Decision regret in men living with and beyond nonmetastatic prostate cancer in the United Kingdom: A population-based patient-reported outcome study

Influential Factors Impacting Treatment Decision-making and Decision Regret in Patients with Localized or Locally Advanced Prostate Cancer: A Systematic Literature Review

CONTEXT

Treatment decision-making (TDM) for patients with localized (LPC) or locally advanced (LAPC) prostate cancer is complex, and post-treatment decision regret (DR) is common. The factors driving TDM or predicting DR remain understudied.

OBJECTIVE

Two systematic literature reviews were conducted to explore the factors associated with TDM and DR.

EVIDENCE ACQUISITION

Three online databases, select congress proceedings, and gray literature were searched (September 2022). Publications on TDM and DR in LPC/LAPC were prioritized based on the following: 2012 onward, ≥100 patients, journal article, and quantitative data. The Preferred Reporting Items Reviews and Meta-analyses guidelines were followed. Influential factors were those with p < 0.05; for TDM, factors described as "a decision driver", "associated", "influential", or "significant" were also included. The key factors were determined by number of studies, consistency of evidence, and study quality.

EVIDENCE SYNTHESIS

Seventy-five publications (68 studies) reported TDM. Patient participation in TDM was reported in 34 publications; overall, patients preferred an active/shared role. Of 39 influential TDM factors, age, ethnicity, external factors (physician recommendation most common), and treatment characteristics/toxicity were key. Forty-nine publications reported DR. The proportion of patients experiencing DR varied by treatment type: 7-43% (active surveillance), 12-57% (radical prostatectomy), 1-49% (radiotherapy), 28-49% (androgen-deprivation therapy), and 21-47% (combination therapy). Of 42 significant DR factors, treatment toxicity (sexual/urinary/bowel dysfunction), patient role in TDM, and treatment type were key.

CONCLUSIONS

The key factors impacting TDM were physician recommendation, age, ethnicity, and treatment characteristics. Treatment toxicity and TDM approach were the key factors influencing DR. To help patients navigate factors influencing TDM and to limit DR, a shared, consensual TDM approach between patients, caregivers, and physicians is needed.

PATIENT SUMMARY

We looked at factors influencing treatment decision-making (TDM) and decision regret (DR) in patients with localized or locally advanced prostate cancer. The key factors influencing TDM were doctor's recommendation, patient age/ethnicity, and treatment side effects. A shared, consensual TDM approach between patients and doctors was found to limit DR.

Patient engagement in designing and publishing research in prostate cancer: a scoping review

Patients with cancer have the unique ability of being able to offer valuable insights into how cancer therapeutics may impact the overall patient experience and improve clinical outcomes. Patient engagement could therefore contribute to tailoring treatment strategies and research design according to patient needs. This study evaluated patient engagement in prostate cancer research by identifying patient input in the prostate cancer literature. We performed a keyword cluster analysis of articles from multiple databases and congresses in which patients provided input on disease management or were involved in study design, manuscript authorship or presentation of results (patient voice). In total, 112 studies were included. Patients were involved in the design of 11 studies and were credited as authors in four studies. This review suggests a lack of meaningful patient involvement in prostate cancer research and publications.

Novel two-tiered screening approach identifies synergistic combinations of natural compounds for prostate cancer prevention and treatment

Prostate cancer (PCa) is the second most common cancer type among American men and it is estimated that in 2023, 34,700 men will die from PCa. Since it can take a considerable amount of time for the disease to progress to clinically evident cancer, there is ample opportunity for effective chemopreventive strategies to be applied for the successful management of PCa progression. In the current study, we have developed a two-tiered metabolomics-based screen to identify synergistic combinations of phytochemicals for PCa chemoprevention. This involves an initial screen for ATP depletion in PCa cells followed by a targeted screen for blocking glutamine uptake in the same cells. One of the phytochemical combinations (enoxolone [ENO] + silibinin [SIL]), identified via this screen, was examined for effects on PCa cell survival, oncogenic signaling and tumor growth in vivo. This combination was found to synergistically reduce cell survival, colony formation and cell cycle progression of PCa cell lines to a greater extent than either agent alone. The combination of ENO and SIL also synergistically reduced tumor growth when administered ad libitum through the diet in a HMVP2 allograft PCa tumor model. Treatment with the combination also significantly reduced STAT3 and mTORC1 signaling pathways in mouse and human PCa cells while significantly reducing levels of critical cell cycle regulatory proteins, contributing to the synergistic inhibition of tumor growth observed. Collectively, the current results demonstrate a novel approach to identifying synergistic combinations of phytochemicals for chemoprevention of PCa and possibly other cancers.

Decision regret of cancer patients after radiotherapy: results from a cross-sectional observational study at a large tertiary cancer center in Germany

PURPOSE

The decision-making process regarding cancer treatment is emotionally challenging for patients and families, harboring the risk of decision regret. We aimed to explore prevalence and determinants of decision regret following radiotherapy.

