Scientific ArticleThe Informational Needs of Prostate Cancer Patients Treated with Radical Prostatectomy Regarding Adjuvant or Salvage Radiotherapy: Determinants of Community Health Pilot Project
Introduction
Prostate cancer is the most frequently diagnosed cancer in Canadian men and is the third most prevalent cause of cancer death among Canadian men. Approximately half of all newly diagnosed prostate cancers occur in Canadians aged 70 or older [1]. Radical prostatectomy is a well-known treatment modality for localized prostate cancer. Adjuvant radiotherapy (RT) refers to radiation treatment administered within the first six months after radical prostatectomy, whereas salvage RT refers to radiation treatment administered when biochemical failure has occurred (i.e., a detectable elevation in prostate-specific antigen [PSA]) [2].
The role of adjuvant and salvage RT remains controversial in terms of the timing of the treatment after radical prostatectomy. Numerous retrospective studies and three recently completed randomized trials have demonstrated improved biochemical control and/or disease-free survival with adjuvant RT [2], [3], [4], [5]. However, the overall survival benefit is unclear because the randomized trials comparing post-prostatectomy RT with observation alone were underpowered to detect significant improvement, and longer follow-up is necessary. Adjuvant RT after radical prostatectomy, for men with pathological stage T3 prostate cancer, significantly reduced the risk of metastasis and increased survival [6]. Despite these encouraging results, several investigators still propose waiting for evidence of biochemical failure and subsequently attempting salvage RT [2], [3], [4], [5], [6].
Many post-prostatectomy patients are not referred for adjuvant RT or are referred for salvage RT when their PSA becomes elevated. Waiting decreases the chances of success of postoperative RT and can have a negative impact on disease control. Ultimately, it is the patient’s decision whether to undergo adjuvant or salvage RT; however, the patient’s decision will likely be based on information provided by various health care providers such as radiation oncologists, urologists, and family physicians. Because there is ambiguity and uncertainty surrounding adjuvant RT and salvage RT, this information may be conflicting in content, difficult to understand, and may contain personal bias [7]. Thus the patients may experience feelings of anxiety and/or depression if they have not been offered adequate information or conflicting information regarding their treatment plan [8], [9].
There are many factors that could affect the informational needs of prostate cancer patients and how informed they feel in the decision-making process regarding their treatment plan. Some of these factors might include socioeconomic status, social support, and language ability. Levels of income and associated educational attainment have been shown in the literature to affect prostate cancer patients’ informational needs. One such study conducted in Australia found that unmet psychological need was greatest in low-income prostate cancer patients, and prostate cancer patients with a primary education had the greatest need with respect to health system information and psychological and sexuality domains [10]. Another study from the University Medical Associates Clinic at the University of Virginia and the Central Virginia Community Health Center in Buckingham County, both low-income general medical clinics, investigated knowledge about prostate cancer among African-American men older than age 40. It was found that men from these clinics had limited comprehension about prostate cancer [11]. This informational gap is also seen in patients with other types of cancers. For example, Hwang reported that a lower level of education was a significant predictor of unmet informational need in breast cancer patients in Korea. Additionally, this study showed that breast cancer patients with a higher level of education were more likely to report unmet needs to their health care professionals [12].
It has been well-established in the literature that patient participation in their health care decisions not only helps facilitate informed consent, but has also increased patient satisfaction with treatment choices and associated outcomes. In addition, participation has been linked with decreased psychological morbidity associated with treatment. To help patients with treatment choices, decision aids (DAs) have been frequently used. DAs are educational tools used within the health care setting designed to help patients through the decision-making process [13]. The content that is put into a DA comes from both the medical experts (health care professionals) and from the patients [13]. However, it has been demonstrated that there is considerable variability among health care professionals and patients about what information is considered important to the decision [7], [13], [14]. Therefore, a pilot study was conducted to explore postprostatectomy prostate cancer patients’ informational needs and experiences going through the decision-making process of salvage or adjuvant RT. Furthermore, by determining the influence that socioeconomic status, with respect to income and education, has on the patients’ information gaps, health care providers can further refine the delivery and content of information. The findings from this study will provide information for the future development and testing of a DA for patients with prostate cancer after radical prostatectomy to assist them in making decisions about their adjuvant or salvage RT treatment options.
Section snippets
Questionnaire Development
The questionnaire format was chosen as the most relevant method of evaluation as the majority of information needs assessment studies identified in the literature used a questionnaire or survey format as the main tool for data collection. Questionnaires are easy to administer and are a fairly straightforward method for analyzing and interpreting the results. A closed-format questionnaire was chosen to allow for responses to be grouped and a Likert scale was used for easy data interpretation and
Results
Of the 10 participants, five were between the ages of 55 and 64 years and the other five were between 65 and 74 years of age. Seven participants were white (Caucasian/European) and the other three were black (African/Caribbean/American). The participants’ total annual income and their level of education were broadly distributed among five categories (Figure 1, Table 1).
The mode for each Likert item was a 3, which corresponded to having “some” knowledge about the topic, except for two Likert
Discussion
Our pilot study of 10 participants suggests that post-prostatectomy prostate cancer patients appear to have some knowledge about the disease and its treatments. The questionnaire highlighted certain knowledge gaps, largely in the management of RT-related side effects, survival rates for different treatment options, local recurrence rates for various treatments, and symptoms that may signal recurrence. Providing information to patients can enhance their ability to cope with the disease and
Conclusion
This pilot study demonstrated that prostate cancer patients have some knowledge about the disease and its treatments, but were lacking information in areas such as the management of RT-related side effects, survival rates for different treatment options, local recurrence rates for various treatments, and symptoms that may signal recurrence. These topics should be comprehensively discussed with the patients by the radiation oncologists in the initial consultation.
Despite correlations observed in
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