Prostate cancer treatment

Patients frequently have a difficult time deciding between the many treatment options for nonmetastatic prostate cancer. Some treatment options can produce intolerable and emotionally devastating side effects, yet extend life expectancy beyond what other treatment options can. To make an informed choice of treatment option, patients need to determine what is more important to them and their families. Sculpher and colleagues used the technique of discrete choice experimentation to elicit patient preferences for the most common nonmetastatic prostate cancer therapies.

The authors initially interviewed 14 men with nonmetastatic prostate cancer to identify key attributes that would be incorporated into a larger study. The key attributes were identified as diarrhea, hot flushes, breast swelling or tenderness, energy level, sex drive, ability to maintain an erection for sexual activity, life expectancy, and out-of-pocket expenses. These eight attributes were used as the basis of a questionnaire and structured interview offered to 180 men with nonmetastatic prostate cancer who had received or had never received anti-androgen therapy.

Only 129 men completed the interview, during which the men were presented with scenarios that required them to choose between a series of paired treatment options. They were given standardized information about the anticipated outcomes and side effect profiles of each treatment option.

The average age of the participants was 70 years. At diagnosis, 58 percent of the men had T scores of 1 or 2. The researchers calculated coefficients for all of the attributes, showing patient preferences for different scenarios (e.g., side effects and success rates of aggressive treatments; side effects and success rates of conservative treatments). Then they calculated how much life expectancy men were willing to trade off to improve specific symptoms. Patients placed high value on energy levels by being willing to forgo three months of life expectancy in exchange for "pep." In addition, they were willing to forgo 1.9 and 1.8 months of life expectancy to avoid breast swelling and frequent diarrhea, respectively. Men younger than 70 years were significantly concerned about problems in maintaining an erection and were willing to give up 1.8 months of life expectancy to avoid these problems (by contrast, men older than 70 years were willing to give up 0.9 months).

The authors conclude that patients perceive some side effects of prostate cancer therapy as being more significant than others and that the priorities of men younger than 70 years differ from the priorities of those older than 70 years. The authors encourage physicians to use personalized approaches to help patients with prostate cancer make informed treatment choices.

ANNE D. WALLING, M.D.

Sculpher M, et al. Patients' preferences for the management of non-metastatic prostate cancer: discrete choice experiment. BMJ February 14, 2004;328:382-5.