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Articles: Grace A. Lin, David S. Aaronson, Sara J. Knight, Peter R. Carroll, and R. Adams Dudley Patient Decision Aids for Prostate Cancer Treatment: A Systematic Review of the Literature CA Cancer J Clin 2009; 59: 379-390 [Abstract] [Full text] [PDF]

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eLetter to "Patient Decision Aids for Prostate Cancer Treatment"

Siwang Wang, Hua Li and Bangle Zhang   (28 December 2009)

Factors that help explain decision aids' variable effect on cancer treatment decisions

Wen Wang, Sheng-Xi Wu, Yun-Qing Li   (28 December 2009)

Does patient or doctor play center role in making decision on cancer treatment?

Jinwu Chen, Liqiang Shi, Pei Wang, Yimin Zhao   (10 November 2009)

eLetter to "Patient Decision Aids for Prostate Cancer Treatment" 28 December 2009
Siwang Wang, Professor Institute of Materia Medica, School of Pharmacy, Fourth Military Medical University, Hua Li and Bangle Zhang Send letter to journal: Re: eLetter to "Patient Decision Aids for Prostate Cancer Treatment" wangsiw{at}fmmu.edu.cn Siwang Wang, et al.	Dear Editor: We greatly appreciated the article by Lin et al published recently in this journal [1]. In fact, treatment decision-making is difficult and complex both for clinicians and patients, especially in low-risk prostate cancer. As for patients in China, most of them lack appropriate knowledge and treatment experience when regarding the optimal treatment strategy and the choice of therapy. Although DAs on treatment choice are useful, existing factors such as attitude towards the disease and economic capacity could strongly influence the choice of the patients in the treatment decision-making process, and the leading role of clinicians in estimating harms and benefits of treatment should not be ignored. In China, patients will usually accept the advice of experienced clinicians for their treatment decisions, which could explain the fact that "The effect of DAs on treatment choice was less clear," as mentioned in the text [1]. In addition, different DAs have different outcomes in decision-making [2, 3]. The effect of DAs on treatment choice depends on the quality standards of DAs. If an ineffective type of DA is applied to the clinic, it would easily become a burden between clinicians and patients. When the DAs between clinicians and patients function only to notify and to choose, that is, "notification & choice mode," the aftereffect not only causes a sense of hopelessness and anxiety in patients [4], but also complicates the decision-making process. Clinicians who are familiar with the art of DAs should play an active leading role in the treatment decision-making process. Yours sincerely, Hua Li, MD (1) Bangle Zhang, Associate Professor (2) Siwang Wang, Professor (1) 1 Institute of Materia Medica, School of Pharmacy, Fourth Military Medical University, 17 Changle West Road, Xi'an, Shaanxi, People's Republic of China. 2 Department of Pharmaceutics, School of Pharmacy, Fourth Military Medical University, 17 Changle West Road, Xi'an, Shaanxi, People's Republic of China. Correspondence: Siwang Wang, Professor; E-mail: wangsiw@fmmu.edu.cn or Bangle Zhang, Associate Professor; E-mail: blezhang@fmmu.edu.cn References 1. Lin GA, Aaronson DS, Knight SJ, Carroll PR, Dudley RA. Patient decision aids for prostate cancer treatment: A systematic review of the literature. CA Cancer J Clin. 2009;59:379-390. 2. Brackett C, Kearing S, Cochran N, Tosteson AN, Blair Brooks W. Strategies for distributing cancer screening decision aids in primary care. Patient Educ Couns. 2009 Aug 6. [Epub ahead of print]. 3. Hoffman RM, Couper MP, Zikmund-Fisher BJ, et al. Prostate cancer screening decisions: results from the National Survey of Medical Decisions (DECISIONS Study). Arch Intern Med. 2009;169:1611-1618. 4. Ouill TE, Brody H. Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Ann Intern Med. 1996;125:763-769.
Factors that help explain decision aids' variable effect on cancer treatment decisions 28 December 2009
