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Patient Goals Should Figure Prominently in Tx Discussions


Wanted: Physicians who will interact with patients the way a good financial counselor would.

A recent study of men with early-stage prostate cancer found no difference in 10-year death rates, regardless of whether their doctors actively monitored the cancers for signs of growth or eradicated the men's cancers with surgery or radiation.

What does this study mean for patients? Based on research we have conducted on prostate cancer decision-making, the implications are clear: Patients need to find physicians who will interact with them the way a good financial counselor would, taking the time to understand them well enough to help them find the treatment that fits their goals.

Imagine a couple in their 40s who ask a financial counselor for advice on retirement planning, and the counselor tells them how much to invest in domestic and foreign stocks versus bonds versus real estate without asking them about their goals. A good counselor would find out what ages the couple wishes to retire at, what kind of retirement income they hope to live off of, how much risk they are willing to take to achieve their goals, and how devastated they would be if their high-return investments go south, forcing them to delay retirement or reduce their retirement spending.

Far too often in medical care, physicians don't behave like good financial counselors-they give treatment recommendations without taking the time to understand their patients' goals. Consider early-stage prostate cancer, a typically slow-growing tumor that is not fatal for the vast majority of patients who receive the diagnosis. In some men, the tumor lies indolent for decades.

For that reason, men sometimes choose to monitor their cancers-have their doctors conduct regular blood tests or biopsies to see if the tumor is beginning to spread. Such monitoring has the advantage of being relatively noninvasive, but it can create anxiety for patients who wonder, every 6 months, whether their next checkup will bring bad news.

For that reason, some men prefer active treatments like surgery or radiation that eradicate their cancers and therefore reduce cancer-related anxiety. But these more active treatments have their own downsides-each treatment is relatively arduous, and they can cause both erectile dysfunction and urinary incontinence.

The choice between active treatment and active monitoring depends on a patient's goals-on how they view the trade-off between outcomes like cancer-related anxiety and erectile dysfunction. When counseling patients with early-stage prostate cancer, physicians need to help patients focus on these trade-offs.

Unfortunately, in our study of more than 200 prostate cancer patients, the vast majority received treatment recommendations from their physicians with little or no discussion of their treatment goals. In fact, before patients met with their physicians, we asked each of them several questions about the importance of sex in their lives. (The study was led by Angie Fagerlin of the University of Utah; the first author was Karen Scherr, a medical student at Duke, where I work; and we were joined by a wonderful team of collaborators.) All else equal, a man who places significant importance on maintaining normal sexual function should be more likely to forego treatments like surgery and radiation that can cause erectile dysfunction. But in our study, the importance of sexuality in men’s lives had no connection to which treatment they received.

Instead, physicians gave patients treatment recommendations based on their age and on how their tumor looked under a microscope, guiding patients toward what they thought the best treatment would be given these medical facts. With the best of intentions, they would urge younger men with slightly more aggressive tumors to receive surgery or radiation, without exploring the impact that erectile or bladder problems would have on their quality of life. Most of the patients in our study followed these recommendations dutifully, figuring physicians knew what was best for them.

Which brings us back to financial planning. One of the men in our study was 62 years old, and his surgeon told him that monitoring the cancer was not an option given his relative youth. The patient pushed back, explaining he was retiring in 3 years and could not afford to miss work in the meantime, as would be necessary if he received surgery or radiation. After some back-and-forth, his physician relented. It is impossible to know how many patients had similar reservations about what their physician recommended but were not comfortable pushing back.

Patients with early-stage prostate cancer-or any kind of illness where "one treatment doesn't fit all"-should not have to push back when they receive medical recommendations. Instead, patients should make sure physicians understand their goals well enough to help them make the right choices.

Peter Ubel is a physician and behavioral scientist who blogs at his self-titled site, Peter Ubel; he can be reached on Twitter @PeterUbel. He is the author of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together. This article originally appeared in Forbes, and also appeared on KevinMD.com.

This article was first published on MedPage Today and reprinted with permission from UBM Medica. Free registration is required.

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