If only we could predict the future!

Roger Ladouceur

This month, on page 137, Birnie and Robinson present the results of a literature review designed to determine the place of psychosocial variables and the role of a family physician in decision making about therapy for patients suffering from localized prostate cancer. Essentially, they claim that family physicians can aid their patients by ensuring the accuracy and appropriateness of the information used by these patients in decision making, by clarifying their values and ensuring that these values are taken into consideration, and by addressing the influence of patients’ social support networks on decision making about treatment. They suggest that family physicians thus have an important role and can help to minimize the regret so often felt by patients after they have chosen treatments.

Even if this advice is very wise, these authors also bring to light the delicate position that family physicians put themselves in when they try to manage uncertainty and support decision making without necessarily possessing all the expertise required and when nothing is for certain. No one can predict the evolution of prostate cancer, even when it is localized. Certainly, stage of disease, atypical cell development, score on the Gleason index, prostate-specific antigen levels, age, clinical state, and comorbidity are salient factors that can guide us, but none of them proves that the disease will follow a definite and predictable course. We have all heard anecdotes of patients with localized prostate cancer that followed atypical courses—of patients, however well they seemed to be, dying a few months later, and of extremely ill patients miraculously surviving against all expectations.

In fact, when the time comes to help a patient with localized prostate cancer choose among radical prostatectomy, external radiotherapy, brachytherapy, cryotherapy, or simply watchful waiting, both patient and physician face a dilemma. Is it preferable to subscribe to conservative management and take the chance that the disease will evolve more rapidly than foreseen and progress to an incurable stage, or to opt for an invasive treatment—often the specialist’s choice—in the hope of eradicating the cancer but also bringing with it a load of complications and doubts?

It is true that many patients who chose an invasive treatment, be it surgery or radiotherapy, ended up deploring their choice. Birnie and Robinson report that between 4% and 19% of patients regretted their choices owing to unwanted side effects, such as impotence, urinary incontinence, and post-radiation problems. But on the other hand, we should not underestimate the often very strong reactions of those who, having chosen conservative management, suddenly find themselves confronted with advanced metastatic disease and relegated to palliative care. Even if the decision has been made by an informed patient in a clear manner, how many times have we heard patients in these dire straits say:

Doctor, I don’t understand! How is this possible? You told me before that it would be preferable not to undergo an operation or to receive radiotherapy [when in reality, the decision was made by the patient!] I should not have listened to you.

Because the objectives of decision making in the face of localized prostate cancer are to allow an informed decision to be made and to minimize the regret associated with it, family physicians would be wise to discuss openly the absolutely worst-case scenarios possible: “How would you feel if you chose watchful waiting and the disease progressed more rapidly than foreseen and you found yourself with advanced metastatic disease at a palliative stage?” And on the other hand: “How would you feel if you chose surgery and you found yourself impotent or incontinent (after-effects of surgery); or if you chose radiotherapy or brachytherapy and you found yourself in pain or with a pelvic fistula (after-effects of radiation)?” Because the perception of these eventualities is much more explicit than the perception of death (we know we are going to die one day, but no one knows when or where) or of morbidity and quality of life (relative concepts perceived differently by different people), open discussion should help patients make a much more clearly informed choice.

Whatever the case, deciding what to do in the face of localized prostate cancer is never easy. No one can predict the future.