Shared Decision-Making: A Critical Adjunct to Prostate Cancer Care
As a urologist specializing in prostate cancer, Elias S. Hyams, MD, helps navigate the diversity of perspectives that confound physicians and patients alike in making decisions on screening, diagnosis, and treatment.
“There’s a lot of confusion among referring physicians, primary care doctors, and certainly among lay people about prostate cancer,” says Dr. Hyams, a member of the Department of Urology at NewYork-Presbyterian/Columbia University Irving Medical Center. “A cancer diagnosis can trigger a strong emotional reaction, but it’s critical to convey that many prostate cancers are slow growing and incidental to the aging process. Conversely, a subset can metastasize or cause death, and should be diagnosed early to prevent harm. It’s our job to diagnose the latter at an early point, while avoiding “over-diagnosis” of the former. Also, men frequently have concerns about adverse urinary and sexual side effects of treatment, and can have difficulty weighing the pros and cons of different treatment approaches. My goal has been to understand the process of a patient’s decision-making in both diagnostic and treatment settings, and how I can help them make decisions that they will be content with in the long-term, and will enable them to have the best level of health.”
With this in mind, Dr. Hyams has embraced the shared decision-making model, which involves engaging with the patient, ensuring that they review and comprehend the proper educational materials and decision aids, and correct any misconceptions they have about prostate cancer. “I spend a lot of time counseling men about prostate cancer, from initial screening and other early assessments, through decisions about whether to proceed with a biopsy and treatment,” says Dr. Hyams, whose clinical expertise in risk-based screening for prostate cancer, advanced diagnosis techniques such as image-guided biopsy, and minimally invasive surgery, including robotic prostatectomies, for prostate cancer, guides the dialogue with his patients. “If they would like to undergo treatment, I shepherd them through the process of understanding the various options, from observation to more involved therapies and interventions.”
What Influences a Patient’s Decision-Making?
Dr. Hyams is interested in understanding what level of concern and risk on average motivates men to proceed with biopsies and invasive procedures. He is also studying how men process probabilities and statistical information presented in educational materials, and how that affects the decision-making process as it relates to prostate cancer screening and treatment.
In 2017, while on the faculty of Dartmouth Hitchcock Medical Center, Dr. Hyams and his colleagues there assessed the impact of patients’ numeracy (understanding of statistical concepts) on their understanding of the risk reduction benefits of PSA screening. They found that of the 200 men completing a survey, 56 percent answered at least one of the three numeracy questions incorrectly, and the accuracy of perceived risk reduction of prostate cancer mortality was poor at 20 percent overall. The authors concluded that “how risk data are presented to patients can have a profound effect on their ability to interpret and apply the data accurately,” and suggest that “alternative methods of communicating concepts of risk to patients, particularly among those with lower numeracy and literacy, may facilitate shared decision-making in the early detection of prostate cancer.”
“My goal has been to understand the process of a patient’s decision-making and how I can help them make decisions that they will be happier with over the long-term, and that will enable them to have the best level of health.”
— Dr. Elias S. Hyams
“Many decision aids focus on statistical information, and I’m very skeptical about the utility of that,” notes Dr. Hyams. “When we share information with men saying, ‘you have a 20 percent lower risk of dying from prostate cancer in this scenario,’ what does that mean to them? Can he interpret the statistic to potentially help make a decision about whether to be screened? I think we need to walk patients through what the statistics really mean, so that they don’t inflate either the risks or benefits of the options available to them.”
One such issue is the ongoing confusion surrounding PSA screening. Working around the limitations and drawbacks of the test, such as false-positive and false-negative results, discomfort or pain, and over-diagnosis or overtreatment, is where Dr. Hyams’ shared decision-making process becomes so relevant. “The challenge of screening is to identify potentially dangerous cancers during a window of curability and avoid detecting low-risk cancers not destined to cause harm,” says Dr. Hyams. “It’s important to have a discussion about risks and benefits of screening and to individualize that discussion based on age, family history, ethnicity, and other factors that can affect risk. This is a much more reasonable approach.”
In the past, notes Dr. Hyams, men went directly from a PSA screening to a biopsy. Today, Dr. Hyams and his colleagues use an approach called “risk-based” screening, using the PSA as a starting point in appropriate men to understand their risk, followed by a deeper discussion about options available for clarifying risk. “Today, there are potentially many intervening steps, such as novel blood and urine tests, and imaging studies that allow patients to avoid the discomforts and risks of a biopsy. But prostate cancer can be a morbid and lethal process. It kills many men, and can be very disabling when it’s metastatic or advanced. We now have the tools to allow us to hone in on the men who are at greatest risk and treat them accordingly.”
Internet-based sources and consumer advertising are also obscuring the risk versus benefit messaging for men with regard to treatment options, and Dr. Hyams and his colleagues are looking at this as well. The results of a comprehensive search by Dr. Hyams and his Columbia urology faculty colleagues of the Internet for information regarding “ablative” therapies for prostate cancer revealed substantial inaccurate and incomplete information from both academic and private practice websites.
In a study related to the influence of advertising for treatment with stereotactic body radiation therapy (SBRT), the researchers randomly assigned 400 men, aged 40-80, to one of four arms of an online survey they created: 1) an SBRT (“Cyberknife”) advertisement, 2) the same advertisement with disclaimers, 3) scientific information obtained from peer-reviewed literature, and 4) an unrelated control ad. Subjects answered questions regarding risks/benefits of Cyberknife and the likelihood of pursuing this versus other prostate cancer treatments.
“We hypothesized that those viewing an advertisement for Cyberknife versus factual information would have inaccurate impressions of effectiveness and safety,” says Dr. Hyams. “We found that respondents who viewed scientific information were less likely to agree Cyberknife is superior regarding impotence and urinary dysfunction, and those who viewed the advertisement and the advertisement with disclaimer were more likely to consider Cyberknife superior. The reality is much more muddled because patients’ disease risk and susceptibility to side effects vary greatly, and there is limited comparative evidence between SBRT and other therapies.”
“Because men are presented with a deluge of options and mixed messages, we ensure that our patients are fully counseled, have access to multidisciplinary care, and can reach the decision that is best for them, whether it be treatment versus observation, one type of therapy or another, or to do further testing following an initial PSA,” adds Dr. Hyams. “I think all of those decision points are very important, and it is our job to guide men through the process with evidence and an individualized understanding of their priorities.”
Caputo JM, Lee HJ, Chiles B, Hyams ES. Exposure to direct-to-consumer advertising is associated with overestimation of benefits regarding ultrahypofractionated radiation therapy for prostate cancer. Prostate Cancer and Prostatic Diseases. 2020 May 4. [Online ahead of print]
Asafu-Adjei D, Mikkilineni N, Sebesta E, Hyams E. Misinformation on the Internet regarding ablative therapies for prostate cancer. Urology. 2019 Nov;133:182-86.
Koo K, Hyams ES. Assessment of men’s risk thresholds to proceed with prostate biopsy for the early detection of prostate cancer. International Urology and Nephrology. 2019 Aug;51(8):1297-1302.
Koo K, Brackett CD, Eisenberg EH, Kieffer KA, Hyams ES. Impact of numeracy on understanding of prostate cancer risk reduction in PSA screening. PLoS One. 2017 Dec 28;12(12):e0190357.