Study results point to a need for shared decision-making in prostate cancer

In this interview, Angela Fagerlin, PhD, discusses some of the key findings and takeaways from the recent study, “Two specialists, two recommendations: discordance between urologists’& radiation oncologists’ prostate cancer treatment recommendations,” highlighting the need for increased shared decision-making based on the data. Fagerlin is the Chair of the Department of Population Health Sciences at the University of Utah School of Medicine, Salt Lake City.

Video Transcript:

First Slide:

What we found is that when a urologist and a radiation oncologist saw the same exact patients —this is a real patient in the clinic, just like in the studies—urologists were more likely to recommend surgery and radiation oncologists were more likely to recommend radiation. To put some numbers behind that, urologists recommended surgery for 79% of the patients that they saw. Interestingly, radiation oncologists recommended surgery for 57% of the patients, so there was about a 25% difference.

Similarly, radiation oncologists recommended radiation 68% of the time, but a little bit differently, surgeons only recommended radiation therapy about a third of the time. So, they did still recommend each other specialty on occasion, but by far were more likely to recommend their own type of treatment than the others.

Physicians—either type—can recommend surgery, radiation, or active surveillance. We looked to see how often they agreed in their recommendation of 1, 2, or 3 of these. We found that very rarely did they actually agree on the recommendation in terms of how many they recommended. In fact, I think only about a third of the patients did they completely agree on the recommendations that they made.

We're a little surprised that number was so low. We thought that there would be more concordance, especially because most of these patients were early-stage prostate cancer where likely, surgery, radiation, and active surveillance would have been an appropriate treatment for most of the patients. We were just surprised that there wasn't that much agreement between the radiation oncologists and the urologists.

Second Slide:

I would just ask that urologists really think about their biases. It's been interesting. In a number of cases, we've seen urologists say, "Hey, I'm biased. I'm a surgeon. I was taught that this is a great method. You need to go talk to my colleagues who are radiation oncologists, just so that you can balance this out." We actually showed in a study in the Proceedings of the National Academy of Science that when the physician said that, the patients actually trusted them more, because they acknowledged that they have this potential bias.

We're all human, including urologists and radiation oncologists, so we need to be aware of those biases and be honest about it. Though, that often made people trust the urologist so much that they didn't go to see the radiation oncologist, so that might be not exactly what we're hoping for. It really suggests that before you make these recommendations—because of this underlying potential for bias—it’s important to ask the patient questions that get at what they want. In a lot of our recordings, we heard "so you know, I really think that this treatment would be best. What do you think? That sounds good? Patient: 'Yes.’ "

There hadn't been talk about [things like] how much [they are] sexually active. Different treatments have a very big difference in impact on erectile dysfunction. People who are not planning to have sex, they're 75 and they're widowed, or they're no longer having a lot of sex with their partner, that might not be a condition. But a newly married 65-year-old with an active sex life, that might be a real factor in their decision-making. What we've seen from tapes from this study and others is that there aren't a lot of questions about how important these are or how much it would stress them out to do active surveillance and have to worry about the cancer growing. There isn't a lot of this in-depth discussion.

It's more like a data dump: "Hey, here are the treatments, either of the 3 treatments. These are the risks and the benefits." They do a phenomenal job, the radiation oncologists and urologists, of telling you all the risks and benefits and providing all this information. Where we really need to see change is talking about what the patient wants, what they're worried about, and what would work best for them. Do they have a job where they can go to the bathroom frequently if they're having incontinence issues? Or are they a truck driver, where it's really hard to go to the bathroom? Asking these questions and involving the patient is what I would ask urologists to try to incorporate a little bit more in their practice.

This transcript has been edited for clarity.