METHODS

This cross-sectional observational study was conducted at a tertiary cancer center to assess decision regret following radiotherapy. The study employed the German version of the Ottawa Decision Regret Scale (DRS) which was validated in the study population. Decision regret was categorized as absent (0 points), mild (1-25 points), and strong (> 25 points). Various psychosocial outcome measures were collected using validated questionnaires to identify factors that may be associated with decision regret.

RESULTS

Out of 320 eligible patients, 212 participated, with 207 completing the DRS. Median age at start of radiotherapy was 64 years [interquartile range (IQR), 56-72], genders were balanced (105 female, 102 male), and the most common cancer types were breast (n = 84; 41%), prostate (n = 57; 28%), and head-and-neck cancer (n = 19; 9%). Radiotherapy was applied with curative intention in 188 patients (91%). Median time between last radiotherapy fraction and questionnaire completion was 23 months (IQR, 1-38). DRS comprehensibility was rated as good or very good by 98% (196 of 201) of patients. Decision regret was reported by 43% (n = 90) as absent, 38% (n = 78) as mild, and 18% (n = 38) as strong. In the multiple regression analysis, poor Eastern Cooperative Oncology Group performance status, low social support, and dissatisfaction with care were independent risk factors for higher decision regret after radiotherapy.

CONCLUSIONS

The German version of the DRS could be used to assess decision regret in a diverse cohort of cancer patients undergoing radiotherapy. Decision regret was prevalent in a considerable proportion of patients. Further studies are necessary to validate these findings and obtain causal factors associated with decision regret after radiotherapy.

What can patient-reported experience measures tell us about the variation in patients' experience of prostate cancer care? A cross-sectional study using survey data from the National Prostate Cancer Audit in England

OBJECTIVES

A national survey aimed to measure how men with prostate cancer perceived their involvement in and decisions around their care immediately after diagnosis. This study aimed to describe any differences found by socio-demographic groups.

DESIGN

Cross-sectional study of men who were diagnosed with and treated for prostate cancer.

SETTING

The National Prostate Cancer Audit patient-reported experience measures (PREMs) survey in England.

PARTICIPANTS

Men diagnosed in 2014-2016, with non-metastatic prostate cancer, were surveyed. Responses from 32 796 men were individually linked to records from a national clinical audit and to administrative hospital data. Age, ethnicity, deprivation and disease risk classification were used to explore variation in responses to selected questions.

PRIMARY AND SECONDARY OUTCOME MEASURES

Responses to five questions from the PREMs survey: the proportion responding to the highest positive category was compared across the socio-demographic characteristics above.

RESULTS

When adjusted for other factors, older men were less likely than men under the age of 60 to feel side effects had been explained in a way they could understand (men 80+: relative risk (RR)=0.92, 95% CI 0.84 to 1.00), that their views were considered (RR=0.79, 95% CI 0.73 to 0.87) or that they were involved in decisions (RR=0.92, 95% CI 0.85 to 1.00). The latter was also apparent for men who were not white (black men: RR=0.89, 95% CI 0.82 to 0.98; Asian men: RR=0.85, 95% CI 0.75 to 0.96) and, to a lesser extent, for more deprived men.

CONCLUSIONS

The observed discrepancies highlight the need for more focus on initiatives to improve the experience of ethnic minority patients and those older than 60 years. The findings also argue for further validation of discriminatory instruments to help cancer care providers fully understand the variation in the experience of their patients.

Friedelin, a novel inhibitor of CYP17A1 in prostate cancer from Cassia tora

In prostate cancer (PC), drugs targeting CYP17A1 have shown great success in regulating PC progression. However, successful drug molecules show adverse side effects and therapeutic resistance in PC. Therefore, we proposed to discover the potent phytochemical-based inhibitor against CYP17A1 using virtual screening. In this study, a phytochemicals library of ∼13800 molecules was selected to screen the best possible inhibitors against CYP17A1. A molecular modelling approach investigated detailed intermolecular interactions, their structural stability, and binding affinity. Further, in vitro and in vivo studies were performed to confirm the anticancer activity of identified potential inhibitor against CYP17A1. Friedelin from Cassia tora (CT) is identified as the best possible inhibitor from the screened library. MD simulation study reveals stable binding of Friedelin to conserved binding pocket of CYP17A1 with higher binding affinity than studied control, that is, Orteronel. Friedelin was tested on hormone-sensitive (22Rv1) and insensitive (DU145) cell lines and the IC50 value was found to be 72.025 and 81.766 µg/ml, respectively. CT extract showed a 25.28% IC50 value against 22Rv1, ∼92.6% increase in late Apoptosis/Necrosis, and three folds decrease in early apoptosis in treated cells compared to untreated cells. Further, animal studies show a marked decrease in prostate weight by 39.6% and prostate index by 36.5%, along with a reduction in serum PSA level by 71.7% and testosterone level by 92.4% compared to the testosterone group, which was further validated with histopathological studies. Thus, we propose Friedelin and CT extract as potential leads, which could be taken further for drug development in PC.[Figure: see text]Communicated by Ramaswamy H. Sarma.

