Session number: 1120
Abstract title: Treatment Decision Intervention for Veterans with Prostate Cancer
Author(s):
CL Bennett - The Chicago VA Healthcare System and the Mid-West Center for Health Services and Policy Research
AL Siston - Northwestern University Medical School Department of Psychiatry and Behaovrial Studies
MS Wolf - Institute of Health Services Research and Development, Northwestern University, Chicago, IL
DP Nathan - The Chicago VA Healthcare System and the Mid-West Center for Health Services and Policy Research
Objectives: The purpose of this pilot study is to evaluate the feasibility of a shared decision making approach to prostate cancer among Veterans. Information on patient utilities, clinical characteristics, and therapeutic outcome probabilities is incorporated into a decision analytic model that produces quality adjusted life year estimates for surgery, watchful waiting, and radiation therapy.
Methods: Medical record data were obtained on patient comorbidities, histologic grade of the biopsy, and age, for Veterans with newly diagnosed localized prostate cancer at the Chicago Lakeside VA. Using a time-trade off technique interviewers obtained patient utilities for 5 health states. Before the first patient-physician discussion, expected quality adjusted life years for each treatment option were communicated to the treating physician.
Results: Six patients rated the five health states as 1.0 and 4 patients had inconsistent ratings between development of sexual and bladder dysfunction and sexual or bladder dysfunction alone. For patients < 70 years (n= 6), there was concordance between the model and physician recommendation for 5 patients. In the single discrepancy, the doctor’s decision to pursue surgery over the model’s recommendation of watchful waiting appears to be based on his concern that younger men with early stage cancers undergo potentially curative surgery. For patients > 70 years (n =6), the model’s recommendations coincided with those of the physician in 2 patients. In the 4 discordant cases, the treatment selected by the model was radiation therapy versus the physician’s choice of watchful waiting. In each instance, the physician’s decision appeared to be influenced by older age and patient psychosocial concerns.
Conclusions: This study was faced with three methodologic concerns: 1) 10 of 12 Veterans responded to the utility exercise in a manner not predicted by the literature; 2) the model appears to favor radiation therapy as a treatment for older patients; and 3) in one case, treating physician support for surgery was very strong, and appeared to be unaffected by patient preference.
Impact statement: This decision analytic model may improve shared decision making between physicians and patients in patients who are < 70 years of age and who prefer no treatment. The study is ongoing, but modifications are being implemented.