Long‐term decision regret after post‐prostatectomy image‐guided intensity‐modulated radiotherapy

Abstract

Introduction: Decision regret (DR) may occur when a patient believes their outcome would have been better if they had decided differently about their management. Although some studies investigate DR after treatment for localised prostate cancer, none report DR in patients undergoing surgery and post-prostatectomy radiotherapy. We evaluated DR in this group of patients overall, and for specific components of therapy. Methods: We surveyed 83 patients, with minimum 5 years follow-up, treated with radical prostatectomy (RP) and post-prostatectomy image-guided intensity-modulated radiotherapy (IG-IMRT) to 64-66 Gy following www.EviQ.org.au protocols. A validated questionnaire identified DR if men either indicated that they would have been better off had they chosen another treatment, or they wished they could change their mind about treatment. Results: There was an 85.5% response rate, with median follow-up post-IMRT 78 months. Adjuvant IG-IMRT was used in 28% of patients, salvage in 72% and ADT in 48%. A total of 70% of patients remained disease-free. Overall, 16.9% of patients expressed DR for treatment, with fourfold more regret for the RP component of treatment compared to radiotherapy (16.9% vs 4.2%, P = 0.01). DR for androgen deprivation was 14.3%. Patients were regretful of surgery due to toxicity, not being adequately informed about radiotherapy as an alternative, positive margins and surgery costs (83%, 33%, 25% and 8% of regretful patients respectively). Toxicity caused DR in the three radiotherapy-regretful and four ADT-regretful patients. Patients were twice as regretful overall, and of surgery, for salvage vs adjuvant approaches (both 19.6% vs 10.0%). Conclusion: Decision regret after RP and post-prostatectomy IG-IMRT is uncommon, although patients regret RP more than post-operative IG-IMRT. This should reassure urologists referring patients for post-prostatectomy IG-IMRT, particularly in the immediate adjuvant setting. Other implications include appropriate patient selection for RP (and obtaining clear margins), and ensuring adequately discussing definitive radiotherapy as an alternative to surgery.

Toxicity after post‐prostatectomy image‐guided intensity‐modulated radiotherapy using Australian guidelines

“…It is known that toxicity plays a major role in the decisional regret that patients may experience after radiotherapy, and the higher rates of toxicity after post‐prostatectomy radiotherapy may lead to higher levels of decisional regret. Our own results reflect this, with 16.9% of patients who underwent PPRT having decisional regret about their radical prostatectomy compared to 4.2% regretting their PPRT, whereas only 3.8% expressed regret after definitive IMRT, although potentially biased by the ‘failure’ of prostatectomy in requiring PPRT.…”

Patterns of care for men with prostate cancer: the 45 and Up Study

“…We identified several socio‐demographic and socio‐economic characteristics that may influence the type of treatment received by men with prostate cancer in NSW. This is an important public health question, given the potential harms of treatment, including long term side effects 3,20,21 and the financial costs 8 . The Prostate Cancer Outcomes Registry of Australia and New Zealand (PCOR‐ANZ) is rapidly becoming a useful source of population‐wide clinical, treatment, and outcomes data 28 .…”

“…However, EBRT is less invasive than radical prostatectomy, and can be performed as an outpatient procedure without anaesthesia. Side effects of treatment for prostate cancer can be associated with decision regret 21 …”

“…Side effects of treatment for prostate cancer can be associated with decision regret. 21 Given the impact these differences may have on quality of life, patients should be informed about all treatment options. However, only 13% of patients in our study who had radical prostatectomies had had radiation oncology consultations before the operation.…”

Long‐term outcomes in 1121 Australian prostate cancer patients treated with definitive radiotherapy

“…These results are in the American context however may also be applicable to Australian patients. A further interesting consideration is the concept of long‐term decision regret, which was researched by Shakespeare et al . Eighty‐three percent of patients reported regret over their decision on surgery due to toxicity, and 33% reported regret of not being adequately informed about radiotherapy as an alternative.…”