“If there is such a clear difference between what different physicians are recommending, that calls into the need for patients to be more involved in decisions,” says Angela Fagerlin, PhD.
A secondary analysis of data from a randomized clinical trial (NCT02053389) was recently published looking at the level of concordance or discordance between physician recommendations for treatment of patients with prostate cancer.1 In this interview, Angela Fagerlin, PhD, discusses some of the key findings and takeaways from the study, highlighting how the results point to a need for increased shared decision-making. Fagerlin is the Chair of the Department of Population Health Sciences at the University of Utah School of Medicine, Salt Lake City.
Back in the 1990s, there were a couple of studies showing that in survey studies where physicians would read scenarios about different patients, urologists would recommend surgery for those patients and radiation oncologists would recommend radiology for the same patient. This was published in JAMA,2,3 and there was a little bit of an uproar about how there could be bias here and that people were being driven by their specialty in the recommendations they made for patients.
At the time, I was at a different institution than I am now, and that institution had multidisciplinary clinics where a patient would see both a urologist and a radiation oncologist, often at the same visit in a random order. Sometimes they would start with a urologist, sometimes they would start with the radiation oncologist. We thought that this setting would be a really great place to test whether surgeons and radiation oncologists are still making different recommendations based on their own specialty and potentially the biases that their specialty training has brought out to them.
This scenario, this multidisciplinary clinic, would be a place where it would be less likely, potentially, for that to happen, because the radiation oncologists and urologists work together to develop this clinic. They work well together and [although] I'm not a physician, my scene of the interactions suggested they really respected each other and each other's specialty. We thought it'd be a great place to test out whether this was still happening, this tendency to recommend your specialty for any given patient.
What we found is that when a urologist and a radiation oncologist saw the same exact patients —this is a real patient in the clinic, just like in the studies—urologists were more likely to recommend surgery and radiation oncologists were more likely to recommend radiation. To put some numbers behind that, urologists recommended surgery for 79% of the patients that they saw. Interestingly, radiation oncologists recommended surgery for 57% of the patients, so there was about a 25% difference.
Similarly, radiation oncologists recommended radiation 68% of the time, but a little bit differently, surgeons only recommended radiation therapy about a third of the time. So, they did still recommend each other specialty on occasion, but by far were more likely to recommend their own type of treatment than the others.
Physicians—either type—can recommend surgery, radiation, or active surveillance. We looked to see how often they agreed in their recommendation of 1, 2, or 3 of these. We found that very rarely did they actually agree on the recommendation in terms of how many they recommended. In fact, I think only about a third of the patients did they completely agree on the recommendations that they made.
We're a little surprised that number was so low. We thought that there would be more concordance, especially because most of these patients were early-stage prostate cancer where likely, surgery, radiation, and active surveillance would have been an appropriate treatment for most of the patients. We were just surprised that there wasn't that much agreement between the radiation oncologists and the urologists.
We're still thinking about that a little bit. I have moved institutions and am doing a little bit different research now, but there seems to be an area where we could move this work forward. One of the issues is how do we get patients involved in the decisions? If there is such a clear difference between what different physicians are recommending, that calls into the need for patients to be more involved in decisions.
Other work that I have done and have published has shown that the primary driving factor of what treatment a patient gets is a physician's recommendation. So, not the patient's preferences, their goals, any of those things, but rather it was the physician recommendation. If we could work with physicians to help when they're making those recommendations pull out more about what the patient wants, I think that would be really powerful. Getting to do that is tricky. These appointments are complex and long as it is, but that's where I would think would be the next place to go. How can we get the patient's voice more activated?
In a couple of studies that we've recorded the visits between patients and their prostate cancer physicians, there's not a lot of talking about the patients. That's where it would be really interesting to see if we could change that dynamic and interaction between patients and their providers.
I would just ask that urologists really think about their biases. It's been interesting. In a number of cases, we've seen urologists say, "Hey, I'm biased. I'm a surgeon. I was taught that this is a great method. You need to go talk to my colleagues who are radiation oncologists, just so that you can balance this out." We actually showed in a study in the Proceedings of the National Academy of Science4 that when the physician said that, the patients actually trusted them more, because they acknowledged that they have this potential bias.
We're all human, including urologists and radiation oncologists, so we need to be aware of those biases and be honest about it. Though, that often made people trust the urologist so much that they didn't go to see the radiation oncologist, so that might be not exactly what we're hoping for. It really suggests that before you make these recommendations—because of this underlying potential for bias—it’s important to ask the patient questions that get at what they want. In a lot of our recordings, we heard "so you know, I really think that this treatment would be best. What do you think? That sounds good? Patient: 'Yes.’ "
There hadn't been talk about [things like] how much [they are] sexually active. Different treatments have a very big difference in impact on erectile dysfunction. People who are not planning to have sex, they're 75 and they're widowed, or they're no longer having a lot of sex with their partner, that might not be a condition. But a newly married 65-year-old with an active sex life, that might be a real factor in their decision-making. What we've seen from tapes from this study and others is that there aren't a lot of questions about how important these are or how much it would stress them out to do active surveillance and have to worry about the cancer growing. There isn't a lot of this in-depth discussion.
It's more like a data dump: "Hey, here are the treatments, either of the 3 treatments. These are the risks and the benefits." They do a phenomenal job, the radiation oncologists and urologists, of telling you all the risks and benefits and providing all this information. Where we really need to see change is talking about what the patient wants, what they're worried about, and what would work best for them. Do they have a job where they can go to the bathroom frequently if they're having incontinence issues? Or are they a truck driver, where it's really hard to go to the bathroom? Asking these questions and involving the patient is what I would ask urologists to try to incorporate a little bit more in their practice.
1. Delaney RK, Sisco-Taylor BL, Wang X, et al. Two specialists, two recommendations: discordance between urologists’& radiation oncologists’ prostate cancer treatment recommendations. Urology. 2022;169:156-161.doi:10.1016/j.urology.2022.06.009
2.Fowler Jr. FJ, McNaughton Collins M, Albertsen PC, Zietman A, Elliott DB, Barry MJ. Comparison of recommendations by urologists and radiation oncologists for treatment of clinically localized prostate cancer. JAMA. 2000;283(24):3217-3222. doi:10.1001/jama.283.24.3217.
3. Wilt TJ. Uncertainty in prostate cancer care: the physician’s role in clearing the confusion. JAMA. 2000;283(24):3258-3260. doi:10.1001/jama.283.24.3258
4. Sah S, Fagerlin A, Ubel P. Effect of physician disclosure of specialty bias on patient trust and treatment choice. Proc Natl Acad Sci U S A. 2016;113(27):7465-7469. doi:10.1073/pnas.1604908113