Physicians report difficulty convincing patients with prostate cancer about the merits
of active surveillance (AS); as a result, a majority of patients unnecessarily choose
to undergo radical treatment.
To develop and evaluate a systematic approach for physicians to counsel patients with
low-risk prostate cancer to increase acceptance of AS.
Design, setting, and participants
A systematic counseling approach was developed and piloted in one clinic. Then five
surgeons participated in a 1-h training session in which they learned about the approach.
A total of 1003 patients with Gleason 3 + 3 prostate cancer were included in the study. We compared AS rates for 761 patients
who were counseled over a 24-mo period before the training intervention with AS rates
for 242 patients who were counseled over a 12-mo period afterwards, controlling for
temporal trends and case mix.
A systematic approach for communicating the merits of AS using appropriate framing
techniques derived from principles studied by negotiation scholars.
Outcome measurements and statistical analysis
The rate of AS acceptance by patients for management of low-risk prostate cancer.
Results and limitations
In the pilot phase, 81 of 86 patients ( 94%) accepted AS after counseling by the physician who developed the counseling approach.
In the subsequent study, the cohort for the training intervention comprised 1003 consecutive
patients, 80% of whom met the Epstein criteria for very low-risk disease. The proportion
of patients who selected AS increased from 69% before the training intervention to
81% afterwards. After adjusting for time trends and case mix, the rate of AS after
the intervention was 9.1% higher (95% confidence interval −0.4% to 19.4%) than expected,
a relative reduction of approximately 30% in the risk of unnecessary curative treatment.
A systematic approach to counseling can be taught to physicians in a 1-h lecture.
We found evidence that even this minimal intervention can decrease overtreatment.
Our novel approach offers a framework to help address cancer screening–related overtreatment
that occurs across medicine.
In this study, we evaluated the impact of teaching physicians how to better communicate
the benefits and risks of prostate cancer treatments on the willingness of patients
to choose active surveillance. Decisions related to cancer are often guided by emotions
and biases that lead most patients to seek radical treatment; however, we demonstrated
that if discussions are framed differently, these biases can be overcome and more
patients will choose active surveillance.