Decision Regret in Patients with Localised Prostate Cancer: A Systematic Review and Meta-analysis

CONTEXT

Treatment choice for localised prostate cancer remains a significant challenge for patients and clinicians, with uncertainty over decisions potentially leading to conflict and regret. There is a need to further understand the prevalence and prognostic factors of decision regret to improve patient quality of life.

OBJECTIVE

To generate the best estimates for the prevalence of significant decision regret localised prostate cancer patients, and to investigate prognostic patient, oncological, and treatment factors associated with regret.

EVIDENCE ACQUISITION

We performed a systematic search of MEDLINE, Embase, and PsychINFO databases including studies evaluating the prevalence or patient, treatment, or oncological prognostic factors in localised prostate cancer patients. A pooled prevalence of significant regret was calculated with the formal prognostic factor evaluation conducted per factor identified.

EVIDENCE SYNTHESIS

Significant decision regret was present in a pooled 20% (95% confidence interval 16-23) of patients across 14 studies and 17883 patients. This was lower in active surveillance (13%), with little difference between those who underwent radiotherapy (19%) and those who underwent prostatectomy (18%). Evaluation of individual prognostic factors demonstrated higher regret in those with poorer post-treatment bowel, sexual, and urinary function; decreased involvement in the decision-making process; and Black ethnicity. However, evidence remains conflicting, with low or moderate certainty of findings.

CONCLUSIONS

A significant proportion of men experience decision regret after a localised prostate cancer diagnosis. Monitoring those with increased functional symptoms and improving patient involvement in the decision-making process through education and decision aids may reduce regret.

PATIENT SUMMARY

We looked at how common regret in treatment decisions is after treatment for early-stage prostate cancer and factors linked with this. We found that one in five regret their decision, with those who had experienced side effects or were less involved in the decision-making process more likely to have regret. By addressing these, clinicians could reduce regret and improve quality of life.

Decision Regret and Bother With the Addition of Androgen Deprivation Therapy to Definitive Radiation Treatment for Localized Prostate Cancer

PURPOSE

Androgen deprivation therapy (ADT) combined with radiation treatment (RT) is recommended by the National Comprehensive Cancer Network guidelines for unfavorable intermediate and high-risk localized prostate cancer. Although there is a variable survival benefit conferred by ADT, there are potential side effects to consider for patient decision-making. We aimed to assess the side effects and bother of adding ADT to RT, the degree of regret, and what overall survival (OS) benefit men would want to justify adding or extending the duration of ADT, after their experience with this treatment.

METHODS AND MATERIALS

Men receiving ADT with definitive RT completed a questionnaire asking about the side effects and degree of bother from ADT using a 4-point scale. They were also asked about regret, and what survival benefit would warrant ADT.

RESULTS

In the study, 846 patients received definitive RT, of whom 356 received ADT and were asked about their experience with ADT. Of these, 234 responded (66%). In 54%, ADT caused some bother, most commonly hot flushes (32%), fatigue (29%), and sexual problems (29%). Five percent regretted receiving ADT "quite a lot" or "very much." Approximately one-third of men deemed a 1% OS benefit from ADT worthwhile, whereas one-third (34%) would want a >10% OS benefit enough to justify choosing ADT again. In addition, 49% of patients who received short-term ADT would accept longer duration ADT for a 6% OS benefit.

CONCLUSIONS

Significant regret for ADT was low (5%). There was a clear dichotomy between those who deemed any OS benefit from ADT worthwhile versus those who needed a significant survival benefit to justify the side effects. Given that some men may change their opinion on the relative value of ADT after experiencing its effects, this study emphasizes the importance of revisiting patients after 6 months to given patients an opportunity to renegotiate their treatment.

Prevalence and determinants of decision regret in long-term prostate cancer survivors following radical prostatectomy

BACKGROUND

Patients with localized prostate cancer (PC) are faced with a wide spectrum of therapeutic options at initial diagnosis. Following radical prostatectomy (RP), PC patients may experience regret regarding their initial choice of treatment, especially when oncological and functional outcomes are poor. Impacts of psychosocial factors on decision regret, especially after long-term follow-up, are not well understood. This study aimed to investigate the prevalence and determinants of decision regret in long-term PC survivors following RP.

