Has this ever happened to you? You don’t feel well or you have a weird symptom and you make an appointment with your doctor. After discussion and maybe a test or two, your doc gives you a diagnosis. You have a condition that is not life threatening at the moment (such as low-risk prostate cancer) but could eventually become dangerous. You are offered two basic options from which to choose: immediate treatment or monitor it closely.

You ask questions, such as:

• How long before it becomes a threat?
• What would monitoring it involve?
• If I wanted to treat it, what are the choices in my case?
• What possible side effects for each treatment, and how long do they last?
• If it was your body, what would you do?

Doctors and patients don’t always agree

This opens up a discussion, a process now called shared decision-making. Ideally, your physician is able to take all the time needed to answer your questions, in clear and understandable clinical terms. At the same time, he/she asks about your current life situation (intimate relationship, job, leisure activities, etc.) in order to empathize with how potential side effects might impact your quality of life.

However, the last question about what your doc would do in your situation is tricky. Some doctors simply avoid it, saying that everyone is unique and that you have to choose what you’re most comfortable with. On the other hand, if the response is either “I’d treat it” or “I’d hold off and monitor,” it may reveal the doctor’s professional or personal values. Now, in itself that’s not a bad thing. However, studies have shown that “treatment decision-making among patients with low-risk PCa was dominated by physicians’ recommendations (mostly based on clinical factors), whereas patients’ preferences were overlooked.”^[i] This obviously biases decision-making toward the doctor, not the patient.

When a doctor’s recommendation clashes with a patient’s values or preferences, the patient who views a doctor as knowing what’s best may stoically let go of his personal wishes. Perhaps he’ll simply cross his fingers and hope treatment outcomes won’t lead to temporary or permanent loss of lifestyle quality.

Doctor-patient agreement may be increasing

Hopefully, the scenario described above may be gradually disappearing. A new analysis of what drives decision-making for low-risk prostate cancer (PCa) found that doctors and patients share similar factors they take into account.^[ii] This was generally true even in culturally diverse populations, though certain themes emerged:

1. Age and stage of life – Doctors and patients tended to agree on age/life stage as influencing choice. Older patients leaned toward monitoring, while younger patients expressed a wider range of treatment preferences.
2. Side effects – Doctors and patients widely agreed that potential side effects matter greatly. While fear of side effects or past experience from other medical treatments had the most influence, a patient’s family often swayed patients when loved ones strongly wanted their loved one to survive more than anything else (and associated aggressive treatment with better survival).
3. Patients’ research before decision – Doctors and patients both felt that when patients first inform themselves by researching PCa, treatments, etc., it made having conversations easier and facilitated shared decision-making. Doctors found that poorly informed patients were less able to engage in discussions and had a harder time grasping potential treatment side effects and how it would affect their lives.

Focal treatment as a middle ground

Previous research has suggested that doctors tend to steer younger men toward aggressive treatment because this age group is healthier and more active with less likelihood of conditions that are associated with greater side effect risks and longer recovery. However, younger men not only have greater life expectancy, they are also more likely to still be employed and to have active sex lives—factors that may deter the idea of surgical gland removal or whole gland radiation. They may be more likely to push back against a doctor’s recommendation for a definitive whole-gland treatment.

Thankfully, there’s a middle ground alternative to either radical treatment or monitoring by Active Surveillance: focal treatment. Unlike earlier generations of PCa patients, today’s low-risk patient has the benefit of confident diagnosis thanks to 3T multiparametric MRI, real-time MRI targeted biopsy, and precise tumor destruction by means of Focal Laser Ablation (FLA), MRI-guided Focused Ultrasound (MRgFUS), or Transurethral Ultrasound Ablation (TULSA).

Our expert focal therapy approaches at the Sperling Prostate Center involve successful shared decision making. Our patients typically do their own research even before our initial consultation, and we encourage them to continue to do so even as we explain their imaging results in detail, converse about their life situations, and answer their questions with full transparency. I and my staff have experienced that when we achieve a high degree of agreement on treatment choice matched to an individual’s disease, wishes and circumstances, our patients have an equally high degree of satisfaction with their treatment results.

Want to experience the difference that doctor-patient agreement makes? We invite you to call us or request to be contacted to learn how we can best serve your diagnostic, treatment, and follow-up needed.

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] Guan A, Santiago-Rodríguez EJ, Chung BI, Shim JK et al. Patient and physician perspectives on treatments for low-risk prostate cancer: a qualitative study. BMC Cancer. 2023 Dec 5;23(1):1191.
[ii] Ibid.