Patient trade-off

The trade-off dilemma in prostate cancer treatment refers to the choice between different treatments for localized prostate cancer (a tumor that is contained within the prostate). The choice is a trade-off between the expected beneficial and harmful effects in terms of patient survival and quality of life.

Symptoms specifically related to prostate cancer treatment, include urinary and bowel symptoms and waning sexual function which is the most prevalent source of severe distress in prostate cancer patients.Helgason ÁR, Adolfsson J, Dickman P, Fredrikson M, Arver S, Steineck G. Waning sexual function - the most important disease-specific distress for patients with prostate cancer. Br. J. Cancer. 1996: 73: 1417-1421.] The prevalence of these symptoms and the extent to which they distress the men vary between treatment forms and patients. Also, the relationship between distress owing to these symptoms and overall well-being varies considerably between patients. [Helgason ÁR, Adolfsson J, Dickman P, Fredrikson M, Steineck G. Distress due to unwanted side-effects of prostate cancer treatment is related to impaired well-being (quality of life). Prostate Cancer and Prostatic Diseases. 1998: 1:128-133.]

In the case of clinically localized prostate cancer one option is to abstain from curative treatment to avoid side effects. However, symptoms from the cancer and the fear of living with an untreated tumor may outweigh the fear of negative side-effects.

When doing trade-off's of this nature it is of central importance for the patient and the physician to have access to empirical information on established treatment benefits and side effects.

One example of a complicated trade-off is the willingness to trade off an intact sexual function for the possibility of a prolonged life expectancy by abstaining from curative treatment. A Swedish study found that the willingness to do this kind of trade-off varied considerably among the men included in the study. While six out of ten were willing to consider a trade-off between life expectancy and intact sexual function, given the present knowledge of treatment benefits for clinically localized prostate cancer, four out of ten stated that they would under all circumstances choose treatment irrespective of the risk for waning sexual function. In general the phenomenon of conceptual trade-off is poorly understood. The trade-off between the decreased risk of survival and the increased probability of intact quality of life is one such problem. Access to valid empirical information is crucial for such decision making. However the individual’s feeling towards the subject in question is also a factor based on emotional values and theological positions rather than knowledge. An individual that does not care about a certain documented side effect of treatment, even if there is no documented treatment benefit, may decide to choose the treatment so long as the theoretical possibility exists that there may be some positive treatment effects, although this has not been empirically established. The relatively complex dynamics of this kind of compromise are an interesting subject that needs to be studied in more detail.

A substantial proportion of patients and physicians for that matter, experience stress owing to trade-off between different treatment options and treatment side-effects. Given this stressful situation in addition to the stress of being diagnosed with cancer it is of great concern that eight out of ten prostate cancer patients have no one to confide in except their spouse and one out of five live in total emotional isolation. [Helgason ÁR, Dickman PW, Adolfsson J, Steineck G. Emotional isolation : Prevalence and the effect on well-being among 50-80 year old prostate cancer patients. Scandinavian Journal of Urology and Nephrology 2001 :35;97-101.] This indicates that psycho social support widely available at cancer clinics may not get through to men.

How localized prostate cancer should be treated may never be answered. We can only continue collecting valid information about the basis for the trade-off between different treatment forms and learn to communicate the data to the patient in a fruitful way.

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