Medicine operates under an assumption that “patients will naturally gather evidence about the risks and benefits of each medical choice, apply their values to that evidence, and reach a considered decision.” In other words, that patients will generally make “autonomous” decisions, meaning decisions that are 1) intentional rather than habitual, impulsive, accidental, or forced; 2) involve substantial understanding of the nature of the decision, the foreseeable consequences, and possible outcomes; and 3) are not subject to controlling influences. Although this assumption has been challenged in other areas of medical decision-making, herein we want to challenge it within the context of treatment decision-making regarding localized, low-risk prostate cancer. Many men will face this decision given that there are 220,800 new cases of prostate cancer diagnosed each year in the United States. Yet there is alarming evidence to indicate that patients may not be properly informed about their options, particularly expectant management options such as watchful waiting or active surveillance. In addition, there is further evidence that men may be especially prone to using intuition, impulse, and “heuristics” or mental shortcuts in their decision-making, all of which threaten autonomous decision-making. Two recent articles in this journal have highlighted the complexities of treatment decision-making in patients with low-risk prostate cancer. As Filson et al note in their article, men with a new diagnosis of localized prostate cancer face an array of treatment options, each associated with high disease-specific survival given the slow-growing nature of many prostate cancers. Radical prostatectomy and radiation therapy are the most commonly used treatments for localized prostate cancer, and each has associated treatment-related complications that impact men’s quality of life. Increasingly, active surveillance is being recommended by clinical guidelines as a treatment option for men with low-risk disease. Unlike watchful waiting, active surveillance involves careful monitoring of the disease with an expectation of curative treatment if there is progression. Although active surveillance has disadvantages of periodic testing and associated anxiety, its major advantage is the preservation of current health and the avoidance of treatment-related complications, including impotence and urinary and rectal incontinence. Despite the appropriateness of expectant management strategies such as active surveillance for patients with early-stage prostate cancer, as highlighted by Filson et al in their article, men who might benefit from expectant management are not routinely offered the option. Other studies have reported similar findings. One report found that only 10 of 25 patients with early-stage prostate cancer were offered a treatment choice, whereas another found that of 21 men (19 of whom chose surgery or radiation), few remembered active surveillance being presented as a viable option and another study found that health professionals were less likely to discuss active surveillance for localized prostate cancer with Hispanic patients compared with white patients. Furthermore, studies have found biases and heuristics at work in patients’ decision-making (all favoring surgery or radiation) such as the “commission bias” (doing something is better than “doing nothing” even if the “something” causes more harm) and the “availability bias” (reliance on anecdotal stories), in addition to fear, heavy reliance on physician recommendation, reported pressure from family, and lack of awareness that treatment does not guarantee improved survival. These findings regarding prostate cancer decisionmaking are ethically significant given that they imply that prostate cancer decision-makers may not be as autonomous as we would assume. They also raise concerns about patient well-being given the risk of harm associated with surgery and radiation. An 8-year follow-up study of 272 men showed that men who underwent surgery consistently reported more urinary leakage and impaired erection and libido. Findings from the Prostate Cancer Intervention Versus Observation Trial (PIVOT) showed higher rates of urinary leakage and erectile dysfunction among men

中文翻译：

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在前列腺癌治疗决策中迈向道德上负责任的选择架构

医学的运作假设“患者自然会收集有关每种医疗选择的风险和益处的证据，将他们的价值观应用于该证据，并做出深思熟虑的决定。” 换句话说，患者通常会做出“自主”决定，即：1) 有意而非习惯性、冲动性、偶然性或强迫性的决定；2) 涉及对决定的性质、可预见的后果和可能的结果的实质性理解；3) 不受控制影响。尽管这一假设在医疗决策的其他领域受到了挑战，但在这里我们想在关于局部低风险前列腺癌的治疗决策的背景下挑战它。鉴于有 220 个，许多男人将面临这个决定，美国每年诊断出 800 例新的前列腺癌病例。然而，有令人震惊的证据表明，患者可能没有正确地了解他们的选择，尤其是期待的管理选择，例如观察等待或主动监测。此外，还有进一步的证据表明，男性可能特别容易在决策中使用直觉、冲动和“启发式”或心理捷径，所有这些都会威胁到自主决策。该杂志最近的两篇文章强调了低风险前列腺癌患者治疗决策的复杂性。正如 Filson 等人在他们的文章中指出的那样，新诊断为局限性前列腺癌的男性面临着一系列治疗选择，鉴于许多前列腺癌的缓慢生长性质，每一种都与高疾病特异性存活率相关。根治性前列腺切除术和放射治疗是局部前列腺癌最常用的治疗方法，每种方法都有相关的治疗相关并发症，影响男性的生活质量。临床指南越来越多地推荐主动监测作为低危男性患者的治疗选择。与观察等待不同，主动监测涉及对疾病的仔细监测，并期望在出现进展时进行治愈性治疗。尽管主动监测存在定期检测和相关焦虑的缺点，但其主要优点是保持当前健康并避免治疗相关并发症，包括阳痿、尿失禁和直肠失禁。尽管 Filson 等人在他们的文章中强调了诸如对早期前列腺癌患者进行主动监测等预期管理策略的适当性，但通常不会为可能从预期管理中受益的男性提供这种选择。其他研究报告了类似的发现。一份报告发现，25 名早期前列腺癌患者中只有 10 名被提供了治疗选择，而另一份报告发现，在 21 名男性（其中 19 人选择手术或放疗）中，很少有人记得主动监测是一种可行的选择，而另一研究发现，与白人患者相比，卫生专业人员不太可能与西班牙裔患者讨论对局部前列腺癌的主动监测。此外，研究发现在患者的决策（都倾向于手术或放疗）中存在偏见和启发式方法，例如“委员会偏见”（即使“某事”会造成更大的伤害，做某事也比“不做”要好）和“可用性偏差”（依赖轶事）、恐惧、严重依赖医生推荐、来自家人的报告压力以及缺乏治疗并不能保证提高生存率的意识。这些关于前列腺癌决策的发现在伦理上具有重要意义，因为它们意味着前列腺癌决策者可能不像我们想象的那样自主。考虑到与手术和辐射相关的伤害风险，他们还引起了对患者健康的担忧。一项对 272 名男性进行的为期 8 年的随访研究表明，接受手术的男性始终报告更多的尿漏和勃起和性欲受损。前列腺癌干预与观察试验 (PIVOT) 的结果显示男性尿漏和勃起功能障碍的发生率较高