METHODS

3408 PC survivors (mean age 78.8 years, SD = 6.5) from the multicenter German Familial PC Database returned questionnaires after an average of 16.5 (SD = 3.8) years following RP. The outcome of decision regret concerning the initial choice of RP was assessed with one item from the Decision Regret Scale. Health-related quality of life (HRQoL), PC-anxiety, PSA-anxiety, as well as anxiety and depressive symptoms were considered for independent association with decision regret via multivariable logistic regression.

RESULTS

10.9% (373/3408) of PC survivors reported decision regret. Organ-confined disease at RP (OR 1.39, 95%CI 1.02-1.91), biochemical recurrence (OR 1.34, 1.00-1.80), low HRQoL (OR 1.69,1.28-2.24), depressive symptoms (OR 2.32, 1.52-3.53), and prevalent PSA anxiety (OR 1.88,1.17-3.01) were significantly associated with increased risk of decision regret. Shared decision-making reduced the odds of decision regret by 40% (OR 0.59, 0.41-0.86).

CONCLUSIONS

PC survivors may experience decision regret even after 16 years following RP. Promoting shared decision-making in light of both established and novel, potentially less invasive treatments at initial diagnosis may help mitigate long-term regret. Awareness regarding patients showing depressive symptoms or PSA anxiety should be encouraged to identify patients at risk of decision regret in need of additional psychological support.

Temporal trends in cardiovascular burden among patients with prostate cancer receiving androgen deprivation therapy: a population-based cohort study

BACKGROUND

Although androgen deprivation therapy (ADT) is associated with cardiovascular risks, the extent and temporal trends of cardiovascular burden amongst patients with prostate cancer receiving ADT are unclear.

METHODS

This retrospective cohort study analyzed adults with PCa receiving ADT between 1993-2021 in Hong Kong, with follow-up until 31/9/2021 for the primary outcome of major adverse cardiovascular events (MACE; composite of cardiovascular mortality, myocardial infarction, stroke, and heart failure), and the secondary outcome of mortality. Patients were stratified into four groups by the year of ADT initiation for comparisons.

RESULTS

Altogether, 13,537 patients were included (mean age 75.5 ± 8.5 years old; mean follow-up 4.7 ± 4.3 years). More recent recipients of ADT had more cardiovascular risk factors and used more cardiovascular or antidiabetic medications. More recent recipients of ADT had higher risk of MACE (most recent (2015-2021) vs least recent (1993-2000) group: hazard ratio 1.33 [1.11, 1.59], P = 0.002; Ptrend < 0.001), but lower risk of mortality (hazard ratio 0.76 [0.70, 0.83], P < 0.001; Ptrend < 0.001). The 5-year risk of MACE and mortality for the most recent group were 22.5% [20.9%, 24.2%] and 52.9% [51.3%, 54.6%], respectively.

CONCLUSIONS

Cardiovascular risk factors were increasingly prevalent amongst patients with prostate cancer receiving ADT, with increasing risk of MACE despite decreasing mortality.

Trajectory of Depression among Prostate Cancer Patients: A Secondary Analysis of a Randomized Controlled Trial

Background: While psychological difficulties, such as depression, among prostate cancer patients are known, their longitudinal burden remains understudied. We assessed the burden of depression across low-, intermediate- and high-risk prostate cancer groups, and the association between regret and long-term depression. Methods: Secondary analysis of data from a multi-centered randomized controlled study among localized prostate cancer patients was carried out. Assessments were performed at baseline, and at 3-, 6-, 12- and 24-month follow-up. Depression was assessed using the Center for Epidemiologic Studies Depression (CES-D) scale. A CES-D score ≥ 16 indicates high depression. Regret was measured using the regret scale of the Memorial Anxiety Scale for Prostate Cancer (MAX-PC). The proportion of patients with high depression was compared over time, for each risk category. Logistic regression was used to assess the association between regret, and long-term depression after adjusting for age, race, insurance, smoking status, marital status, income, education, employment, treatment, number of people in the household and study site. Results: The study had 743 localized prostate cancer patients. Median depression scores at 6, 12 and 24 months were significantly larger than the baseline median score, overall and for the three prostate cancer risk groups. The proportion of participants with high depression increased over time for all risk groups. Higher regret at 24-month follow-up was significantly associated with high depression at 24-month follow-up, after adjusting for covariates. Conclusions: A substantial proportion of localized prostate cancer patients continued to experience long-term depression. Patient-centered survivorship care strategies can help reduce depression and regret, and improve outcomes in prostate cancer care.

Patient-Reported Outcomes 12 Years after Localized Prostate Cancer Treatment

Outcomes after Localized Prostate Cancer TreatmentDonovan et al. present the long-term patient-reported outcomes of 1643 randomly assigned participants in the ProtecT (Prostate Testing for Cancer and Treatment) trial. Functional and quality-of-life impacts of prostatectomy, radiotherapy with neoadjuvant androgen deprivation, and active monitoring are described. Over the trial period from 7 to 12 years, generic quality-of-life scores were similar among all groups, with varying degrees of impact on urinary leakage, sexual function, and fecal leakage depending on the treatment group.

