually diagnosed with cancer, and the fourth most common worldwide. Many men with low-risk prostate cancer undergo unnecessary treatments, including prostatectomy and radiation therapy, which are unlikely to affect their survival, even if their disease were left untreated. A case in point is the ProtecT study [1], which showed at a median of 10 years that there was no difference in prostate cancer-specific mortality between treatment with surgery or radiation therapy and no treatment [1]. Although there has been a paradigm shift in the management of low-risk prostate cancer with an increased uptake of active surveillance (AS) [2], the fact is that only ~40% of men with low-risk prostate cancer choose AS.

Because of equivalency in effectiveness of treatment options in low-risk prostate cancer, an explication of the steps involved in the clinical decision-making process were long overdue. In an innovative study in the present issue of BJUI, Loeb et al. [3] report a qualitative analysis using a purposive sampling strategy to explore the decision-making process of physicians caring for patients with prostate cancer undergoing AS. This study used qualitative interviews and investigators then analysed responses to identify factors influencing therapeutic decision-making. It is noteworthy that despite the fact that AS acceptance rates have increased and it is an established therapeutic approach, significant differences still remain with regard to when physicians enroll and how they monitor patients on AS. These findings align with those from a Surveillance Epidemiology and End Results (SEER) registry study of 12 068 men with low-risk prostate cancer whose urologists and radiation oncologists reported a spectrum of observation practices [4]. Neither study accounted for patients’ preference or perspectives.

Although there are many national guidelines for AS, no consensus on optimum AS management exists, but Movember–GAP3 (https://au.movember.com/report-cards/view/id/3372/gap3-prostate-cancer-active-surveillance), an international effort comprising 25 institutions with AS programmes, may change that. It seeks to establish standard guidelines for patient selection and monitoring and to find agreement on a trigger for treatment. The tumour heterogeneity and possible lack of linearity in early disease progression that we can glean from the next-generation sequencing studies in advanced prostate cancer [5] will not make that easy. Given the promise of precision medicine, we anticipate a decision-making process that by integrating clinical and pathological data, imaging, and biomarkers prognostic of risk of disease progression as well as patient comorbidity effectively removes guesswork from the calculation.

As this international effort and the vice president’s work proceed, we urge all to listen to the voices of patients and ensure they are heard as clearly as those of the experts. We know the paternalistic model of medicine, in which physicians are the exclusive decision-makers, has long been outmoded [6]. With so much at stake, let us now act like it.

Spyridon P. Basourakos* Karen Hoffman† and Jeri Kim*

 

*Department of Genitourinary Medical Oncology, and Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, US

 

 

References

 

1 Hamdy F, Donovan J, Lane J et al. 10-year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. N Engl J Med 2016; 375: 141524

 

 

3 Loeb S, Curnyn C, Fagerlin A et al. Qualitative study on decision- making by prostate cancer physicians during active surveillance. BJU Int 2017; 120: 329

 

4 Hoffman K, Niu J, Shen Y et al. Physician variation in management of low-risk prostate cancer: a population-based cohort study. JAMA Intern Med 2014; 174: 14509

 

5 Robinson D, Van Allen E, Wu Y et al. Integrative clinical genomics of advanced prostate cancer. Cell 2015; 161: 121528

 

 

Video: Decision-Making by PCa Physicians During AS

Qualitative study on decision-making by prostate cancer physicians during active surveillance

 

Abstract

Objective

To explore and identify factors that influence physicians’ decisions while monitoring patients with prostate cancer on active surveillance (AS).

Subjects and Methods

A purposive sampling strategy was used to identify physicians treating prostate cancer from diverse clinical backgrounds and geographic areas across the USA. We conducted 24 in-depth interviews from July to December 2015, until thematic saturation was reached. The Applied Thematic Analysis framework was used to guide data collection and analysis. Interview transcripts were reviewed and coded independently by two researchers. Matrix analysis and NVivo software were used for organization and further analysis.

Results

Eight key themes emerged to explain variation in AS monitoring: (i) physician comfort with AS; (ii) protocol selection; (iii) beliefs about the utility and quality of testing; (iv) years of experience and exposure to AS during training; (v) concerns about inflicting ‘harm’; (vi) patient characteristics; (vii) patient preferences; and (viii) financial incentives.

Conclusion

These qualitative data reveal which factors influence physicians who manage patients on AS. There is tension between providing standardized care while also considering individual patients’ needs and health status. Additional education on AS is needed during urology training and continuing medical education. Future research is needed to empirically understand whether any specific protocol is superior to tailored, individualized care.

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