Long-Term Decision Regret After Postprostatectomy Image Guided Intensity Modulated Radiation Therapy

Abstract

Purpose/Objective(s): Decision regret (DR) is a negative emotion experienced when a patient believes that their outcome may have been better if they had decided differently about their management approach. Although some studies investigate DR after treatment for localized prostate cancer, none have reported DR in patients undergoing surgery with post-prostatectomy radiotherapy. Our primary aim was to evaluate DR in this group of patients overall, and for specific components of therapy. Materials/Methods: We surveyed 83 consecutive patients, with a minimum 5 years follow-up, treated with post-prostatectomy image-guided intensity-modulated radiotherapy (PP-IG-IMRT). All patients were treated on the www.EviQ.org.au radiotherapy protocols using fiducial markers, MRI-CT fusion and inverse-planned IMRT, to a dose of 64-66 Gy. We used a validated 2-item questionnaire. Men were classed as regretful if they either indicated that it was true that they would have been better off had they chosen another treatment, or they wished they could change their mind about a treatment at least some of the time. Results: We received 71 responses (85.5%). The median patient age was 72 years (range 56-85), median time since surgery was 92 months, and median follow-up post-IMRT was 78 months. Adjuvant IG-IMRT was used in 28% of patients, salvage in 72%, and ADT in 48%. A total of 70% of patients remained disease-free, 16% had PSA-failure, and 14% had locoregional/distant failures. In all 16.9% of patients were regretful. There was four-fold more regret for the radical prostatectomy component of treatment compared to PP-IG-IMRT (16.9% vs 4.2%, P = 0.01). Of patients receiving ADT, 14.3% were regretful. Patients were regretful of surgery due to toxicity, not being adequately informed about radiotherapy as an alternative, positive margins, and cost of surgery (83%, 33%, 25%, and 8% of regretful patients, respectively). Toxicity was the main cause for regret in the 3 radiotherapy-regretful and 4 ADT-regretful patients. Patients were more regretful overall, and of surgery, for salvage vs adjuvant approaches (both 19.6% vs 10%). Conclusion: Patients are rarely regretful of post-prostatectomy IG-IMRT, but are significantly more regretful of their initial surgery due to surgical toxicity, not being informed adequately pre-operatively about radiotherapy as an alternative to surgery, positive margins, and cost of surgery. Patients are less regretful of surgery when radiotherapy is delivered in an immediate adjuvant approach. These findings have significant implications for urologists and radiation oncologists alike, particularly in relation to patient selection for radical prostatectomy (and likelihood of obtaining clear margins), the ability of urologists to adequately discuss radiotherapy as an alternative to radical prostatectomy, and the usage of immediate adjuvant (vs. early salvage) radiotherapy.