You’ve probably heard the saying that a camel is a horse that was designed by a committee. It is a comic way of recognizing that groups of people with no unifying vision or systematic communication process are likely to fail at collective design. However, there is an effective antidote. It is an approach to gaining consensus called the Delphi method. I wrote about it for the article I posted about a group of international experts in focal therapy who came up with a recommended protocol for focal prostate cancer therapy clinical trials. If everyone followed the same protocol whether they were testing focal laser, HIFU, cryo, electroporation, etc. we would be able to do apples-to-apples treatment comparisons. (See https://sperlingprostatecenter.com/panel-reaches-consensus-focal-therapy-trial-design/) I was amazed at how well the Delphi method worked in that case. Participants did not always see eye to eye as they started the process, but the structure brought out the best in their listening, pondering and experience to produce true collective wisdom (and no camels).
I found an abstract for a journal paper (MacLennan et al., 2015) that poses a worthy challenge: Can patients and doctors agree on priorities and standards for comparing treatment effectiveness in order to make the best choices?[i] The authors represent a number of British and Swedish institutions, and from the looks of it, they are in earnest dialogue. After acknowledging that PCa is a growing global health problem, they describe the controversy surrounding treatment decision-making:
It is unclear which of several surgical, radiotherapeutic, ablative, and surveillance treatments is the most effective. All have cost, process and recovery, and morbidity implications which add to treatment decision-making complexity for patients and healthcare professionals. Evidence from randomised controlled trials (RCTs) is not optimal because of uncertainty as to what constitutes important outcomes. Another issue hampering evidence synthesis is heterogeneity of outcome definition, measurement, and reporting.
The two things that struck me most were a) their recognition that economics (“cost”) can be as much a consideration in choosing a treatment as the treatment, recovery and side effects are, and b) their view that both patients and physicians are equal stakeholders in determining the most effective treatment for each individual with localized PCa. Thus, patients as well as doctors will be participating in the steps to identify what’s most important for patients and clinicians alike.
First, a systematic review of the professional literature will produce a list of “potentially important outcomes and measures” that reflect professional thinking what defines an effective treatment. Since one study often differs from another, they will be looking for a range of factors; also, semi-structured interviews with patients will elicit factors that men consider and prioritize in choosing a treatment. Thus, there will be a large pool of information on potential criteria that matter to healthcare professionals and patients. Then, representatives from each group will be given a system for filtering the information in order to validate the final list of factors to be entered into a three-round Delphi process.
Now the genius of the method comes into full play, like producing a diamond from a lump of coal.:
The Delphi process will refine and prioritise the list of identified outcomes. … Participants will be randomised after round one of the Delphi study to one of three feedback groups, based on different feedback strategies, in order to explore the potential impact of feedback strategies on participant responses. This may assist the design of a future core outcome set and Delphi studies. Following the Delphi study, a final consensus meeting attended by representatives from both stakeholder groups will determine the final recommended core outcome set.
By the end, the participants will have contributed their recommendation for a standardized core outcome set for comparative effectiveness clinical trials of localized PCa treatments. When the criteria for effectiveness, including monetary costs, facts about the treatment itself, recovery times and experiences, side effects, and success statistics/durability are available for side-by-side comparisons, patients will have a true gem. They will be able to evaluate which options suit their lifestyle as well as their disease. It will be harder for doctors to influence patient decisions with a pat “let’s-just-get-you-into-surgery (or radiation or whatever) and we’ll take care of it.”
My takeaway is: the most effective treatment for localized prostate cancer is the one that is chosen as a result of open, honest collaboration between doctor and patient once all the diagnostic factors are known and the facts about all appropriate treatment choices are apples-to-apples transparent. This is what I hear patients asking for. This is the philosophy and value we embrace at the Sperling Prostate Center, where a man’s ability to know his cancer comes from top-shelf 3T mpMRI and MRI-targeted biopsy, and where we thoroughly discuss all therapeutic options, including active surveillance, which will serve his best health and quality of life interest.
Meanwhile, I look forward to hearing the results of the proposed Delphi study on PCa effectiveness trials. I thank MacLennan et al. for working hard to shine new consensus light on this important question.
[i] MacLennan S, Bekema HJ, Williamson PR et al. A core outcome set for localised prostate cancer effectiveness trials: Protocol for a systematic review of the literature and stakeholder involvement through interviews and a Delphi survey. Trials. 2015 Mar 4;16(1):76. doi: 10.1186/s13063-015-0598-0