Because the survival benefit of aggressively treating screen-detected localized prostate cancer (LPC) has not been well established, overtreatment of these cancers is a substantial concern. However, the factors that drive overtreatment of LPC are not well understood.
That's why researchers chose to investigate the survival expectations of patients who had LPC with and without their chosen treatment in a study published in the May/June issue of Annals of Family Medicine.(www.annfammed.org)
The study found most men with LPC underestimate their life expectancy without treatment and overestimate their potential gain in life expectancy with surgery or radiation. These misperceptions may lead to overtreatment, decisional regret and decreased post-treatment quality of life, said the study authors.
Lead study author Jinping Xu, M.D., M.S., an associate professor in the Department of Family Medicine and Public Health Sciences at Wayne State University School of Medicine in Detroit, told AAFP News these patients' beliefs about how treatment would affect their life expectancy could be predicted by factors such as the treatment chosen, patient age, general health perception and perceived cancer seriousness.
- To better understand the overtreatment of localized prostate cancer (LPC), a study in Annals of Family Medicine examined the survival expectations of patients who had LPC with and without their chosen treatment.
- The group found most men with LPC underestimate their life expectancy without treatment and overestimate the gain in life expectancy with surgery or radiation.
- The researchers said such unrealistic expectations are concerning because men who choose active treatment gain virtually no survival advantage compared with those who choose observation, yet active treatment is associated with high rates of impotence and incontinence.
"That suggests that patients have a complex view of how big the threat is from prostate cancer, given other aspects of how they see their health," she said. "This is very important for family physicians to talk with patients about.
"What we actually know about localized prostate cancer is that for most men, it progresses so slowly that they live out their normal life span and die from some other common cause of death like heart disease."
Details From the Study
Researchers conducted a cross-sectional survey of 260 black and white men ages 75 or younger in the Detroit area who had newly diagnosed LPC. The survey found that 33 percent of respondents expected to live fewer than five years if their cancer was left untreated, 41 percent said five to 10 years, 21 percent said 10 to 20 years, and 5 percent said more than 20 years.
With their chosen treatment (i.e., surgery, radiation or watchful waiting/active surveillance), 3 percent of patients expected to live fewer than five years, 9 percent said five to 10 years, 33 percent said 10 to 20 years, and 55 percent said more than 20 years.
And although only 25 percent of all patients in the study overall expected to live more than 10 years, the study authors noted that a recent update(jco.ascopubs.org) of the largest and longest-followed active surveillance cohort of men diagnosed with LPC actually showed prostate cancer-specific survival rates at 10- and 15-year followup of 98 percent and 94 percent, respectively.
Patients in the Annals study who chose surgical treatment expected to gain 12 years of life. However, recently published data showed surgery does not significantly improve prostate cancer-specific survival compared with observation on 10-year followup.
Furthermore, men who perceived their cancer to be more serious expected more benefit from their chosen treatment regardless of their objective cancer risk level.
Two risk factors for LPC -- race and actual tumor risk -- did not affect patients' expectations of dying with and without treatment, Xu said.
"This suggests another mismatch of patients' expectations and the natural history of early-stage prostate cancer," she said. "Family physicians need to find out what patients expect from treatment and work with them to make sure their understandings match reality."
The researchers said these unrealistic expectations are concerning because men who choose active treatment gain virtually no survival advantage compared with those who choose observation, yet active treatment is associated with high rates of impotence and incontinence.
"So whether patients underestimate life expectancy without treatment or overestimate life expectancy with their chosen treatment, the biggest problem is that they need to understand that it doesn't change very much with active treatment (surgery or radiation) compared with observation over time," Xu said.
She added the good news is that LPC is generally slow-growing, and simply following it over time can likely allow for treatment, if indicated, before it becomes more aggressive.
"This is the principle of active surveillance approach, which is to minimize treatment-related side effects while not sacrificing length of survival," Xu said.
Best Approach to LPC Discussions
Xu recommended shared decision-making between physician and patient when discussing LPC and treatment options.
"If family physicians refer a patient for a biopsy, they should encourage the patient to return to talk over the biopsy results before making any treatment decisions," she said. "Patients need to thoroughly understand biopsy results, whether they are negative, low-grade tumor or more aggressive tumor. Family physicians are well placed to do a great job at this."
In addition, Xu said family physicians should encourage patients to take their time making a treatment decision and explain that the speed of making this choice will not affect outcomes and that allowing adequate time for contemplation could actually lead to a better decision.
Xu recommended the Agency for Healthcare Research and Quality's shared decision-making resources,(www.ahrq.gov) including its SHARE Approach to support these efforts. SHARE consists of five steps:
- Seek your patient's participation.
- Help your patient explore and compare treatment options.
- Assess your patient's values and preferences.
- Reach a decision with your patient.
- Evaluate your patient's decision.
It's also important to note that shared decision-making is increasingly becoming an expectation of Medicare and other payers, she said.
"Doing shared decision-making well in localized prostate cancer is an opportunity for family physicians to help patients make decisions that optimize their opportunities for good health," said Xu. "It begins by making a followup appointment each time a patient is referred for a prostate biopsy."
Xu also emphasized there is no single right answer for each patient about which LPC treatment to choose.
"Family physicians are in a great position to broker a decision that is based on good patient understanding of mortality across treatments," she explained. "They are also uniquely well-positioned to help patients base their decisions on their outcome preferences -- whether to choose observation that avoids impotence and incontinence or active treatment that takes out or kills the cancer.
"But to make this decision, patients have to understand that they will live basically the same length of time whichever way they choose."
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