Treatment decision regret in long-term survivors after radical prostatectomy: a longitudinal study

OBJECTIVES

To investigate prevalence, course, and predictors of longitudinal decision regret in long-term prostate cancer (PCa) survivors treated by radical prostatectomy (RP).

PATIENTS AND METHODS

A total of 1003 PCa survivors from the multicentre German Familial PCa Database completed questionnaires on average 7 years after RP in 2007 and at follow-up 13 years later in 2020. Patients completed standardised patient-reported outcome measures on decision regret, decision-making, health-related quality of life, and psychosocial factors. Hierarchical multivariable logistic regression was used to assess predictors of longitudinal decision regret.

RESULTS

Decision regret increased significantly over time (9.0% after 6.9 years in 2007 and 12% after 19 years in 2020; P = 0.009). Favourable localised PCa (odds ratio [OR] 1.97, 95% confidence interval [CI] 1.05-3.68), decision regret in 2007 (OR 6.38, 95% CI 3.55-11.47), and a higher depression score (OR 1.37, 95% CI 1.03-1.83) were associated with decision regret in 2020. Shared decision-making (OR 0.55, 95% CI 0.33-0.93) was associated with less decision regret.

CONCLUSION

The findings of the present study underline the perseverance of decision regret in long-term PCa survivors and the definitive need for involving patients in the decision-making process to mitigate regret over the long term.

Improving access to oncology publications for advocates and people with cancer

Journal articles provide reliable and current information about cancer research. This can offer hope to people with cancer and help them make decisions about their care. Here, the authors suggest ways in which different groups may help people with cancer to find, view, and understand articles. For example, journals should make articles free to view if they describe research that could change patient care. Also, clear titles and easy-to-follow summaries or videos may help people to find relevant articles and understand the main findings. It is important to explore ways to best share research with all those whose lives it may affect.

The use of the Decision Regret Scale in non-clinical contexts

The Decision Regret Scale (DRS) was assessed for its psychometric qualities in measuring decision regret in ordinary life scenarios. Although the scale has typically been used with patients and in the context of medical decision-making in earlier studies, this contribution shows that the instrument may have a variety of uses, retaining excellent metric properties even in non-medical contexts. The tool showed good fits with both the CFA and the gender Measurement Invariance. A non-probabilistic selection of 2,534 Italian university students was conducted. The internal consistency measures were found to be completely appropriate. Correlations with the General Decision-Making Style (GDMS) and Scale of Regulatory Modes were used to check for convergent validity (SRM). Convergence analysis showed that participants with higher regret scores were those who favored a rational decision-making style, while lower regret scores correlated with avoidant and spontaneous styles. With regard to the regulatory modes, the relationship between regret and locomotion was positive. Overall, the directions of association point to an interesting predictive measure of a person's decision-making and self-regulatory orientation through the evaluation of regret using the DRS. The excellent psychometric properties found foreshadow a reliable use in various contexts where knowledge of post-decisional attitude becomes important: school, university, professional orientation, marketing studies, relationship choices, as well as for use in research.

Attitudes of patients with cutaneous melanoma toward prognostic testing using the 31-gene expression profile test

OBJECTIVE

Although most patients diagnosed with early-stage cutaneous melanoma (CM) have excellent outcomes, because of the large number diagnosed each year, many will experience recurrence or death. Prognostic testing for CM using the 31-gene expression profile (31-GEP) test can benefit patients by helping guide risk-appropriate treatment and surveillance plans. We sought to evaluate patients' attitudes toward prognostic testing with the 31-GEP and assess whether patients experience decision regret about having 31-GEP testing.

METHODS

A 43-question survey was distributed by the Melanoma Research Foundation in June-August 2021 to CM patients enrolled in their database. Patients were asked questions regarding their decision to undergo 31-GEP testing and the extent to which they experienced decision regret using a validated set of Decision Regret Scale questions.

RESULTS

We analyzed responses from patients diagnosed in 2014 or later (n  = 120). Of these, 28 had received 31-GEP testing. Most respondents (n  = 108, 90%) desired prognostic information when diagnosed. Of those who received 31-GEP testing, most felt the results were useful (n  = 22 out of 24) and had regret scores significantly less than neutral regret, regardless of their test results (Class 1: p  < 0.001; Class 2: p  = 0.036). Further, decision regret scores were not significantly different between patients who received a Class 1 31-GEP result and those who received a Class 2 result (mean Class 1 = 1.39 and mean Class 2 = 1.90, p  = 0.058).

CONCLUSIONS

Most newly diagnosed CM patients desired prognostic information about their tumors. Patients who received 31-GEP testing felt it was useful and did not regret their decision to undergo 31-GEP testing.