Wen Wang, Associate Professor Fourth Military Medical University, Sheng-Xi Wu, Yun-Qing Li Send letter to journal: Re: Factors that help explain decision aids' variable effect on cancer treatment decisions wangwen{at}fmmu.edu.cn Wen Wang, et al.	Dear Editor, Lin et al. provided us a promising review that decision aids (DAs) affect patients with low-risk prostate cancer on the knowledge of disease, patients’ role in treatment decision-making, and treatment options. DAs were found to enrich the patients’ knowledge of the disease and make the patients actively involved in the treatment decision making process. On the other hand, the DAs’ effect on patients’ final treatment options varied from study to study. The reasons can be the non-standardized DA protocols used in different studies, patients’ possible decision change before going to visit a physician, etc, as stated by the authors [1]. However, we argue that some of the patients’ characteristics may contribute to explaining the variability. Unfortunately, after carefully checking the 13 original articles reviewed in this paper, we could not find such information in any of the studies. The characteristics include race, education level, and spirituality. In the United States, striking features of prostate cancer are the pronounced racial/ethnic disparities in incidence and mortality rates. African Americans experience the highest burden due to the highest incidence and mortality rate [2], as well as the earlier diagnosed age compared with whites [3]. Moreover, African American prostate cancer patients tend to use complementary and alternative medicine (CAM), including prayer, to fight against cancer; it is reasonable to expect that such therapy preference affects the final treatment option even after patients are actively involved in treatment decision making [4]. Thus, it is very important to stratify the race factor so as to check the DAs’ real effect. Education level is one important factor that affects decision making for localized prostate cancer [5]; this effect possibly exists even after patients obtain full knowledge of prostate cancer with the help of DAs. Unfortunately, in most of the reviewed literature, the education level has not been stratified. Spirituality is another important factor which may affect the patients’ final treatment decision even after DAs. It is previously reported that spiritual beliefs and practices may play an important role in the formation of treatment choices for some patients; they tend to decline conventional therapy and turn to CAM [6]. This is one, probably strongest, factor which can affect the final treatment decision with a preference to CAM. We believe these three factors contribute to explain the variable findings reported in the 13 reviewed articles and thus, together with future well-organized randomized controlled trials taking these factors into consideration, help our physicians’ community decide whether it is worth introducing such a system into their routine work. Wen Wang, MD, PhD, Associate Professor Sheng-Xi Wu, MD, PhD, Professor Yun-Qing Li, MD, PhD, Professor Unit of Evidence-Based Medicine Department of Anatomy Fourth Military Medical University China Correspondence: Yun-Qing Li, MD, PhD and Sheng-Xi Wu, MD, PhD, Unit of Evidence-Based Medicine, Department of Anatomy, Fourth Military Medical University, e-mail: deptanat@fmmu.edu.cn or shengxi@fmmu.edu.cn References 1. Lin GA, Aaronson DS, Knight SJ, Carroll PR, Dudley RA. Patient decision aids for prostate cancer treatment: a systematic review of the literature. CA Cancer J Clin. 2009;59:379-390. 2. Odedina FT, Akinremi TO, Chinegwundoh F, et al. Prostate cancer disparities in Black men of African descent: a comparative literature review of prostate cancer burden among Black men in the United States, Caribbean, United Kingdom, and West Africa. Infect Agent Cancer. 2009;4 Suppl 1:S2. 3. Shao YH, Demissie K, Shih W, et al. Contemporary risk profile of prostate cancer in the United States. J Natl Cancer Inst. 2009;101:1280-1283. 4. Jones RA, Taylor AG, Bourguignon C, et al. Complementary and alternative medicine modality use and beliefs among African American prostate cancer survivors. Oncol Nurs Forum. 2007;34:359-364. 5. Zeliadt SB, Ramsey SD, Penson DF, et al. Why do men choose one treatment over another?: a review of patient decision making for localized prostate cancer. Cancer. 2006;106:1865-1874. 6. White M, Verhoef M. Cancer as part of the journey: the role of spirituality in the decision to decline conventional prostate cancer treatment and to use complementary and alternative medicine. Integr Cancer Ther. 2006;5:117-122.
