Discussion
Our study identifies four key thought processes in considering PGA among men with very-low-risk, low-risk, and favorable intermediate-risk PCa on AS, namely the perception of psychological safety in a lower risk diagnosis, the prioritization of minimally invasive options with fewer side effects, the dependence on the provider in the decision-making process, and the consideration of treatment aggressiveness with respect to disease severity. These concepts were further explored in the context of considering PGA as a treatment option, for incorporation into shared decision-making discussions. Our cohort reflects recent treatment expansion of AS to include men with favorable intermediate-risk PCa along with men with very-low-risk and low-risk PCa.8 Overall, 9 patients expressed interest in speaking with their provider to discuss PGA at their current risk category and 11 expressed interest in the event their cancer progresses.
Most men described a feeling of psychological safety with having low-risk disease on AS. This finding parallels other studies that identified men’s acute perception of the low-risk category and non-immediate threat to life.13 21 However, some men in our study expressed a significant discomfort with the uncertainty of their diagnosis and were considering other treatment options. This uncertainty has been observed by others and shown to be associated with lower quality of life.22 Men expressing uncertainty about AS were more receptive to PGA, and many patients comfortable on AS were also interested in further discussion at their current risk level.
Earlier studies of AS assert that patients with low-risk PCa valued prolonged survival over preservation of urinary and sexual functions,17 18 thus are likely to pursue definitive treatment over AS.23 24 However, our findings concur with more recent findings that indicate a cultivating preference for minimally invasive treatments by men with a refined understanding of their low-risk condition.13 15 Currently it is widely known that men with low-risk PCa managed on AS have higher quality of life,25 explaining men’s motivation to trade off low uncertainty over survival for preservation of urinary function.15 PGA was appealing as a curative alternative to AS and a less invasive option to radical prostatectomy for men in this study. However, 15% of men interviewed perceived PGA as a temporary cure when compared with whole gland treatments as the uncertainty of recurrence remains.
Trust in the physicians and their recommendations has been shown to play a key role in pursuing any treatment strategy,9 26 27 although some men also value playing an active role28 and taking ownership over their choices.13 27 29 Regardless, greater patient knowledge is also associated with greater decision-making difficulty,30 which suggests an important role in shared decision-making with providers. Our study is consistent with prior findings that patients who established a collaborative relationship with their physicians31 are more likely to seek their physician’s expertise and ‘decisional support’29 when surveying new treatment options, including PGA. However, few patients did not find the recommendations for focal treatments to be candid, as they found specialists predisposed to recommending procedures they primarily perform.
Many men identified a logical process in their decision-making in which their low-risk disease was appropriately managed by the observational nature of AS. Previous studies have identified men’s understanding of the rationale behind AS as a contributing factor toward staying on AS.21 Our findings contribute that men on AS respect the escalation of treatment invasiveness that parallels disease progression. This novel concept of treatment intensity matching disease can be explored in shared decision-making discussions with the introduction of PGA as an intermediate option in the PCa treatment spectrum. Interestingly, these men differed in their opinions on where PGA stands in this hierarchy, with some finding it an appropriate option for low-risk disease and others believing it is only necessary for higher risk disease.
Earlier studies found men with low-risk PCa having higher overall satisfaction with care with definitive treatments than with AS.31 However, definitive treatments for patients with low-risk localized PCa are currently considered overtreatment and introduce unnecessary side effects.23 Nevertheless, many men elect to undergo definitive therapy to address the uncertainty of cancer.17 Although short-term oncological outcomes vary and may depend on the specific modality used,2 3 32 PGA emerges as middle ground that encompasses the satisfaction of curative treatment and preservation of quality of life.23 Additional research on men’s preferences and attitudes focused on each treatment modality under PGA, including high-intensity focused ultrasound, irreversible electroporation, cryotherapy, photodynamic therapy, and focal laser thermal ablation, will further guide shared decision-making for PGA.
This study is not without limitations. First, this was a qualitative study of 20 men on AS from a single tertiary care center located in New York City. Patients in this study were mostly white educated men residing in areas of higher income. Thus, our findings may not be generalizable to men from different backgrounds. Additionally, sampling bias must be considered given that our cohort includes only men who volunteered to be interviewed. Second, our study concerns men with lower risk PCa who never received treatment on AS. However, inclusion of men of similar risk category with recent diagnosis undecided on a treatment plan and men with history of PCa treatment still eligible for PGA would provide a more comprehensive insight into the perceptions and attitude of all eligible men for PGA, not just those on AS. Moreover, the time since diagnosis averaged 2.6 years in our study and may have contributed to recall bias, loss of details about the initial consultation, and establishment of comfort regarding their diagnosis and treatment options. Additionally, semistructured interviews required probing patients with unprompted questions, adding to both interviewer and response bias. Lastly, phone interviews do not provide visual cues and may contribute to the loss of non-verbal data and contextual information and misinterpretation of responses.33 However, phone interviews offer facial anonymity, which may empower patients to disclose sensitive information more readily.33 Of note, 2 out of 20 men interviewed (10%) had a Gleason score of 3+4. While these patients serve to reflect the recent change in treatment paradigm to include men of favorable intermediate-risk PCa in AS, they are not representative of the entire group of men with PCa on AS.
In conclusion, as PGA develops there has been an emerging consensus that men with tumor characteristics eligible for AS may be the best candidates for PGA; however, there is little knowledge of men’s attitudes and perspectives on PGA. Herein we identify four themes and their relation to men’s considerations of PGA: the feeling of psychological safety associated with low-risk disease, a preference for minimally invasive treatment, the central role of the physician, and the pursuit of treatment option intensity that parallels disease severity. In a small sample size of highly educated men with low-risk PCa that is experienced with AS, we demonstrate that almost half of men have potential interest in PGA, despite low-grade evidence concerning intermediate and long-term outcomes.