Treatment Regret Not Common in Prostate Cancer Survivors

Pam Harrison

August 03, 2017

Long-term survivors of localized prostate cancer don't often express regret over how they chose to be treated, but informing men better upfront about their treatment options, especially the option of active surveillance, may help mitigate what regret they have over time, say investigators reporting long-term data from the Prostate Cancer Outcomes Study (PCOS).

"Men being diagnosed today with a low-risk cancer should be informed about the option of active surveillance to avoid the harms of overtreatment and because there is no survival benefit for active treatment, as we've learned from the ProtecT study," lead author Richard Hoffman, MD, MPH, professor of internal medicine and epidemiology, University of Iowa Carver College of Medicine, Iowa City, told Medscape Medical News in an email.

"Our findings also suggest that informed decision making might also reduce regret, particularly if it leads more men to select active surveillance," he added.

The findings on treatment regret come from a survey completed by men 15 years after they had received treatment for prostate cancer. The findings were published online May 11 in the Journal of Clinical Oncology.

The survey involved 934 men with newly diagnosed prostate cancer who had been enrolled in the PCOS between October 1994 and October 1995.

Participants were younger than 75 years at the time of their diagnosis.

"Most respondents had undergone radical prostatectomy, only 10.8% were treated conservatively," the study authors note. Specifically, 696 men underwent initial prostatectomy, 146 received radiation therapy, and the remaining 92 participants were treated with either watchful waiting or androgen deprivation therapy within a year of diagnosis, they add.

Men were contacted at multiple time points following their initial enrollment and were asked to comment on a variety of health-related quality-of-life outcomes, including treatment regret 15 years after receiving their diagnosis.

Some 14.6% of the overall cohort expressed regret over their treatment decision, the investigators report.

The likelihood that a man would regret his treatment decision was lowest, at 8.2%, for those who underwent conservative treatment; it was 15% for those who underwent radical prostatectomy. The highest rate, at 16.6%, was seen among men who received radiotherapy.

"The amount of reported urinary or sexual bother did not vary significantly by initial treatment," the researchers note. More men, at 39%, expressed "moderate" or "big" bother with sexual dysfunction compared with only 16.6% for urinary dysfunction.

The authors note that the men in their study might have been expecting changes in urinary function as they aged and so did not report that they were bothered by these changes or associate them with treatment regret.

The two quality-of-life symptoms most often associated with treatment regret were sexual and bowel symptoms, the researchers note.

In addition, "the extent to which a man is preoccupied with PSA [prostate-specific antigen] as an indicator of disease is still associated with feelings of regret, independently of other measures of cancer control," investigators note.

As Dr Hoffman explained, men who expressed anxiety about their PSA levels are still worried about their cancer, regardless of their treatment selection.

Men who had undergone surgery were the least likely of the three treatment groups to report they were concerned about either PSA levels or bowel function.

The study authors also note that men who were older at the time of diagnosis were less likely than younger men to express regret over their treatment decision.

Decision-Making Process

Being poorly informed in the decision-making process was the most prominent reason why men expressed regret over their treatment decision.

Thus, as the authors suggest, making sure patients understand the risks and the benefits of each treatment option so they can choose the best option for themselves may help minimize regret later on.

"In the short-term — as we've previously reported — surgical patients are indeed more likely to have [sexual and urinary] problems," Dr Hoffman noted.

In a previous report, PCOS authors found that all functional outcomes declined during early, intermediate, and long-term follow-up of men who underwent either prostatectomy or radiotherapy for localized prostate cancer, but at 15 years, functional profiles of both groups were similar.

"The striking finding in this study was that regret was higher among those undergoing active treatment vs conservative management," he added.

"And men who had urinary and sexual dysfunction, which is related to active treatment, were more likely to express regret," Dr Hoffman concluded.

Urgent Rush

Asked by Medscape Medical News to comment on the study, Narek Shaverdian, MD, chief resident in radiation oncology, University of California, Los Angeles, noted that when a patient is first diagnosed with cancer, there is always a sense of urgency to begin treatment ― both from the patient's perspective and on the physician's side.

"Treatments are very complicated — surgical treatments are complicated, radiation treatments are complicated — so a patient can't do one-stop shopping and get all the answers about radiation from a surgeon, and he can't get answers about surgery from a radiation oncologist," Dr Shaverdian said.

Dr Shaverdian also noted that some of his own research suggests that, for example, patients who receive their knowledge about radiation from a urologist don't get all of the details they need to make an informed decision about which option would be best for them.

"This study showed that regardless of a patient being cancer free or not, lack of informed decision making was associated with treatment regret," Dr Shaverdian said.

This should be a call to both patients and providers to say that there is no need to rush into treatment. Dr Narek Shaverdian

"So this should be a call to both patients and providers to say that there is no need to rush into treatment, but rather a need for patients to discuss treatment with multiple providers. There is no substitute to patients sitting down with their physician and having a detailed discussion," he added.

Studies have linked treatment regret, especially from patients with prostate cancer, to the patient's having experienced poor quality of life across multiple domains after undergoing treatment, so treatment regret is a very important outcome in this setting, Dr Shaverdian observed.

The study was supported by grants from the National Cancer Institute and the Holden Comprehensive Cancer Center. Neither Dr Hoffman nor Dr Shaverdian have disclosed any relevant financial relationships.

J Clin Oncol. Published online May 11, 2017. Abstract

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