Does patient or doctor play center role in making decision on cancer treatment? 10 November 2009
Jinwu Chen, Associate Professor School of Stomatology, Fourth Military Medical University, China, Liqiang Shi, Pei Wang, Yimin Zhao Send letter to journal: Re: Does patient or doctor play center role in making decision on cancer treatment? jinwuechen{at}yahoo.com.cn Jinwu Chen, et al.	Dear Editor, In the excellent review by Lin et al, the author said "Given recent data indicating a low rate of prostate cancer mortality and a risk of overdiagnosis in patients undergoing PSA screening, ensuring that patients are making informed decisions is crucial to providing appropriate, patient-centered care" [1]. However, regarding the effect of DAs on treatment of cancer, we hold that too much patient involvement remains to be an arguable issue for the following three considerations. Firstly, altered psychological states often influence the susceptibility of an individual to illness or modify the course of the illness and its prognosis [2]. Every individual has a preference of view of life, either optimistic or pessimistic, and there is no exception with prostate cancer patients. Patients' different views of life bring about two opposite attitudes towards their illness: positive one and negative one. Patients' positive attitude may stimulate immune system to ward off the disease, while the negative attitude may suppress the immune system and discount the effect of treatment. Secondly, with the rising concerns over chronic health conditions and their prevention and management, health literacy is emerging as an important public health issue [3]. Compared with doctors with specialist identification, patients have low health literacy, especially short on systemic knowledge of prevention, diagnosis, and treatment of cancer. This poor health literacy may impair the quality of DAs and thus interfere with physicians' diagnosis and treatment. Just as the authors said, "A minority of physicians (18%) believed that DAs complicated the decision-making process, particularly in patients with low health literacy" [1]. Thirdly, economic condition is also very important. For patients in countries with sophisticated insurance systems, the cost of medical treatment may not pose as much of a financial burden. But for those patients in developing countries where insurance system is still in its infancy, medical costs may become a primary concern and make the treatment decision-making difficult for both patients and physicians. It is not unusual to see that patients give up receiving treatment simply because they cannot afford it [4]. These considerations suggest that the investigation of effect of DAs on prostate cancer treatment in the developing countries be biased. Jinwu Chen, MD, PhD Liqiang Shi, MD Pei Wang, MD Yimin Zhao, MD, PhD Department of Radiology and Intervention Therapy, School of Stomatology, Fourth Military Medical University, China Correspondence: Yimin Zhao MD and Jinwue Chen MD, School of Stomatology, Fourth Military Medical University, e-mail: zhaoym@fmmu.edu.cn or jinwuechen@yahoo.com.cn References 1. Lin GA, Aaronson DS, Knight SJ, Carroll PR, Dudley RA. Patient decision aids for prostate cancer treatment: a systematic review of the literature. CA Cancer J Clin 2009;59:379-390. 2. Maldonado MD, Perez-San-Gregorio MA, Reiter RJ. The role of melatonin in the immuno-neuro-psychology of mental disorders. Recent Pat CNS Drug Discov 2009;4(1):61-69. 3. Wharf Higgins J, Begoray D, Macdonald M. A social ecological conceptual framework for understanding adolescent health literacy in the health education classroom. Am J Community Psychol 2009 Oct 17. [Epub ahead of print]. 4. Ochoa-Diaz Lopez H, Sanchez-Perez HJ, Ruiz-Flores M, Fuller M. Social inequalities and health in rural Chiapas, Mexico: agricultural economy, nutrition, and child health in La Fraylesca region. Cad Saude Publica 1999;15(2):261-270.