Regret After Prostate Cancer Treatment
By: Dan Sperling, MD
Originally published: 5/7/2015
Nearly 10 years have passed since we posted the 2015 blog below so it’s time for an update. In April, 2025 the journal International Urology and Nephrology published a study of factors leading to decision regret after radical prostatectomy. The study involved 590 patients, and an objective questionnaire called the Decision Regret Scale was used to assess each patient’s “distress or remorse” following surgery. Not surprisingly, the authors found that side effects of urinary and sexual dysfunction were linked with higher levels of decision regret[i], a finding that has been consistent across such studies during the decade between our original blog and this update. In fact, a 2023 British analysis that pooled 14 studies comprising over 17,000 patients treated for localized prostate cancer found that an average of 20% of patients had significant decision regret across all interventive treatments, linked with side effects and feeling less involved in the decision-making process.[ii] On balance, patients who undergo focal therapy generally report high levels of satisfaction due to low rates of urinary or sexual side effects.
Prostate cancer (PCa) is most often detected when it is in its very early stages and has no symptoms. For men who are in otherwise good health, it is hard to believe that they have a cancer when they don’t feel sick, and there are no other signs than a blood test or abnormal DRE (digital rectal exam). As they talk with their doctors, seek second opinions, do internet research and attend support groups, they learn that being treated for prostate cancer will likely cure the disease, but may leave them with less well-being than they had before they were diagnosed. It is a cruel trade-off to gain a long lifespan at the price of urinary, sexual or bowel function. Research shows that treatments differ in their impact on quality of life. For example, surgery patients report more of decline in sexual function and urinary continence than radiation patients, while radiation patients experience more urinary irritation and late onset bowel difficulties than prostatectomy patients.
Research shows that treatments differ in their impact on quality of life. For example, surgery patients report more of decline in sexual function and urinary continence than radiation patients, while radiation patients experience more urinary irritation and late onset bowel difficulties than prostatectomy patients. [iii],[iv],[v] Other factors such as ethnicity, culture and age can also influence the experience of regret; one study about the impact of side effects on individuals and relationships reports that young African American men were more likely to have regret than older African American men, but older Anglo Americans were more likely to regret their treatment choice than their African American counterparts.[vi] Among patients with recurrent PCa following treatment, African American men were nearly twice as likely to regret their treatment as non-African American men.[vii]
A new Australian paper describes a review of published literature on this topic.[viii] The authors sought to identify factors that play into treatment disappointment by a search of online clinical databases since 1997, using search terms “prostate” and “regret.” Of the 422 articles they identified, 28 contained data suitable for their analysis, comprising a population of 8118 patients. The authors wrote that the most common sources of regret were “…treatment toxicity factors, especially sexual and urinary function. Other factors included older age and longer time since treatment.” Dissatisfaction and regret were generally higher after prostatectomy than beam radiation or seed implants. Their findings were similar to research published in 2007 that revealed an increase in decisional regret between 6 and 12 months after diagnosis, which was more substantial for surgery patients than radiation patients. This was particularly so if urinary dysfunction restricted lifestyle activity, and also if bother due to sexual and urinary dysfunction continued to linger more than 6 months.[ix]
Virtually all authors who write about “buyer’s remorse” after prostate cancer treatment acknowledge that decisional regret is real for many patients, and remains a pressing issue. There is a growing trend on the part of professional urologic organizations to encourage men diagnosed with early stage, low-risk PCa to consider Active Surveillance (AS) as a way to hold off on radical treatment. However, not every patient has the psychological tolerance to live with the idea of cancer in his body, regardless of evidence (biomarkers, imaging) that it is of a slow-growing nature. For some patients who embark on AS, the protocol for monitoring their disease becomes burdensome and they elect definitive treatment. For others, knowing that certain factors will eventually trigger a treatment decision, they worry about “missing a treatment window.”
