Medical Technology

The Hidden Cost of Prostatectomy: Patient regret

Men with localized prostate cancer who opt for radical prostatectomy are more likely to regret their decision than those who opt for radiotherapy or active surveillance, according to a survey study of 2072 patients.

At 5 years, 13% of men surveyed experienced treatment-related regret, which varied by treatment type — 16% (183) of surgery patients regretted their decision vs 11% (76) of men who opted for radiotherapy and 7% (20) who chose active surveillance.

The main driver of regret was a sense of not being fully informed of the risks and benefits of the three options and the risks of surgery, in particular.

“A disconnect between patient expectations and treatment outcomes, in relation to both treatment efficacy and toxicity, contributes more substantially to treatment-related regret than patient-reported functional outcomes,” which includes erectile dysfunction, urinary incontinence, and bowel dysfunction, according to the authors, led by Christopher Wallis, MD, PhD, a urologic oncologist at Mount Sinai Hospital in Toronto, Canada.

The study appeared online on November 18 in JAMA Oncology.

In an accompanying editorial, Randy Jones, PhD, RN, a nursing professor at the University of Virginia, Charlottesville, said the study makes a strong case for the role of in-depth counselling and shared decision-making.

Considering “the potential to enhance quality of life and decrease decisional regret, it is well worth the time for clinicians to assess and address patients’ treatment concerns,” he wrote.

Although not used often in routine practice, Jones noted that interactive decision aids can help. These tools “provide the space for patients, caregivers, and clinicians to discuss the major concerns of the patient, assess and work through any challenges patients and caregivers may have regarding treatment options, provide clear information about the treatment options, and help the patient make the best decision for himself,” Jones wrote.

Study Details

Men surveyed in the analysis were diagnosed with low-risk prostate cancer between January 2011 and December 2012 at several centers in the US.

The study participants were members of the Comparative Effectiveness Analysis of Surgery and Radiation (CEASAR) cohort, launched a decade ago primarily to compare the effectiveness of surgery and radiation.

Median age at diagnosis was 64 years. Radiotherapy patients (32%) were older with more comorbidities and slightly higher-risk disease than surgery patients (55%). Men opting for active surveillance (13%) were typically older than those undergoing surgery but younger than the radiotherapy group, and more likely to have low-risk disease.

The authors gauged patient regret using a validated questionnaire, with statements including “I would [have been] better off with a different treatment,” “I feel the treatment was the wrong one,” “I would choose another treatment if I could,” and “I wish I could change my mind about the treatment I chose.”

The men were surveyed 6 months after diagnosis and then again at 1, 3, and 5 years. At 5 years, the response rate was 71%.

Adjusting for baseline differences, men who had surgery were more than twice as likely to regret their decision at 5 years than men who opted for active surveillance. Men who chose radiotherapy were about 50% more likely to experience regret, although this finding was not statistically significant.

Not surprisingly, regret was far more common among men who judged their treatment to be much less effective than anticipated and their adverse events to be much more severe.

Interestingly, participatory decision-making and social support appeared to protect against regret, as did older age.

The authors noted that many low-risk men in the study who underwent surgery or radiation would likely be counseled toward surveillance today, given National Comprehensive Cancer Network recommendations.

Even so, the findings can inform practice now. “Improved counseling at the time of diagnosis and before treatment, including identification of patient values and priorities, may decrease regret among these patients,” the authors concluded.

The study was funded by the Agency for Healthcare Research and Quality. Several investigators reported industry ties, including Wallis, who disclosed receiving personal fees from Janssen Canada. Jones did not report any disclosures.

JAMA Oncol. Published online November 18, 2021. Abstract, Editorial

M. Alexander Otto is a physician assistant with a master’s degree in medical science and an award-winning medical journalist who has worked for several major news outlets before joining Medscape. He is an MIT Knight Science Journalism fellow. Email: [email protected].

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