Predictors of Decision Regret among Caregivers of Older Canadians Receiving Home Care: A Cross-Sectional Online Survey

Background. In Canada, caregivers of older adults receiving home care face difficult decisions that may lead to decision regret. We assessed difficult decisions and decision regret among caregivers of older adults receiving home care services and factors associated with decision regret. Methods. From March 13 to 30, 2020, at the outbreak of the COVID-19 pandemic, we conducted an online survey with caregivers of older adults receiving home care in the 10 Canadian provinces. We distributed a self-administered questionnaire through Canada’s largest and most representative private online panel. We identified types of difficult health-related decisions faced in the past year and their frequency and evaluated decision regret using the Decision Regret Scale (DRS), scored from 0 to 100. We performed descriptive statistics as well as bivariable and multivariable linear regression to identify factors predicting decision regret. Results. Among 932 participants, the mean age was 42.2 y (SD = 15.6 y), and 58.4% were male. The most frequently reported difficult decisions were regarding housing and safety (75.1%). The mean DRS score was 28.8/100 (SD = 8.6). Factors associated with less decision regret included higher caregiver age, involvement of other family members in the decision-making process, wanting to receive information about the options, and considering organizations interested in the decision topic and health care professionals as trustworthy sources of information (all P < 0.001). Factors associated with more decision regret included mismatch between the caregiver’s preferred option and the decision made, the involvement of spouses in the decision-making process, higher decisional conflict, and higher burden of care (all P < 0.001). Discussion. Decisions about housing and safety were the difficult decisions most frequently encountered by caregivers of older adults in this survey. Our results will inform future decision support interventions.

Late toxicity-related symptoms and fraction dose affect decision regret among patients receiving adjuvant radiotherapy for head and neck cancer

BACKGROUND

Decision regret reflects patient satisfaction with treatment choice and is associated with quality of life. This study aimed to identify patient, tumor, and treatment characteristics and post-treatment symptoms associated with decision regret among patients with head and neck cancer who underwent surgery and adjuvant radiotherapy.

METHODS

In this cross-sectional study, patients completed a questionnaire during a telephone interview. The questionnaire included the Decision Regret Scale (DRS) and several specific symptom-related items. By the time of data collection, all patients had concluded their radiotherapy a minimum of 2 months and maximum of 3.3 years prior.

RESULTS

Among the 108 patients included, 40.5% reported no regret, 30.1% reported mild regret, and 29.4% reported moderate to strong regret. A higher DRS score was most strongly associated with a lower single fraction dose and more restriction in everyday life. Higher DRS scores were also correlated with trouble speaking, trouble swallowing, pain in irradiated areas, dissatisfaction with one's appearance, feeling sad, and worry over one's future health.

CONCLUSIONS

Based on these findings, we recommended that patients with head and neck cancer undergoing adjuvant radiation receive psychosocial support and adequate treatment of late toxicity-related symptoms. When confronted with different therapeutic options, radiotherapy with a higher single fraction dose (i.e., hypofractionation) may be preferred due to its association with lower decision regret.

Molecular modelling studies and identification of novel phytochemical inhibitor of DLL3

Prostate cancer has been recently considered the most diagnosed cancer in male. DLL3 is overexpressed in CRPC-NE but not in localised prostate cancer or BPH. There are no effective treatments for neuroendocrine differentiated prostate cancer due to a lack of understanding of DLL3 structure and function. The structure of DLL3 is not yet determined using any experimental techniques. Hence, the structure-based drug discovery approach against prostate cancer has not shown great success. In present study, molecular modelling techniques were employed to generate three-dimensional structure of DLL3 and performed its thorough structural analysis. Further, all-atom molecular dynamics simulation was performed to obtain energetically favourable conformation. Further, we used a virtual screening using a library of >13800 phytochemicals from the IMPPAT database and other literature to select the best possible phytochemical inhibitor for DLL3 and identified the top five compounds. Relative binding affinity was calculated using the MM-PBSA approach. ADMET properties of the screened compounds reveal the toxic effect of Gnemonol C. We believe these studied physicochemical properties, functional domain identification, and binding site identification would be very useful to gain more structural and functional insights of DLL3; also, it can be used to infer their pharmacodynamics properties of DLL3 which was recently reported as an important prostate cancer target. The current study also proposes that Ergosterol Peroxide, Dioslupecin A, Mulberrofuran K, and Caracurine V have strong affinities and could serve as plausible inhibitors against DLL3. We believe this study would further help develop better drug candidates against neuroendocrine prostate cancer.Communicated by Ramaswamy H. Sarma.

Shared decision-making and the lessons learned about decision regret in cancer patients

The commentary presents reflections on the literature on post-treatment cancer patient regret. Even though a lot of effort has been made to increase patient satisfaction by engaging them in medical decisions, patient regret remains present in clinical settings. In our commentary, we identify three main aspects of shared decision-making that previously have been shown to predict patient regret. Based on these findings, we provide recommendations for physicians involved in the shared decision-making process. In addition, we make methodological suggestions for future research in the field.

