When and How to Use Informatics Tools in Caring for Urologic Patients

Michael W Kattan

Disclosures

Nat Clin Pract Urol. 2005;2(4):183-190. 

In This Article

Summary and Introduction

Making predictions is an essential part of any medical decision. It is particularly crucial when considering treatment of clinically localized prostate cancer. Nomograms and prediction model software typically provide the most accurate predictions. Many nomograms have been developed, for all prostate cancer clinical states. Some of these are discussed in this review, as is their utility in facilitating decision making and informed consent.

The individual patient's decision of how or whether to treat his clinically localized prostate cancer clearly deserves considerable attention. While there are no randomized controlled trial data showing survival benefit for one form of therapy over another, it is unlikely that consensus will be reached that any particular form of therapy is best for all patients. Owing to patient preferences regarding the potential adverse effects of treatment or observation, the treatment decision will always be a personal one. Patients differ in how much they value health-related quality of life aspects such as potency and continence, and in how much they fear cancer progression and the knowledge that they have prostate cancer; therefore, trading one adverse effect for another might be of great importance to one patient but inconsequential to another. Because of these differences in preference, the prostate cancer treatment decision will always need to be tailored to the individual patient.

When comparing treatment alternatives, both quantity and quality of life should be considered. For illustration, consider the following example. Suppose a patient has been diagnosed with an illness that implies a 10-year life expectancy. In this hypothetical example, a treatment is available that provides an additional year of life; however, the treatment must be delivered immediately and causes immediate blindness. Very few people would prefer this treatment (i.e. prefer to live 11 years blind rather than 10 years with sight). This example illustrates that no one would choose a treatment solely on the basis of survival benefit. Quality of life, in the form of preferences regarding different adverse effects, must be considered; moreover, the crucial preferences are those of the individual patient facing the decision, not those of the physician or the physician's perception of the patient's preferences.

It is therefore very difficult for anyone to make treatment decisions on behalf of the patient with clinically localized prostate cancer. The decision maker must know the preferences of the patient and consider these appropriately (i.e. based on the likelihood and severity of complications). Complicating the situation is the fact that any error in making this decision comes with a high penalty. Prostate cancer is typically slow growing, so patients will probably have to live many years (possibly decades) with any adverse effect of treatment. An adverse effect that is greatly despised by the patient, and that cannot be effectively remedied, can therefore weigh heavily. It seems likely that making a treatment decision on behalf of the patient, when that treatment leads to a despised adverse effect, is associated with regret of treatment choice. Lack of patient involvement has been identified as a major risk factor for regret of treatment choice.[1] Patients who make their own decisions when given adequate information should be less likely to regret their treatment choice than those whose physicians made the decision for them, particularly when complications arise.[2] A patient who knew what was at stake when the decision was made should feel less surprised and regretful in the event of a sudden complication of treatment than the patient who did not know that this complication was likely or even possible. A patient who wishes he had tried a different form of therapy, if he had it to do over again, is not a treatment success, particularly when he has many years of life remaining.

Informal methods for making prostate cancer treatment decisions might not be working well. Patients are clearly very frustrated at being excluded from the decision-making process.[3] What's more, physicians tend to recommend only the treatments that they themselves provide.[4] More formal approaches might help. Decision analysis is the classic formal approach to medical decision making.

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