The Hidden Cost of Prostate Cancer Surgery: Patient Regret

According to a survey of 2072 patients, men with early-stage prostate cancer who chose radical prostatectomy, the operation for prostate cancer, were more likely to regret their decision than those who chose radiotherapy or active surveillance.

At 5 years, 13% of the men surveyed experienced treatment-related regret, with differences by type of treatment:

• 16% of surgical patients (183) regretted their decision, compared with
• 11% of men who chose radiotherapy (76) and
• 7% of those who chose active surveillance (20).

NOTE: Active surveillance: If someone has low-risk cancer, active surveillance may be a good option. It may be recommended for people with slow-growing cancer or other serious health problems. This approach involves monitoring the cancer with regular tests and biopsies. Active surveillance is preferred when we consider the disease a process that needs to be followed over time rather than an immediate threat.

Reasons for Regret

In all 3 groups, the main reason for regret was the feeling that patients had not been fully informed about the risks and benefits of these approaches, particularly the risks of surgery.

Contributing to treatment-related regret were other factors as follows:

• a disconnect between patient expectations and treatment outcomes regarding both treatment effectiveness and side effects,
• erectile dysfunction,
• urinary incontinence and
• patient-reported functional outcomes that included bowel dysfunction.

The study was published online on November 18, 2021 in JAMA Oncology.

This study provides strong evidence for the need to give in-depth information about medical interventions and make treatment decisions jointly.

Given the potential to improve quality of life and reduce decisional regret, doctors need to take time to assess and address patients' treatment concerns.

Study Details

The men surveyed had been diagnosed with low-risk prostate cancer at various centers in the United States between January 2011 and December 2012.

The participants were members of the Comparative Effectiveness Analysis of Surgery and Radiation (CEASAR) study, launched a decade earlier primarily to compare the effectiveness of surgery and radiation.

The median age at diagnosis was 64. Radiotherapy patients (32%) were older, had more comorbidities (additional illnesses) and had slightly higher-risk prostate cancer than surgical patients (55%). Men who chose active surveillance (13%) were typically older than those who underwent surgery but younger than the radiotherapy group, and were more likely to have low-risk disease.

The authors measured patients' regret using a questionnaire with statements such as:

"I would have been better off with a different treatment",

"I think the treatment was wrong",

"I would choose another treatment if I could",

"I wish I could change my mind about the treatment I chose" — these were among the statements included in the questionnaire.

The surveyed patients with prostate cancer were assessed 6 months, 1 year, 3 years and 5 years after diagnosis. At year 5, the survey response rate was 71%.

After adjustment for baseline differences, men who underwent surgery were, 5 years later, twice as likely to regret their decision as men who chose active surveillance.

Unsurprisingly, regret was much more common among men who judged their treatment to be much less effective and its side effects much more severe than expected.

Interestingly, participatory decision-making and social support appeared to protect against regret.

The study authors noted that, given the recommendations of the US National Comprehensive Cancer Network, many men with low-risk disease who previously underwent surgery or radiotherapy could be offered active surveillance today.

Even so, improved information at diagnosis and before treatment, including identifying patients' values and priorities, may reduce regret among these patients.