Patient Preferences for Communication of Life Expectancy in Prostate Cancer Treatment Consultations

Life expectancy (LE) is a critical factor in treatment decision-making for men with prostate cancer, since limited LE is associated with lower likelihood of sufficient longevity to benefit from treatment,¹ higher treatment morbidity,² and decreased treatment effectiveness.³ Despite a prominent role of LE in guidelines, men with limited LE are often overtreated for indolent cancers and undertreated for high-risk cancers.⁴ Previous studies suggest that such mismanagement may be because of ineffective communication of LE by clinicians.⁵ Yet, patient perspectives on how LE should be ideally communicated are unknown.

We conducted semistructured interviews with men after treatment consultations for prostate cancer (Gleason score ≤7) between March 2019 and December 2020. Views on importance of LE, if or how it had been expressed, barriers to discussing LE, confidence in LE estimates, and ideal modes of communication were assessed using open-ended questions (eMethods in the Supplement). We used an inductive qualitative coding approach with ATLAS.ti version 8.4.5 (ATLAS.ti Scientific Software Development GmbH) to identify emerging themes. The study was approved by the Cedars-Sinai Institutional Review Board. Informed consent (written or verbal) was obtained by the study team.

A total of 26 men participated. The median age in the sample was 67 (IQR, 60-72) years, and 5 of 26 had LEs less than 10 years (19%). Of participants who recalled discussing LE (19 of 26 [73%]), three-quarters recalled LE as being communicated as a generalization (eg, “long”; 7 of 19 [37%]) or a survival probability at a point (eg, “20% probability of living 15 years”; 7 of 19 [37%]), while one-quarter recalled it as a number of years (“you’ll live to 90”; 5 of 19 [26%]). Six of 7 (86%) who did not recall discussing LE thought it would have been helpful.

In a hypothetical scenario addressing the ideal mode of LE communication, most preferred a number of years (12 of 24 [50%]) or survival probability at a point (9 of 24 [38%]) rather than a generalization (3 of 24 [13%]). Those who preferred a number of years noted it was easily understandable (6 of 12 [50%]) and concrete (5 of 12 [38%]). Those who preferred survival probability indicated it offered hope, even if it was low (5 of 9 [56%]). Those opposed to generalization felt that “doctors [were] not giving patients credit” as part of shared decision-making. Preferences did not differ among those with LEs less than 10 years compared with those with LEs greater than 10 years.

The predominant barrier to discussing LE was anxiety (15 of 26 [58%]), which participants noted could be reduced by using a range of years (eg, “10-15 years”; 3 of 15 [20%]), depersonalizing language (eg, “for patients like you”; 2 of 15 [13%]), and other methods (Table). Most had low (6 of 24 [25%]) or moderate (13 of 24 [54%]) confidence in LE estimates, which participants noted could be improved by explaining the calculation method (11 of 25 [44%]), mentioning that health status (7 of 25 [28%]) or family history or genetics (5 of 25 [20%]) was considered, and other methods (Table). Twenty-two of 26 (87%) felt that LE should always be provided in consultations.

We sought to understand patient perspectives on how LE should be optimally communicated to create patient-centered strategies that address the emotional, rhetorical, and attitudinal challenges preventing effective LE communication. Most men in the sample (1) endorsed LE as a key component of treatment counseling that should not be omitted (87%); (2) preferred LE to be communicated as specific, quantitative information rather than a generalization (88%); (3) had low to moderate confidence in LE estimates (79%) but offered language-based methods for improving confidence; and (4) endorsed anxiety (58%) as the main barrier to discussing LE, which could be alleviated by language-based approaches (Table). Interestingly, the preference for detailed LE information in men with prostate cancer contrasts with LE preferences in screening populations,⁶ which may be attributable to their need to weigh competing risks of mortality against substantial treatment-associated morbidity. Future studies will need to confirm the generalizability of these findings to men with low health literacy or numeracy (since our sample was drawn from a well-educated, health-literate population), non–English-speaking populations, and individuals in other clinical settings (eg, advanced disease).

Based on our findings, we created an annotated example for how LE should be optimally communicated (Figure). Using patient-centered language to describe this computationally challenging and emotionally evocative concept may improve understanding and acceptance, leading to more informed shared decision-making.

Accepted for Publication: September 11, 2021.

Published Online: November 10, 2021. doi:10.1001/jamasurg.2021.5803

Corresponding Author: Timothy J. Daskivich, MD, MSHPM, Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, 8635 W Third St, Ste 1070W, Los Angeles, CA 90048 (timothy.daskivich@csmc.edu).

Author Contributions: Dr Daskivich had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Daskivich, Khodyakov, Anger, Freedland, Spiegel.

Acquisition, analysis, or interpretation of data: Daskivich, Gale, Luu, Anger, Freedland, Spiegel.

Drafting of the manuscript: Daskivich, Gale, Luu, Freedland.

Critical revision of the manuscript for important intellectual content: Daskivich, Gale, Khodyakov, Anger, Freedland, Spiegel.

Statistical analysis: Daskivich, Luu, Anger.

Obtained funding: Daskivich, Spiegel.

Administrative, technical, or material support: Gale, Spiegel.

Supervision: Daskivich, Anger, Freedland, Spiegel.

Other—qualitative data analysis: Khodyakov.

Conflict of Interest Disclosures: Dr Daskivich reported grants from the National Cancer Institute during the conduct of the study. No other disclosures were reported.

Funding/Support: This work was supported by a Career Development Award (K08 CA230155 [Dr Daskivich]) from the National Cancer Institute.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We would like to recognize the substantial contributions of the following individuals to the work reported in this article: Edwin Posadas, MD, Department of Medicine, Division of Medical Oncology, Cedars-Sinai Medical Center (data collection and manuscript editing); Howard Sandler, MD, Department of Radiation Oncology, Cedars-Sinai Medical Center (data collection and manuscript editing); Carine Khalil, PhD, Cedars-Sinai Center for Outcomes Research and Education, Cedars-Sinai Medical Center (manuscript editing); Aurash Naser-Tavakolian, MD, Department of Surgery, Division of Urology, Cedars-Sinai Medical Center (manuscript editing); and Abhi Venkataramana, MD, Department of Urology, USC Medical Center (manuscript editing). These individuals were not compensated for their contributions.