Offering a Treatment Choice in the Irradiation of Prostate Cancer Leads to Better Informed and More Active Patients, Without Harm to Well-Being

doi:10.1016/j.ijrobp.2007.06.058

International Journal of Radiation OncologyBiologyPhysics

Volume 70, Issue 2, 1 February 2008, Pages 442-448

https://doi.org/10.1016/j.ijrobp.2007.06.058 Get rights and content

Purpose

To examine, in prostate cancer patients, the effect of (1) being offered a choice between radiation doses in three-dimensional conformal radiotherapy, and of (2) accepting or declining the possibility to choose.

Methods and Materials

A total of 150 patients with localized prostate cancer (T1–3N0M0) were offered a choice with a decision aid between two radiation doses (70 and 74 Gy). A control group of 144 patients received a fixed radiation dose without being offered a choice. Data were collected at baseline (before choice), before treatment (after choice), and 2 weeks and 6 months after treatment completion.

Results

Compared with the control group, the involvement group, receiving the decision aid, showed increased participation in decision making (p < 0.001), increased knowledge (p < 0.001), and improved risk perception (p < 0.001); they were more satisfied with the quality of information (p = 0.002) and considered their treatment a more appropriate treatment (p = 0.01). No group differences were found in well-being (e.g., general health, European Organization for Research and Treatment of Cancer quality of life, anxiety). Within the involvement group, accepting or declining the option to choose did not affect well-being either.

Conclusions

Offering a choice of radiation dose, with a decision aid, increased involvement in decision making and led to a better-informed patient. In contrast to earlier suggestions, a strong increase in involvement did not result in improved well-being; and in contrast to clinical concerns, well-being was not negatively affected either, not even in those patients who preferred to leave the decision to their physician. This study shows that older patients, such as prostate cancer patients, can be informed and involved in decision making.

Introduction

Cancer patients today tend to become more involved in treatment decisions. Some studies have suggested that increasing patient involvement in decision making may increase anxiety in cancer patients 1, 2. Other studies, however, have found it to cause no harm 3, 4 or even improve the decision-making process 5, 6 and patients' well-being 7, 8.

Patients differ in the role they wish to play in decision making. Patients who prefer to leave the treatment decision to their physician may be adversely affected by being offered a choice (9). Such preferences are more likely to be found among older cancer patients 10, 11. This study focuses on the effect of increasing patient involvement in cancer treatment choice for prostate cancer patients, typically an older cancer patient group.

Patient involvement in decision making usually refers to involvement in a treatment choice, trading off the pros and cons of different treatment options. In some clinical settings, however, treatment choices are not based on individual trade-offs but are frozen in local or national treatment protocols. This applies, for example, to the decision regarding the radiation dose in the treatment of localized prostate cancer. In the present study, the effect of patient involvement is studied in patients with localized prostate cancer by introducing a choice between two radiation doses (70 Gy and 74 Gy) for three-dimensional conformal radiotherapy (3D-CRT). This choice encompasses a trade-off between the risks and benefits of a higher dose as compared with a lower dose. A higher radiation dose is associated with a higher chance of cure but also a higher risk of side effects (12). The unique feature of the study is that the choice is not hypothetical. The preference of the patient actually is carried out.

Our previous research has shown that almost 80% of patients with localized prostate cancer accept the option to choose their own radiation dose (13). In addition, patients have shown individual differences in their trade-off between cure and side effects (14). The present study focuses on whether there are any positive or negative effects of this patient involvement in the months after treatment. Patients who were offered a choice are compared with control patients, who were treated by protocol (i.e., who were not offered a choice). Second, patients who preferred to leave the treatment decision to their physician were monitored to examine possible negative effects in this group.

Section snippets

Patients

Between April 2002 and September 2005, 294 patients with a primary localized prostate carcinoma (T1–3 N0M0), to be treated with 3D-CRT, were included in this prospective study. Exclusion criteria were mental disorders and insufficient knowledge of the Dutch language. Patients were enrolled at two locations: the Radboud University Medical Centre in Nijmegen and the Arnhems Radiotherapeutic Institute in Arnhem, The Netherlands. The study was approved by the research ethics committees of both

Control patients

Data on control patients were collected in two episodes: one episode before (n = 103) and one after (n = 41) the period in which involvement patients were offered a choice. No differences were found between these two control subgroups for the 34 variables collected at t1 and the 14 variables collected at t2, except that at t1 the second control group had fewer urinary problems and higher Gleason scores compared with the first control group. Because the two control subgroups were comparable on

