Mechanisms of decision‐making in preoperative assessment for older adult prostate cancer patients—A qualitative study

Abstract

Background and Objective: Little research exists which investigates the contextual factors and hidden influences that inform surgeons and surgical teams decisionmaking in preoperative assessment when deciding whether to or not to operate on older adult prostate cancer patients living with aging-associated functional declines and illnesses. The aim of this study is to identify and examine the underlying mechanisms that uniquely shape preoperative surgical decision-making strategies concerning older adult prostate cancer patients.Methods: Qualitative methodologies were used that paired ethnographic field observations with semistructured interviews for data collection. An inductive thematic analysis approach was used to identify, analyze, and describe patterns in the data.Results: Factors underlining surgical decision-making originated from the context of two categories: (1) clinical and surgery-specific factors; and (2) non-patient factors.Thematic subcategories included personal experiences, methods of assessment during medical encounters, anticipation of outcomes, perceptions of preoperative assessment instruments for frailty and multimorbidity, routines and workflow patterns, microcultures, and indirect observation and second-hand knowledge.Conclusion: Surgeon's personal experiences has a significant impact on the decisionmaking processes during preoperative assessments. However, non-patient factors such as institutional microcultures passively and actively influence decision-making process during preoperative assessment. K E Y W O R D S frailty, medical decision-making, multimorbidity, older adults, preoperative assessment, prostate cancer, surgical assessment 1 | INTRODUCTION Prostate cancer is the second most common form of cancer diagnosed among men in the United States. 1 It is projected that there will be 164 690 new cases and 29 430 deaths in 2018 as a result of the disease, 2and older men represent the majority of prostate cancer diagnoses and mortalities. 3 In general, radical prostatectomy is considered one of the primary treatments available with curative intent for men diagnosed with clinically localized prostate cancer and a life expectancy of more than 10 years. 4-8 Given that older adults (defined herein as age 65 years or more 9,10 ) account for a significant ratio of the patient population, special attention and consideration must be given by surgeons and surgical teams during the stages of preoperative assessment when deciding whether or not to operate.However, the decision to operate in older adults is a complex task since the rate of adverse postoperative outcomes increases How to cite this article: Kierkegaard P, Vale MD, Garrison S, Hollenbeck BK, Hollingsworth JM, Owen-Smith J.Mechanisms of decision-making in preoperative assessment for older adult prostate cancer patients-A qualitative study.

Estimating patient health in prostate cancer treatment counseling

“…Frailty assessments recently developed to evaluate fitness to undergo surgery and optimize perioperative outcomes focus on short-term surgical optimization, rather than on evaluating the longer-term role for curative intervention in a patient with comorbidities. ( 20 – 22 ) A Canadian observational cohort study of >36 000 men undergoing prostatectomy showed substantial variability among observed and predicted 10-year survival, underscoring the uncertainty physicians face: the observed 10-year survival rate was 88.9%, while the life-table predicted survival rate was 83.3% and the rate estimated by Aggregated Diagnosis Groups (ADG) risk-assessment was just 76.0%. ( 23 ) While the high observed 10-year survival rate may imply that surgeons are correctly choosing patients who will benefit from surgery, the discrepancies among LE assessment tools raises concerns.…”

Shared decision‐making with older adults with cancer: Adaptation of a model through literature review and expert opinion

“…Supporting Information S1: file 2 provides an overview of the included studies. Half of the studies focused on breast (10/29) [26][27][28][29][30][31][32][33][34][35] or prostate (5/29) [36][37][38][39][40] cancer. Three studies focused on any type of cancer and comorbid dementia (3/29).…”

Differences in rates of pelvic lymph node dissection in National Comprehensive Cancer Network favorable, unfavorable intermediate- and high-risk prostate cancer across United States SEER registries

“…[ 1 , 17 , 18 ] Third, the SEER database does not account for comorbidities, and it may be postulated that PLND may not be performed in patients with a less favorable comorbidity profile, and an adjustment for that variable could not be made in the present study. [ 19 , 20 ] Finally, we did not have information on the extent to which urologists relied on the NCCN guidelines at the time of deciding upon PLND in the patients enrolled in the current study. However, these data are not available in any retrospective multi-institutional or population-based study analyzing adherence to guideline recommendations for PCa as well as for other diseases.…”