A Patient’s Dilemma: Which prostate cancer treatment to pick?

Editor’s note: Far from the days when “doctor knows best” was the ruling sentiment in medical suites, today patients have more of a voice in decisions about their care. The physician has more medical knowledge, but the patient’s own preferences matter enormously in true patient-centered care. “A Patient’s Dilemma” is a new occasional series that tells the stories of how people deal with the choices they face. As with our popular “Medical Mystery” feature (which also is continuing), we start by explaining the situation and then revealing the resolution. If you have a story to tell, email us at health@inquirer.com.

When my patient Mr. G learned that he had prostate cancer, he felt more stressed out than he ever had in his life.

Then it got worse. He learned that he was supposed to participate in choosing his treatment. How, he wondered, was he, as a nonphysician, supposed to manage that? Up again went his stress level.

His story began when, as Mr. G’s primary-care physician, I requested a PSA (prostate-specific antigen) blood test which, combined with rectal examination, is our best available screening tool for prostate cancer. I explained that the PSA test is imperfect and sometimes can be elevated for reasons other than prostate cancer, such as prostate enlargement or inflammation (a “false positive”), and biopsy may be needed to distinguish between them. That was exactly the case for Mr. G.

When the urologic surgeon discussed his diagnosis, he presented Mr. G with two options for treatment: surgery or radiation therapy. He was told that the long-term prognosis was similar for either option. “If you were my father,” the surgeon said, “I would recommend surgery, hands down.”

But Mr. G keeps up with the news and was aware that for older men such as himself, slow-growing prostate cancers may never become life-threatening. So he asked about a third option.

“What if I do nothing?” he asked.

“Well, then you’re just leaving things to chance. Chance doesn’t have your back,” the surgeon replied.

Mr. G then went to what he believed was his most trusted consultants: the internet. A highly educated scientist and savvy researcher, he spent hours studying the medical literature on treatment options for prostate cancer and the common side effects.

But even that wasn’t enough to make his choice clear.

When we met for his recent office visit, Mr. G looked exhausted as he told me he was still unsure about treatment. “Watchful waiting,” monitoring the tumor to see whether it was turning aggressive, is a choice many men are making and certainly is not the same as doing nothing. But Mr. G wasn’t comfortable with that option.

I complimented him on the thoroughness of his research and asked which aspect of the treatment and potential side effects he was struggling with most. For him, the worst treatment side effect he could imagine would be incontinence. He knew this could be a risk no matter which option he chose, but minimizing that risk was his priority.

I suggested that he speak with his surgeon about this.

“If you were my father” was kind and well-intentioned but wasn’t getting to Mr. G’s main concern. I also suggested he share the results of his own research, assuring him that many physicians, myself included, want to know what our patients are learning.

The following week, he returned to see the specialist and shared his worries about incontinence, along with his internet research conclusions.

After a thorough discussion of risks and benefits, Mr. G and his urologist decided that external beam radiation would best meet his needs, based on the characteristics of his tumor and treatment side effect profiles. Initially, the urologist shared a preference influenced by his own experience and review of medical studies, and in many cases, this may suffice. For Mr. G, a shared decision best aligned to his personal priorities.

“What matters most to you” is a question that helps build trust and can light up a pathway to the best choice for the individual patient. When shared decision-making is performed well, shared is the operative word. As physicians, we need to seek information as astutely as we disclose it.

Jeffrey Millstein is a primary-care physician and medical director for patient experience-regional practices at Penn Medicine.