Early outcomes and decision regret using PSMA/MRI guided focal boost for prostate cancer SBRT

PURPOSE

SBRT is a recognised treatment for low and intermediate risk prostate cancer with 36.25Gy in 5 fractions the most commonly used regimen. We explored the preliminary efficacy, patient recorded toxicity and decision regret in intermediate and high risk prostate cancer receiving SBRT with PSMA/MRI guided focal gross tumor volume (GTV) boost to 45Gy.

METHODS

Between July 2015 and June 2019, 120 patients received SBRT across 2 institutions with a uniform protocol. All patients had fiducial markers and hydrogel, MRI and PSMA PET scan. All patients received a questionnaire asking the degree of urinary, bowel and sexual bother experienced at set time points, including questions about treatment choice and decision regret.

RESULTS

112 of 120 patients consented, their median age was 72 years and median follow up was 2.3 yrs. As per National Comprehensive Cancer Network guidelines, 78% had intermediate risk and 20% high risk. Androgen deprivation was combined with radiation in 6 patients. Most patients (74%) reported that receiving SBRT significantly influenced their choice of treatment. Five men (4%) expressed "quite a lot" (n=4) or "very much" regret (n=1) regarding their choice of treatment, whilst 89% expressed "no regret". Similar to pre-treatment levels, "Quite a lot" or "Very much" urinary or bowel bother was expressed in 8% and 6% of patients respectively. Two patients experienced nadir +2 biochemical failure, both found to have bone metastases. A 3^rd patient underwent PSMA PET at nadir + 1.7, and had disease at the penile bulb, which was out of field. Three year estimated freedom from biochemical failure was 99% for intermediate and 85% for high risk groups.

CONCLUSIONS

We have demonstrated promising efficacy and low toxicity with PSMA/MRI guided SBRT focal boost. Less than 5% of patients expressed significant decision regret for their choice of treatment.

Low conflict and high satisfaction: Decisional outcomes after attending a combined clinic to choose between robotic prostatectomy and radiotherapy for prostate cancer

BACKGROUND

Decisional conflict and post-treatment decisional regret have been documented in men with localised prostate cancer (LPC). However, there is limited evidence regarding decisional outcomes associated with the choice between robotic-assisted radical prostatectomy (RARP) and radiotherapy, when both treatment options are available in the public health system. There is increasing support for multidisciplinary approaches to guide men with LPC in their decision-making process. This study assessed decisional outcomes in men deciding between RARP or radiotherapy treatment before and after attending a LPC combined clinic (CC).

METHODS

Quantitative longitudinal data were collected from 52 men who attended a LPC CC, where they saw both a urologist and radiation oncologist. Patients completed questionnaires assessing involvement in decision-making, decisional conflict, satisfaction and regret before and after the CC, three months, six months and 12 months post-treatment. Urologists and radiation oncologists also reported their perceptions regarding patients' suitability for, openness to, perceived preferences and appropriateness for each treatment. Data was analysed using paired/independent samples t-tests and McNemar's tests.

RESULTS

Most participants (n = 37, 71%) opted for RARP over radiotherapy (n = 14, 27%); one participant deferred treatment (2%). Urologists and radiation oncologists reported low agreement (κ = 0.26) regarding the most appropriate treatment for each patient. Participants reported a desire for high levels of control over their decision-making process (77.5% patient-led, 22.5% shared) and high levels of decisional satisfaction (M = 4.4, SD = 0.47) after the CC. Decisional conflict levels were significantly reduced (baseline: M = 29.3, SD = 16.9, post-CC: M = 16.3, SD = 11.5; t = 5.37, P < 0.001) after the CC. Mean decisional regret scores were 'mild' at three-months (M = 16.0, SD = 17.5), six-months (M = 18.8, SD = 18.7) and 12-months (M = 18.2, SD = 15.1) post-treatment completion.

CONCLUSION

This is the first Australian study to assess decisional outcomes when patients are offered the choice between RARP and radiotherapy in the public health system. A CC seems to support decision-making in men with LPC and positively impact some decisional outcomes. However, larger-scale controlled studies are needed to confirm these findings.

Time pressure predicts decisional regret in men with localized prostate cancer: data from a longitudinal multicenter study

PURPOSE

A substantial proportion of men with localized prostate cancer (lPCa) later regret their treatment decision. We aimed to identify factors contributing to decisional regret.

METHODS

We conducted a longitudinal study, in which men with lPCa were surveyed at four measurement points: T0 (baseline) = prior to treatment; T1 = 6; T2 = 12; T3 = 18 months after baseline. χ²-tests and independent t-tests were used to compare men undergoing different treatments [Active Surveillance (AS) vs. local treatment]. Logistic regression models were fitted to investigate the associations between predictors (time pressure, information provided by the urologist, impairment of erectile functioning, satisfaction with sexual life) and the criterion decisional regret.

