Patients Preferences in Prostate Cancer Screening

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Robyn Foster
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1 Patients Preferences in Prostate Cancer Screening Murray Krahn MD MSc FRCPC Director, THETA F. Norman Hughes Chair and Professor University of Toronto

2 Shared Decision Making Decision analysis 1. Invite the patient to participate 2. Present options Choices 3. Present information on benefits and risks 4. Assist patient in evaluating options based on goals and concerns Chances Outcomes 5. Facilitate deliberation and decision making 6. Assist with implementation

4 Outline... PSA screening is a preference sensitive decision Patient preferences and clinical practice guidelines A sad story... Preferences in prostate cancer what we know

5 LE gains, QALY losses

7 What is a preference sensitive decision?

10 Preference sensitivity Reasonable alternatives exist. Competing risks and benefits Evidence is weak Preferences (for outcomes/treatments) vary

11 Clinical practice guidelines and preferences.

12 a sad story...

13 CCO Clinical Practice Guideline Committee Systematic Review of the evidence 0 decision analyses... 0 cost effectiveness analyses 0 quality of life studies... 0 preference studies...

16 AUA Guidelines Guideline Statement 1: The Panel recommends against PSA screening in men under age 40 years. (Recommendation; Evidence Strength Grade C) Guideline Statement 2: The Panel does not recommend routine screening in men between ages 40 to 54 years at average risk. (Recommendation; Evidence Strength Grade C) Guideline Statement 3: For men ages 55 to 69 years the Panel strongly recommends shared decision-making for men age 55 to 69 years that are considering PSA screening, and proceeding based on a man's values and preferences. (Standard; Evidence Strength Grade B) Guideline Statement 4: To reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening Guideline Statement 5: The Panel does not recommend routine PSA screening in men over age 70 years or any man with less than a 10 to 15 year life expectancy. (Recommendation; Evidence Strength Grade C)

17 Scientific Paradigm an entire constellation of beliefs, values and techniques shared by the members of a given community [Kuhn, T S; The Structure of Scientific Revolutions, 2nd Ed., Univ. of Chicago Press, Chicago & London, 1970, p.175]

18 Scientific Paradigm what is to be observed and scrutinized, the kind of questions that are supposed to be asked how these questions are to be structured, how the results of scientific investigations should be interpreted. [Kuhn, T S; The Structure of Scientific Revolutions, 2nd Ed., Univ. of Chicago Press, Chicago & London, 1970, p.175]

19 Paradigm 1 Evidence Based Medicine Clinimetrics (Feinstein) Clinical Epidemiology (Sackett) Rational diagnosis and treatment (Wulff) Outcomes /Health Services Research Knowledge Translation

20 Paradigm 2 Decision Analysis/ Economic Evaluation Cost effectiveness analysis Pharmacoeconomics Health Economics Clinical Decision Analysis Preference/utility measurement Consumer decision support

21 Paradigm 3 Bioethics / Social Science Accountability for Reasonableness Ethics of Resource Allocation Resource Allocation Decision Making Bioethics Sociology of Science Political Science

22 Method EBM ideas about evidence Context-free Efficacy Effectiveness Diagnosis Prognosis Context-sensitive ethics economic Colloquial values politics Relevance Lomas and Culyer

23 EBM techniques

24 values evidence

25 What are preferences? Patient centered care Values Preferences Decision utility Experienced utility Satisfaction Needs/desires/expectations Subjective well being

26 Utility- a history 18 th -19 th centuries, Utilitarian philosophers pleasure, good, or happiness, or prevention of pain, evil, or unhappiness, which was produced by an object. Interestingly MORALITY also grounded in utility, moral behaviours were defined as those which increased the happiness or pleasure of the individual or the community.

27 Lenert et. al. Validity and interpretation of preference based measures of health-related quality of life Medical Care 2000;388: suppl II,

28 In the medical context Utility- preference, attached to a health-related outcome, often referred to as a health state reflects not only health status, but valuation of health status Health status anchored at 0 (dead) and 1) (full health)

29 Advantages meaning of symptoms to the individual are captured global measure of health status strong theoretical foundation can be used in economic evaluation

30 Standard Gamble P (vary) Perfect health 1-p Immediate death SG Intermediate health state

31 EQ-5D (3L)

32 Preferences for what? Table 2. Health Effects in Cancer Screening Programs Outcomes in Cancer Screening Screen itself (discomfort, pain) Confirmatory tests Early labeling, cancer Cancer anxiety in false positives or indeterminate tests Reassurance that no cancer is present Effects of cancer treatment Effects of treatment complications Effects of disease recurrence/progression Effects of treatment for disease progression Advanced or metastatic disease Treatment of advanced or metastatic disease

37 PORPUS WEIGHTING SYSTEM Pain Energy Social Support MD communication Emotional Urinary frequency Urinary leakage Sexual function Sexual interest Bowel problems Utility (worst sexual function) Utility (worst urinary function) Utility (worst bowel function) Best health state Worst health state Dead 0

41 Clinical and demographic predictors of utilities in 540 community-dwelling PC patients Variable PORPUS-U i HUI2 HUI3 Patient-related Age Marital status Education Employment Income Comorbidity r 2 (patient-related) Disease-related Radical prostatectomy Radiation therapy Hormone therapy Metastatic disease Tumour grade r 2 (patient & disease-related) System-related Year of diagnosis County r 2 (patient, disease, & system-related) Symptom-related PCI Bowel function <0.001 <0.001 <0.001 PCI Sexual function < PCI Urinary function < r 2 (all variables) p-values are from a regression model with all variables r 2 values are from 4 models: the first included patient-related variables, the second included patient and disease-related variables, the third included patient, disease, and system-related variables, and the fourth used all variables

46 Allan Detsky JAMA 2012;307:1035-6

47 Summary PSA screening for prostate cancer is a preference sensitive decision CPG s that acknowledge the legitimacy of preferences are likely to recommend shared decision making Outcomes: Validated, patient derived, preference based instruments exist for PC patients Complications of treatment Significant and lasting But modest in size (on average) No measurable effect of screening/labeling, reassurance (but.. )

51 Why do guidelines for prostate cancer screening differ?

52 Outline Decision analysis and shared decision making? PSA screening is a preference sensitive decision Guidelines differ (in part) because of the relative weight of preferences What outcomes should we elicit preferences for

55 Summary PC screening guidelines differ One reason is varying weights placed on patient values/experiences PC screening is a preference sensitive decision Bringing preferences into evidence based decision making has risks but is probably overdue.

Screening and Diagnosis Prostate Cancer

Screening and Diagnosis Prostate Cancer Daniel Heng MD MPH FRCPC Chair, Genitourinary Tumor Group Tom Baker Cancer Center University of Calgary, Canada @DrDanielHeng Outline Screening Evidence Recommendations