Discussion

In the present study, patients could choose between two different radiation doses of 3D-CRT with the support of a decision aid. Being offered a choice led to a more active role in decision making and more knowledge compared with not being offered a choice. No adverse effect of the intervention was found on patients' well-being in terms of general health, specific health problems (urinary, gastrointestinal, and sexual), anxiety, depression, and mental adjustment to cancer. Within the group that

References (26)

T.F. Hack et al.
Relationship between preferences for decisional control and illness information among women with breast cancer: A qualitative and quantitative analysis
Soc Sci Med
(1994)
C.G. Blanchard et al.
Information and decision-making preferences of hospitalized adult cancer patients
Soc Sci Med
(1988)
D. Rothenbacher et al.
Treatment decision in palliative cancer care: Patients' preferences for involvement and doctors' knowledge about it
Eur J Cancer
(1997)
J.J. van Tol-Geerdink et al.
A systematic review of the effect of radiation dose on tumor control and morbidity in the treatment of prostate cancer by 3D-CRT
Int J Radiat Oncol Biol Phys
(2006)
J.J. van Tol-Geerdink et al.
Do prostate cancer patients want to choose their own radiation treatment?
Int J Radiat Oncol Biol Phys
(2006)
J.D. Cox et al.
Toxicity criteria of the Radiation Therapy Oncology Group (RTOG) and the European Organization for Research and Treatment of Cancer (EORTC)
Int J Radiat Oncol Biol Phys
(1995)
M.E. Stefanek et al.
Predictors of and satisfaction with bilateral prophylactic mastectomy
Prev Med
(1995)
J.M. Deadman et al.
Taking responsibility for cancer treatment
Soc Sci Med
(2001)
S.M. Levy et al.
Breast conservation vs mastectomy: Distress sequelae as a function of choice
J Clin Oncol
(1989)
M. Gattellari et al.
When the treatment goal is not cure: Are cancer patients equipped to make informed decisions?
J Clin Oncol
(2002)

B.J. Davison et al.

Decisional regret and quality of life after participating in medical decision-making for early stage prostate cancer

BJU Int

(2003)

A.M. O'Connor et al.

Decision aids for patients facing health treatment or screening decisions

Cochrane Database Syst Rev

(2003)

M.D. Brundage et al.

A treatment trade-off based decision aid for patients with locally advanced non-small cell lung cancer

Health Expect

(2000)

Cited by (35)