RESULTS

At baseline, the sample included N = 176 men (AS: n = 100; local treatment: n = 76). At T2 and T3, men after local therapies reported higher regret than men under AS. Decisional regret at T3 was predicted by time pressure at baseline (OR 2.28; CI 1.04-4.99; p < 0.05), erectile dysfunction at T2 and T3 (OR 3.40; CI 1.56-7.42; p < 0.01), and satisfaction with sexual life at T1-T3 (OR 0.44; CI 0.20-0.96; p < 0.05).

CONCLUSIONS

Time pressure, erectile dysfunction, and satisfaction with sexual life predict decisional regret in men with lPCa. Mitigating time pressure and realistic expectations concerning treatment side effects may help to prevent decisional regret in PCa survivors.

TRIAL REGISTRATION NUMBER

DRKS00009510; date of registration: 2015/10/28.

A systematic review of the factors associated with regret post-cancer treatment

PROBLEM IDENTIFICATION

Expanding on previous work in specific cancer populations, this review aimed to explore factors associated with decisional regret following treatment for a range of cancer types.

LITERATURE SEARCH

A systematic search of four databases identified 1747 studies, using search terms relating to cancer survivors and decisional regret. Following quality appraisal, correlates of regret were abstracted and analyzed using narrative synthesis.

DATA EVALUATION/SYNTHESIS

Seventy-two studies met the inclusion criteria. Factors associated with treatment regret were categorized as being either modifiable or less modifiable. Regret was associated with various sociodemographic factors, physical health, treatment type, an unsatisfactory decision-making process, poorer mental health and lack of social support.

CONCLUSION

Results highlight the complex nature of regret and illustrate how this can be experienced following a range of cancer treatments. As regret can be an obstacle to full-recovery from cancer, this review suggests some ways in which the emergence of regret may be mitigated.

Perceived importance of affective forecasting in cancer treatment decision making

PURPOSE

To examine whether adults with cancer view affective forecasting as important for treatment decisions, and to examine these perceptions among key subgroups.

DESIGN

Adults with cancer (N = 376) completed a cross-sectional survey that included demographic and clinical characteristics, the IPIP five-factor personality measure, and a rating of the perceived importance of affective forecasting for cancer treatment decisions. Descriptive statistics characterized the importance of affective forecasting. Multivariate analyses examined whether health and personality variables were associated with affective forecasting importance.

FINDINGS

Most participants (89.6%) identified affective forecasting as important for treatment decisions. Affective forecasting was more likely to be rated as important among patients with prostate cancer (p < .001), patients lower in neuroticism (p = .02), and patients higher in agreeableness (p = .004). Conclusions/Implications: Patients believe it is important to understand how treatments will impact their emotional well-being. Oncology clinicians should discuss with patients these consequences during healthcare decision-making.

Decision regret in men living with and beyond nonmetastatic prostate cancer in the United Kingdom: A population-based patient-reported outcome study

Objective

Clinical options for managing nonmetastatic prostate cancer (PCa) vary. Each option has side effects associated with it, leading to difficulty in decision‐making. This study aimed to assess the relationship between patient involvement in treatment decision‐making and subsequent decision regret (DR), and quantify the impact of health‐related quality of life (HRQL) outcomes on DR.

Methods

Men living in the United Kingdom, 18 to 42 months after diagnosis of PCa, were identified from cancer registration data and sent a questionnaire. Measures included the Decision Regret Scale (DRS), Expanded Prostate cancer Index Composite short form (EPIC‐26), EQ‐5D‐5L, and an item on involvement in treatment decision‐making. Multivariable ordinal regression was utilized, with DR categorized as none, mild, or moderate/severe regret.

Results

A total of 17 193 men with stage I‐III PCa completed the DRS: 36.6% reported no regret, 43.3% mild regret, and 20.0% moderate/severe regret. The odds of reporting DR were greater if men indicated their views were not taken into account odds ratio ([OR] = 6.42, 95% CI: 5.39‐7.64) or were involved “to some extent” in decision‐making (OR = 4.63, 95% CI: 4.27‐5.02), compared with men who were “definitely” involved. After adjustment, including for involvement, men reporting moderate/big problems with urinary, bowel, or sexual function were more likely to experience regret compared with men with no/small problems. Better HRQL scores were associated with lower levels of DR.

Conclusions

This large‐scale study demonstrates the benefit of patient involvement in treatment decision‐making for nonmetastatic PCa. However, men experiencing side effects and poorer HRQL report greater DR. Promoting engagement in clinical decision‐making represents good practice and may reduce the risk of subsequent regret.