Decision Support Tools in Prostate Cancer: Predict Prostate and P3P
By: Christopher P. Filson, MD, MS; Rachel A. Pozzar, PhD, RN | Posted on: 01 Jan 2022
It can be difficult for a man newly diagnosed with prostate cancer to decide which management strategy is best for him. There isn’t a “one-size-fits-all” option for men with localized prostate cancer, and patients’ priorities relating to cancer control, sexual function and urinary symptoms may vary according to their preferences and values. In addition, time constraints during a clinic visit can limit a provider’s ability to gauge a patient’s priorities or to relay all details and nuances of available treatment options.
Decision making is optimized when a patient is informed about their options in the context of their preferences and values, and experiences minimal decisional conflict. The concept of decisional conflict incorporates elements of uncertainty, feeling uninformed, lacking clarity related to one’s values, perceiving limited support and reflecting on the extent to which a decision was effective.1 Patients who experience high decisional conflict are at risk for distress, indecisiveness and delayed receipt of cancer treatment or screening tests.2
For patients with prostate cancer, decision support tools can help address the barriers to making an informed choice with minimal decisional conflict. Some of these tools are available to the public and are free to use. One example from the United Kingdom is the Predict Prostate risk communication tool (https://prostate.predict.nhs.uk). This tool allows the user to enter details pertaining to a man’s prostate cancer (eg prostate specific antigen level, tumor grade on biopsy) and provides estimated survival outcomes associated with conservative and radical treatment (fig. 1, A). Predict Prostate also presents nonindividualized information about the possible sexual, urinary and bowel outcomes of different treatments (fig. 1, B). The information that the tool provides is based on the results of the ProtecT trial, which randomized men with localized prostate cancer to undergo radical prostatectomy, radiation therapy or observation.3 Compared to subjects who received usual care, those who used Predict Prostate had lower levels of decisional conflict and more accurate perceptions about survival outcomes associated with different treatments.4
Another example of a decision support tool is the Personal Patient Profile–Prostate (P3P; https://www.p3p4me.org/users/login). There are some important differences between P3P and Predict Prostate. First, unlike Predict Prostate, P3P does not provide an individualized report of mortality risk with observation or radical treatment. Instead, summary statistics from recent literature are presented in various forms. Second, unlike the nontailored content in Predict Prostate, the P3P instrument tailors educational content based on a man’s self-reported “top concerns” (eg years I would expect to live, sexual function etc). The online educational content includes videos of theoretical interactions between patients and providers and provides users with examples of questions for patients to pose to providers about their top concerns.
Third, P3P assesses the patient’s preferred role in treatment decision making. The American Urological Association recognizes the preference-sensitive nature of localized prostate cancer treatment decisions and emphasizes the importance of shared decision making in its most recent guidelines.5 However, the extent to which a patient prefers to participate in or share a treatment decision may vary. While some patients may prefer that the doctor exert the most influence on the final decision, others may prefer to retain control. In P3P, videos of interactions between patients and providers are tailored to the user’s preferred decision-making role.
Finally, P3P provides a standardized report that includes a concise summary of information that is integral to the prostate cancer treatment decision-making process (fig. 2). This report includes the current status of the patient’s decision (eg “thinking about options”), preferred decision-making role (eg “I prefer that my doctor[s] and I share the decision about which option is best”) and the degree of influence attributed to various personal factors (eg the impact of treatment on work). The report also provides a summary of the patient’s baseline sexual, urinary, bowel and vitality-related quality of life based on the validated Expanded Prostate Cancer Index Composite Short Form questionnaire6 and a summary of the patient’s level of interest in sexual activity and satisfaction. This type of report can provide a helpful summary for providers who are short on time during busy clinic visits.
P3P has been shown to have variable impact among different groups of men with prostate cancer. Compared to usual care, use of P3P is associated with lower levels of decisional conflict in single men and those who have had fewer than 2 consultations regarding their diagnosis.7 Black men who used P3P had less decisional regret than those who received usual care; this effect was not seen in White men.8 As with Predict Prostate, the adoption of observational strategies among lower-risk men who used P3P was not higher than among men who received usual care.9 It is important to note that the content of P3P was developed before active surveillance was the preferred management strategy for patients with low-risk prostate cancer. Moreover, the intent of decision support tools is not to replace the role of the provider in guiding patients with low-risk prostate cancer to consider a less-radical approach to managing their disease.
In summary, decision support tools can help decrease decisional conflict and improve other psychosocial outcomes for men making treatment decisions for newly diagnosed prostate cancer. Decision support tools do not replace the need for a shared decision-making process that incorporates patient values and provider expertise, but these tools can facilitate such a process. In turn, tools such as Predict Prostate and P3P have the potential to improve patients’ knowledge and decrease their distress related to an often difficult decision.
- Stacey D, Légaré F, Boland L et al: 20th anniversary Ottawa Decision Support Framework: Part 3 overview of systematic reviews and updated framework. Med Decis Making 2020; 40: 379.
- O’Connor AM, Drake ER, Wells GA et al: A survey of the decision–making needs of Canadians faced with complex health decisions. Health Expect 2003; 6: 97.
- Hamdy FC, Donovan JL, Lane JA et al: 10-Year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. New Engl J Med 2016; 375: 1415.
- Thurtle D, Jenkins V, Freeman A et al: Clinical impact of the Predict Prostate risk communication tool in men newly diagnosed with nonmetastatic prostate cancer: a multicentre randomised controlled trial. Eur Urol 2021; 80: 661.
- Sanda MG, Cadeddu JA, Kirkby E et al: Clinically localized prostate cancer: AUA/ASTRO/SUO guideline. Part I: risk stratification, shared decision making, and care options. J Urol 2018; 199: 683.
- Wei JT, Dunn RL, Sandler HM et al: Comprehensive comparison of health-related quality of life after contemporary therapies for localized prostate cancer. J Clin Oncol 2002; 20: 557.
- Berry DL, Hong F, Blonquist TM et al: Decision support with the personal patient profile-prostate: a multicenter randomized trial. J Urol 2018; 199: 89.
- Berry DL, Hong F, Blonquist TM et al: Decision regret, adverse outcomes, and treatment choice in men with localized prostate cancer: Results from a multi-site randomized trial. Urol Oncol 2021; 39: 493.e9.
- Filson CP, Hong F, Xiong N et al: Decision support for men with prostate cancer: concordance between treatment choice and tumor risk. Cancer 2021; 127: 203.