Shared decision making: Does a decision aid support patients with an atypical cartilaginous tumor in making a decision about treatment
2022, PEC Innovation
Due to new insights, atypical cartilaginous tumors (ACTs) of the long bones are no longer considered malignant and treatment is shifting from surgery to active surveillance. We developed a decision aid in order to support in shared decision making on treatment.
The aim of this study is to evaluate the treatment preferences of patients with an ACT in the long bones.
During thirty-four months, patients received a decision aid digitally with information about the disease, the treatment options, and the risks and benefits of active surveillance and surgical treatment. The given answers to patients' preference questions were evaluated qualitatively in relation to the final choice of treatment.
Eighty-four patients were included. None of the patients who preferred active surveillance later underwent surgery. Only four patients underwent surgery based on patient preference.
In our experience the decision aid is useful for shared decision making as it provides the patient with information and the clinician with insight into patient's preferences. The preference for treatment generally corresponds to the eventual treatment.
When treatment changes, due to new insights, a decision aid seems helpful for both patients and clinicians to discuss the treatment that best suits the patient's situation.
Preferred and Perceived Participation of Younger and Older Patients in Decision Making About Treatment for Early Breast Cancer: A Prospective Study
2018, Clinical Breast Cancer
Older patients are believed to prefer a more passive role in treatment decision making, but studies reporting this relation were conducted over a decade ago or were retrospective. We prospectively compared younger (40-64 years) versus older (≥ 65 years) breast cancer patients' preferences for decision-making roles and their perceived actual roles.
A prospective multicenter study was conducted in Leiden, The Hague, and Tilburg over a 2-year period. Early-stage breast cancer patients were surveyed about their preferred and perceived decision-making roles (active, shared, or passive) concerning surgery type (breast-conserving vs. mastectomy) (n = 74), adjuvant chemotherapy (aCT, n = 43), and adjuvant hormonal therapy (aHT, n = 39).
For all decisions, both age groups most frequently preferred a shared role before consultation, except for decisions about aHT, for which younger patients more commonly preferred an active role. The proportion of patients favoring an active or passive role in each decision was lower for the older than the younger patients, but none of the differences was significant. Regarding perceived actual roles, both groups most frequently reported an active role in the surgical decision after consultation. In deciding about both aCT and aHT, a larger proportion of older patients perceived having had a passive role compared to younger patients, and a greater proportion of younger patients perceived having been active. Again, differences were not statistically significant.
Most older patients preferred to decide together with their clinician, but preferences varied widely. Older patients more often than younger patients perceived they had not been involved in decisions about systemic therapy. Clinicians should invite all patients to participate in decision making and elicit their preferred role.
Systematic Review of Decision Aids for the Management of Men With Localized Prostate Cancer
2018, Urology
Citation Excerpt :
The Preparation for Decision Making Scale44 was used in 1 study that found no difference between the intervention and control groups at the time of decision aid visit but significantly more control over decision making after receiving decisional tool at both 3 months and 1 year follow-up.14 The Problem-solving Decision Making Scale45 was used in 1 study that found the intervention group more active post-intervention and the control group more passive without the decision intervention (P <.001).30 Five studies measured decisional control with study-specific questionnaires8,11,33,34,36 and all demonstrated increased decisional control post-decisional tool.
A broader range of decisional tools should be investigated. This paper will update the decisional outcome data and assess the features of decisional tool. Literature search strictly followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Articles that cited Lin et al and Violette et al were searched. Features of decisional tools were analyzed using the International Patient Decision Aid Standards Instrument criteria. The scores of the 31 decisional tools ranged from 6 to 15, which did not correlate proportionally with the positive decisional outcomes. Personal importance appeared to be a significant component. Multidisciplinary clinics are superior in improving decisional outcomes as they promote more at shared decision making.
Effective follow-up consultations: The importance of patient-centered communication and shared decision making
2013, Paediatric Respiratory Reviews
Paediatricians spend a considerable proportion of their time performing follow-up visits for children with chronic conditions, but they rarely receive specific training on how best to perform such consultations. The traditional method of running a follow-up consultation is based on the doctor's agenda, and is problem-oriented. Patients and parents, however, prefer a patient-centered, and solution-focused approach. Although many physicians now recognize the importance of addressing the patient's perspective in a follow-up consultation, a number of barriers hamper its implementation in practice, including time constraints, lack of appropriate training, and a strong tradition of the biomedical, doctor-centered approach.
Addressing the patient's perspective successfully can be achieved through shared decision making, clinicians and patients making decisions together based on the best clinical evidence. Research shows that shared decision making not only increases patient, parent, and physician satisfaction with the consultation, but also may improve health outcomes. Shared decision making involves building a physician-patient-parent partnership, agreeing on the problem at hand, laying out the available options with their benefits and risks, eliciting the patient's views and preferences on these options, and agreeing on a course of action. Shared decision making requires specific communication skills, which can be learned, and should be mastered through deliberate practice.
In response to ESTRO 2012 strategy meeting: Vision for Radiation Oncology (published April 2012)
2013, Radiotherapy and Oncology
Competencies in radiation oncology: A new approach for education and training of professionals for Radiotherapy and Oncology in Europe
2012, Radiotherapy and Oncology

View all citing articles on Scopus

: Supported by grants from the Dutch Cancer Society, Amsterdam, The Netherlands (KUN 2001-2379 and 2005-3457); registration no. ISRCTN97145188.

: Conflict of interest: none.

View full text

Clinical InvestigationOffering a Treatment Choice in the Irradiation of Prostate Cancer Leads to Better Informed and More Active Patients, Without Harm to Well-Being

Purpose

Methods and Materials

Results

Conclusions

Introduction

Section snippets

Patients

Control patients

Discussion

Soc Sci Med

Soc Sci Med

Eur J Cancer

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Prev Med

Soc Sci Med

Breast conservation vs mastectomy: Distress sequelae as a function of choice

J Clin Oncol

When the treatment goal is not cure: Are cancer patients equipped to make informed decisions?

J Clin Oncol

Decisional regret and quality of life after participating in medical decision-making for early stage prostate cancer

BJU Int

Decision aids for patients facing health treatment or screening decisions

Cochrane Database Syst Rev

A treatment trade-off based decision aid for patients with locally advanced non-small cell lung cancer

Health Expect

Clinical Investigation
Offering a Treatment Choice in the Irradiation of Prostate Cancer Leads to Better Informed and More Active Patients, Without Harm to Well-Being