A Systematic Approach to Discussing Active Surveillance with Patients with Low-risk Prostate Cancer: Beyond the Abstract

Overtreatment of low risk prostate cancer has been recognized by every major medical society across the world as a top priority for physicians and scientists to focus.   As such, efforts to increase enrollment of men with low risk prostate cancer have included research by health policy experts and physician-scientists focusing in health services research and clinical trials.   Despite  data demonstrating safety for men who choose active surveillance, the majority of patients still choose radical treatments including surgery and radiation therapy.   

Uniquely, we addressed how physicians speak with patients and aimed to improve communication of risk associated with monitoring cancer as opposed to undergoing immediate radical treatment.  We were able to assemble a multidisciplinary team of experts and develop a novel counseling approach for physicians incorporating appropriate framing techniques derived from principles studied by negotiation scholars.   The cohort for the training intervention comprised of 1003 consecutive patients and the proportion of patients who selected active surveillance increased from 69% to 81% after physicians were taught the novel communication techniques.   We estimated that teaching physicians to better communicate risk with patients led to a relative reduction of overtreatment by 30%.   Therefore, this study emphasizes that improving physician-patient counseling improves overall health delivery and may potentially decrease costs and suffering.  The goal of this research is not to give physicians scripts or change what they say to patients.  Instead, our aim is to guide physicians to understand patients’ interests and instead of debating the patient’s stated preference for a particular treatment, evoke all of a patient’s interests for pursuing treatment, beyond survival.  

We think the most exciting aspect of this research is that we can use these principles across medicine to improve appropriateness of treatments and improve value in healthcare.  Specifically, we are currently applying these principles to improve prostate cancer screening decision-making.   In addition, these communication principles can be applied to over-prescription of antibiotics in pediatrics or surveillance for patients diagnosed with breast or thyroid cancer.

As surgeons, we dedicate upwards of a decade in training to become expert in radical prostatectomy, the surgical removal of the prostate for the treatment of prostate cancer. This complex procedure follows a highly structured, carefully studied sequence of steps that require significant repetition and practice to achieve proficiency. However, the majority of contemporary patients diagnosed with prostate cancer actually harbor low-risk tumors that do not require immediate treatment and can be safely managed by careful monitoring, with subsequent curative treatment if evidence of cancer progression is found, an approach termed active surveillance.  Surgeons receive little if any training in how to speak to patients about AS, a particular problem as men with prostate cancer report receiving little substantive information about treatment options, many perceive AS as “doing nothing,” and few men seem aware that immediate treatment may not improve their survival.   In our study, we believe we have provided a framework to standardize physician counseling regarding prostate cancer and boost the appropriateness of active surveillance for men with low risk cancer.

Written by: Behfar Ehdaie, MD MPH, Urology Service, Department of Surgery Memorial Sloan Kettering Cancer Center

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