Focal treatment for PCa presents a middle ground between observation and radical treatments. With the increasing evidence that focal therapy for appropriate patients offers comparable cancer control with greatly reduced risk of side effects, this approach is gaining ground among physicians and patients, with patients self-reporting extremely high levels of satisfaction on internet-based discussion forums.
However, for the foreseeable future, radical treatments will continue to dominate patient decision making. What, then, can be done to keep men from ruing the day they had treatment? There is consensus in the literature that frank and extensive doctor-patient dialogue on the risks and likely course of side effects helps men and their loved ones make responsible, informed choices; decision-making aids such as comparison charts and detailed educational materials reinforce factual knowledge. This leads to a sense of empowerment that appears to improve post-treatment attitudes and reduce regret. One research team found that providing patients with an audio recording of their pre-treatment consultations to review at home also “…reduces long-term decision regret, increases patient information recall, understanding and confidence in their decision.”[x] A final recommendation is to pay particular attention to the needs of African American men and other ethnic groups who seem to be more prone to decisional regret over their PCa treatment choice.
It is to be expected that as newly diagnosed men utilize internet-based information, they will bring more questions to the consultations with their doctors. Some of these questions will surely be directed toward focal treatment. It is to be hoped that physicians are prepared to address patient concerns fully and honestly, with the goal of making sure that every patient reaches the other side of treatment prepared to be content with the outcome.
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] Guercio A, Lombardo R, Turchi B, Romagnoli M et al. Patient satisfaction and decision regret in patients undergoing radical prostatectomy: a multicenter analysis. Int Urol Nephrol. 2025 Apr 17.
[ii] Fanshawe JB, Wai-Shun Chan V, Asif A, Ng A et al. Decision Regret in Patients with Localised Prostate Cancer: A Systematic Review and Meta-analysis. Eur Urol Oncol. 2023 Oct;6(5):456-466.
[iii] Lee TK, Breau RH, Mallick R, Eapen L. A systematic review of Expanded Prostate Cancer Index Composite (EPIC) quality of life after surgery or radiation treatment. Can J Urol. 2015 Feb;22(1):7599-606.
[iv] Dearnaley D, Khoo V, Norman A et al. Comparison of radiation side-effects of conformal and conventional radiotherapy in prostate cancer: a randomized trial. Lancet 1999 Jan; 353(9149):267-72.
[v] Colaco RJ, Hoppe BS, Flampouri S et al. Rectal toxicity after proton therapy for prostate cancer: An analysis of outcomes of prospective studies conducted at the University of Florida Proton Therapy Institute. Int J Radiat Oncol Biol Phys. 2014 Nov 5. pii: S0360-3016(14)04060-7.
[vi] Morris BB, Farnan L, Song L et al. Treatment decisional regret among men with prostate cancer: Racial differences and influential factors in the North Carolina Health Access and Prostate Cancer Treatment Project (HCaP-NC). Cancer. 2015 Mar 3. Epub ahead of print. doi: 10.1002/cncr.29309 Pub: 4/27/2015
[vii] Mahal BA, Chen MH, Bennett CL et al. The association between race and treatment regret among men with recurrent prostate cancer. Prostate Cancer Prostatic Dis. 2015 Mar;18(1):38-42.
[viii] Christie DR, Sharpley CF, Bitsika V. Why do patients regret their prostate cancer treatment? A systematic review of regret after treatment for localized prostate cancer. Reference: Psychooncology. 2015 Mar 1. Epub ahead of print. doi: 10.1002/pon.3776
[ix] Diefenbach MA, Mohamed NE. Regret of treatment decision and its association with disease-specific quality of life following prostate cancer treatment. Cancer Invest. 2007 Sep;25(6):449-57.
[x] Good DW, Delaney H, Laird A et al. Consultation audio-recording reduces long-term decision regret after prostate cancer treatment: A non-randomised comparative cohort study. Surgeon. 2015 Jan 27. pii: S1479-666X(14)00139-5. doi: 10.1016/j.surge.2014.10.006. [Epub ahead of print]
