After listening to the treatment alternatives—surveillance, or active treatment with surgery and radiation—a patient just diagnosed with prostate cancer asks you, “what would you recommend?”
How would you respond?
As a clinician, your responsibility is to find out what the patient is actually asking, and to provide a recommendation that reflects his or her preferences, Peter A. Ubel, MD, told attendees at the NCCN 21st Annual Conference.
One answer might be “I might make a different choice than you because I might have different preferences,” said Dr Ubel, the Madge and Dennis T. McLawhorn University Professor of Business, Public Policy, and Medicine at Duke University in Durham, NC.
Such a reply “is what should trigger the true shared decision-making conversation,” he added. Far too often, however, patients are inundated with information they either do not understand or find overwhelming in its sheer volume.
The “right” choice, he outlined, depends on how the patient weighs the trade-off between the anxiety of living with cancer and the side effects of the active treatments.
“To really empower patients to be partners in decisions where their preferences are important in determining what the right course of action is, we have to communicate better,” he said. “We have to understand decision psychology better than we do, and we have to make sure we know the difference between a medical fact and a value judgment.”
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Dr Ubel, with the Duke-Margolis Center for Health Policy, provided an example of an urologist explaining a Gleason score to a patient: “low risk is Gleason 6, intermediate is usually 7s, with 3 + 4 or 4 + 3, depending on how it looks under the microscope. And then 8, 9, and 10 are all high risk. So it’s in the middle. It was 3 + 3 and 3 + 4, so just enough of the atypical cells of the grade 4 to make it 3 + 4, which means you’re intermediate risk.”
Although this represents an earnest explanatory effort, what the clinician is trying to say is, “you do not have the kind of cancer that will kill you, maybe never, but certainly not in the next 10 or 15 years. We have months to decide what to do about this. We found it early enough and we can take care of this.”