Improving Shared Decision Making for Men Diagnosed with Localized Prostate Cancer
By: Simon P. Kim, MD, MPH | Posted on: 01 Jun 2022
Prostate cancer remains one of the most commonly diagnosed male malignancies in the United States. Many men are diagnosed with localized prostate cancer and face difficult choices regarding treatment and disease management. Due to the equipoise in outcomes for surgery and radiation therapy, coupled with the treatment-related quality of life changes with urinary control and erectile function, this prevalent malignancy likely represents one of the first and quintessential diseases for shared decision making (SDM) in urology.1,2 Furthermore, some men diagnosed with low-risk prostate cancer are eligible for active surveillance, but treatment should be based on SDM. Indeed, clinical practice guidelines from the AUA/American Society for Radiation Oncology and the National Comprehensive Cancer Network® uniformly endorse SDM for treatment decisions and clinical practice for newly diagnosed patients and their urologists and radiation oncologists.3,4 Decision aids represent one common way of applying SDM such that men diagnosed with localized prostate cancer can understand all relevant treatment options and disease management strategies, and the risks and benefits of each option, and have their treatment preferences and values incorporated into the treatment decision.
SDM and decision aids have been extensively studied in localized prostate cancer for many years, showing modest improvements in decisional outcome measures such as improving patient knowledge and satisfaction, and reducing decisional conflict and long-term decision regret.5,6 However, several important clinical and research questions remain about the optimal dissemination and implementation of decision aids for prostate cancer regarding the timing of decision aid delivery and the limited information about effectiveness among minority men.
We recently published our large, multicenter, randomized clinical trial aimed at addressing these 2 critical areas of uncertainty for SDM in localized prostate cancer.7 First, we performed a clustered randomized trial where patients would either receive a pre-visit, Web-based decision aid (Knowing Your Options), an in-visit, tablet-based decision aid (Prostate Cancer Choice), both decision aids or usual care. Second, our study also focused on oversampling African American men across 15 urology practices through the National Cancer Institute Community Oncology Research Program Alliance Research Base, which was the first SDM clinical trial performed in this research network. Although our study used patient knowledge as the primary outcome, the results indicated only a trend toward greater gains in patient knowledge for the pre-visit and both the pre-visit and in-visit decision aids compared to usual care. Furthermore, our National Cancer Institute-funded SDM trial was able to accrue the highest number of African American men to date (53.8%). Over time, our analyses will focus on evaluating the association of decision aids and decisional conflict and treatment regret in our study cohort. Furthermore, we will assess for ways the decision aids may help facilitate and reduce racial disparities in these decisional outcome measures.
Several key areas of uncertainty regarding effective dissemination and implementation of decision aids to promote SDM in localized prostate cancer need to be addressed. At present, the national utilization of decision aids for men diagnosed with localized prostate cancer remains unknown. In our national survey, we found only 35% of urologists and radiation oncologists used decision aids for localized prostate cancer in clinical practice.8 Increased attention to understanding the key decisional outcomes that provide the most salience to patients and their physicians and key barriers to routine adoption is needed. Another key aspect in promoting SDM in localized prostate cancer should focus on decreasing decisional regret and improving the quality of treatment outcomes, along with reducing disparities in treatment and outcomes.9,10 Addressing these key knowledge gaps in SDM for localized prostate cancer has the potential to significantly improve the way we deliver patient-centered care for men diagnosed with localized prostate cancer, and minimize racial disparities. Our study also shows that developing clinical trials to assess the effectiveness of decision aids focused on African American men, who are at risk for treatment regret, is highly achievable. In summary, SDM for treatment decision for localized prostate cancer will remain an integral part of patient-centered and high-quality urological care. Addressing these knowledge gaps will be critical in ensuring that all men diagnosed with localized with prostate cancer are making an informed decision based on a high degree of knowledge and incorporating their values and preferences.
- Donovan JL, Hamdy FC, Lane JA et al: Patient-reported outcomes after monitoring, surgery, or radiotherapy for prostate cancer. N Engl J Med 2016; 375: 1425.
- Hamdy FC, Donovan JL, Lane JA et al: 10-Year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. N Engl J Med 2016; 375: 1415.
- 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.
- Schaeffer E, Srinivas S, Antonarakis ES et al: NCCN guidelines insights: prostate cancer, version 1.2021. J Natl Compr Canc Netw 2021; 19: 134.
- Violette PD, Agoritsas T, Alexander P et al: Decision aids for localized prostate cancer treatment choice: systematic review and meta-analysis. CA Cancer J Clin 2015; 65: 239.
- Zhong W, Smith B, Haghighi K et al: Systematic review of decision aids for the management of men with localized prostate cancer. Urology 2018; 114: 1.
- Tilburt JC, Zahrieh D, Pacyna JE et al: Decision aids for localized prostate cancer in diverse minority men: primary outcome results from a multicenter cancer care delivery trial (Alliance A191402CD). Cancer 2022; 128: 1242.
- Wang EH, Gross CP, Tilburt JC et al: Shared decision making and use of decision aids for localized prostate cancer: perceptions from radiation oncologists and urologists. JAMA Intern Med 2015; 175: 792.
- DeWitt-Foy ME, Gam K, Modlin C et al: Race, decisional regret and prostate cancer beliefs: identifying targets to reduce racial disparities in prostate cancer. J Urol 2021; 205: 426.
- Klebaner D, Courtney PT, Garraway IP et al: Association of health-care system with prostate cancer-specific mortality in African American and non-Hispanic White men. J Natl Cancer Inst 2021; 113: 1343.