Let’s Talk About Informed Decision Making

How do you prepare for a prostate cancer consultation? While I can’t speak for everyone in my profession, I believe these days most urologists and radiologists are comfortable with patients bringing in a list of questions. I encourage patients to do so, especially if they are facing a detection, diagnosis, or decision-making process regarding prostate cancer. It’s so important that patients ask for the information they need. It’s also important to clarify. As doctors, we try to explain in clear language, but sometimes we’re guilty of using professional terms we know like the back of our hands, but they are words patients may never have heard before. Given the understandable anxiety that accompanies the prospect of cancer, it’s hard for patients to absorb and retain all the information they are receiving. So bring in that list of questions, and don’t hesitate to take notes.

When I talk with my patients about prostate cancer, I try to give them as much time as they need. If I’m meeting them after a multiparametric MRI scanning session, I have the advantage of being able to show them their imaging results. It’s a very concrete way for me to explain their situation, their options, and answer their questions. I try to relate what I see happening in an individual’s prostate to possible treatment choices, explaining how each form of therapy could have advantages and disadvantages as I also learn about his lifestyle, relationships, and what matters to him. All of this is part of what’s known as informed decision making.

A recent study by a collaborative team from several noteworthy U.S. academic medical centers shows that the quality of physician participation in informed decision making varies.[i] Consultations by 45 Veterans Administration physicians with 252 patients in 4 different VA hospitals were audio taped, and later analyzed according to criteria developed by Braddock, et al. (1999).[ii] In about 95% of discussions, there was talk about treatment choices and the risks/benefits associated with them. However, in more than a third, the doctors did not provide a complete list of all available options, and omitted active surveillance. In many cases, the doctors did not bring up surveillance because of a Gleason 7 score, or because of younger age. The study authors concluded that even when patients had been given some type of decision-making guide or tool, their doctors did not fully engage in shared decision-making, and often did not go into the patient’s preference.

I can’t help but think that doctors who lack today’s mpMRI capacity, including not being trained to read such images, are less well positioned to provide thorough information to patients. I’m guessing that such doctors do not bring up focal treatment as an option, partly because the VA typically offers surgery, radiation, androgen deprivation therapy and active surveillance as the only options they cover, and partly because the doctors themselves would not be confident suggesting focal therapy if they still believe all prostate cancer is multifocal. The field of medicine tends to be conservative. It evolves slowly, but I see daily how patients who inform themselves beyond what their doctors say are seeking alternatives to conventional treatments. The best that I, or any doctor, can hope to do is to change the world of shared decision-making one patient at a time.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

References

[i] Holmes-Rovner M, Montgomery JS, Rovner DR, Scherer L et al. Informed decision making: assessment of the quality of physician communication about prostate cancer diagnosis and treatment. Med Decis Making. 2015 Aug 24. pii: 0272989X15597226. [Epub ahead of print]
[ii] Braddock C, Edwards K, Hasenberg N, Laidley T, Levinson W. Informed decision making in outpatient practice: time to get back to basics. JAMA. 1999 Dec; 282(24): 2313-20.