Negotiation Training Improves Active Surveillance Participation

Behfar Ehdaie, MD, MPH

With a little help from a negotiation expert, prostate cancer specialists persuaded significantly more men with low-risk prostate cancer to enroll in active surveillance, results of an observational study showed.

The proportion of candidates for active surveillance who selected that option increased from 69% in the 24 months before the intervention to 81% in the 12 months afterward. After adjustment for differences in time trends and case mix, the increase translated into a 30% reduction in the relative risk of overtreatment, Behfar Ehdaie, MD, MPH, reported at the 2016 American Urological Association meeting.

“Scholars in negotiation theory have described effective methods for achieving better agreement between individuals who have different perspectives, focusing on the importance of understanding and addressing underlying interests,” said Ehdaie, a surgical oncologist at Memorial Sloan Kettering Cancer Center (MSK) in New York. “In other words, it’s not what you say, but learning how to effectively say it.”

The physicians who treat prostate cancer have shouldered much of the blame for overtreatment of low-risk prostate cancer, as overtreatment often has been ascribed to clinicians’ “misaligned incentives.” However, a recent survey of radiation oncologists and urologists suggested that patient preference for aggressive treatment also contributes to overtreatment.¹

To see whether negotiation skills could play a role in physician-patient discussions about active surveillance, MSK recruited 5 surgical oncologists specializing in prostate cancer to participate in a 1-hour training session with a consultant in negotiation techniques. The consultant had been briefed about the issues surrounding active surveillance as an option for low-risk prostate cancer.

The 5 surgeons then applied the principles discussed during the training session in conversations with patients about active surveillance as an option for newly diagnosed, low-risk prostate cancer. The principal objective of the study was to compare the proportion of men opting for active surveillance in the 24 months prior to the training in negotiation versus the 12 months afterward.

Ehdaie offered 2 examples of how discussions of active surveillance might have differed before and after the surgeons participated in the training session.

Before the training, the surgeons might have said, “Mr. Jones, I recommend active surveillance for your prostate cancer.”

Afterward, the same information might have been conveyed thusly: “Mr. Jones, I spent over 15 years training to be a surgeon, and I enjoy the challenges in the operating room. Despite my belief that surgery is beneficial in most cases, I recommend active surveillance for your prostate cancer.”

Another example related to the approach to follow-up in active surveillance. Before the training, a surgeon might have said, “Mr. Jones, we will monitor your cancer by checking a PSA every 6 months and repeating a biopsy every 2 years.”

After the negotiation training, the conversation might have begun with: “Mr. Jones, we believe that the PSA test has enabled us to find your cancer 4-6 years early, and changes to your tumor are not expected until the second decade after diagnosis. Therefore, we can see you again in 5 years; however, we will monitor your cancer closely and check a PSA every 6 months and repeat the biopsy every 2 years.”

During the 12-month study period, the treatment plan was verified by chart review for each patient who discussed active surveillance with 1 of the 5 surgeons. Additionally, Ehdaie and colleagues collected data about clinic-room time as a surrogate for physician consultation time.

The study included 242 patients enrolled during the study period and 761 who discussed active surveillance in the 24 months before the study. The two groups did not differ with respect to age (60), comorbidity score, race, tumor classification (very low risk, low risk), or PSA level.

The 12% absolute increase in active surveillance in the unadjusted analysis decreased to 9.1% in the fully adjusted analysis. Comparison of the clinic-room time before and after the negotiation intervention showed no significant change in consultation time after the intervention.

“A systematic approach to counseling men, using appropriate framing principles, can be taught to physicians and incorporated in clinic to reduce the burden of overtreatment,” said Ehdaie. “Our approach provides a framework to advance the physician-patient relationship and may help alleviate overdiagnosis and overtreatment that occurs across medicine.”

1. Kim SP, Gross CP, Nguyen PL, et al. Perceptions of active surveillance and treatment recommendations for low-risk prostate cancer: results from a national survey of radiation oncologists and urologists.Medical Care. 2014;52:579—585.