Treatment decision-making among patients with metastatic prostate cancer: Impact of decision locus of control on functional outcomes and decision satisfaction

Treatment decision-making among patients with metastatic prostate cancer: Impact of decision locus of control on functional outcomes and decision satisfaction | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Treatment decision-making among patients with metastatic prostate cancer: Impact of decision locus of control on functional outcomes and decision satisfaction Alicia Morgans, Frank Schumacher, Irene Helenowski, Zequn Sun, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2129512/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Jan, 2023 Read the published version in Prostate Cancer and Prostatic Diseases → Version 1 posted 9 You are reading this latest preprint version Abstract Background Shared decision-making (SDM) for metastatic prostate cancer (mPC) engages patients in the decision-making process and may be associated with better outcomes relative to physician- or patient-directed decision-making. We assessed the association between decision locus of control (DLOC) and patient-reported quality of life (QOL), functional outcomes, and decision satisfaction among mPC patients. Methods After a clinic visit in which a treatment decision was made (baseline), mPC patients completed DLOC and QOL surveys. QOL was re-assessed at 2- and 4-months post-baseline. Mean scores for each QOL dimension (physical, emotional, cognitive, social, and role functioning) were compared by DLOC group using mixed effects models. Patient preferences for DLOC and provider communication techniques were similarly collected via survey. Results Median age of participants (N = 101) was 69 years (range: 49–92); most were White (80%) and married (82%). 62% reported using SDM. At baseline, there were no differences in QOL dimensions between DLOC groups. At 4 months, patient-directed ( p = 0.01) and SDM ( p = 0.03) were associated with better physical functioning than physician-directed decision-making, and there was a trend toward greater decision satisfaction among patients who reported patient-directed (p = 0.06) or SDM (p = 0.10). SDM was the most reported preferred DLOC. Conclusion mPC patients reporting SDM had better physical functioning and a trend toward greater decision satisfaction at 4 months than physician- or patient-directed decision-making, suggesting measurable benefit from patient involvement in decision-making. Future investigations of these associations in larger, more diverse populations can further clarify these previously unmeasured benefits of patient engagement in treatment decisions. Figures Figure 1 Figure 2 Figure 3 Introduction Prostate cancer remains the most common malignancy among American men and an important cause of cancer-related morbidity and mortality. [ 1 ] Despite continuing advances in care, metastatic prostate cancer (mPC) is an incurable disease, and the second leading cause of cancer death among men in the US. Recent advances have created a multitude of treatment options, each with a unique set of benefits and side effects. To date, there have been no direct comparisons of the various treatment options for mPC. This suggests differential benefit in terms of disease control, making treatment decision-making a complicated process for providers and patients. Thus, treatment decisions commonly depend on physician preferences and experience. An individualized approach to treatment decisions is preferred based on efficacy, as well as patient preferences, priorities, potential side effects, follow-up requirements, and cost of care. [ 2 ] This approach may be facilitated by shared decision-making (SDM) among patients, physicians, and caregivers, which has been identified by the National Academy of Medicine, the American Urological Association, and others as a priority method to improve the quality of cancer care in the US through patient engagement and autonomy. Decision-making preferences are highly individualized and vary widely among cancer patients, with patients reporting heterogeneous preferences for decision-making roles. [ 3 – 6 ] The extent that decision-making roles have impacted patient functional outcomes and decision satisfaction in mPC have not been described. Therefore, the primary goal of this study was to assess the impact of decision locus of control (DLOC), whether SDM, physician- or patient-directed, on functional outcomes and decision satisfaction for mPC patients. This study also assessed patients’ preferences for DLOC when making decisions regarding their treatment. We previously reported the communication techniques that patients, caregivers, and physicians felt aided decision-making, and this study further assessed patient preferences for communication techniques. [ 7 ] Materials and Methods Participants and Procedures We assessed DLOC following a clinic visit in which a treatment decision occurred (baseline), and assessed patient-reported functional outcomes at baseline, 2-months post-treatment decision, and 4-months post-treatment decision. We evaluated patient-reported preferences for DLOC among mPC patients following a clinic visit in which a treatment decision had occurred. Treatment decisions included any decision to change the treatment approach to the prostate cancer, associated pain or comorbidities, or to maintain the current treatment approach. This study was approved by the Institutional Review Board at Vanderbilt University Medical Center (VUMC; approval #161441) and Northwestern Memorial Hospital (NMH, approval #STU00206080). Between 2018 and 2020, patients with mPC were recruited from Genitourinary Oncology clinics at VUMC and NMH. Eligible patients spoke English, were able to recall a decision at a clinic visit within the preceding 48 hours and signed informed consent to participate. There were no restrictions or requirements regarding prior local or systemic treatment exposure. Patients completed electronic surveys describing the decision-making process, decision satisfaction, and quality of life (QOL) outcomes via REDCap on tablets in clinic. Patient sociodemographic and clinical characteristics, including age, race/ethnicity, marital/partner status, self-reported health status (i.e., excellent, good, fair, or poor), and insurance status were collected by patient self-report and electronic medical record when possible to reduce missing data. The study was supported by a grant from the Department of Defense Prostate Cancer Research Program (PC150398). Surveys Decision Locus of Control. Patients were enrolled after completing a physician visit in which a treatment decision was made before leaving the clinic. Participants completed a survey describing the role they played in the decision using a modified version of the Control Preferences Scale, [ 4 , 8 , 9 ] which has been used in assessments of decision making among patients with cancer and is reliable in defining decisional preferences in a unidimensional scale. [ 10 – 12 ] This modified version of the 5-item scale asks participants to describe decision roles as physician-directed (e.g., “Your doctors made the decision with little or no input from you”), SDM (e.g., “You and your doctors made the decisions together”), or patient-directed (e.g., “You made the decisions after seriously considering your doctor’s opinion”). Quality of Life. Patients completed the European Organization for Research and Treatment of Cancer Quality of Life of Cancer Patients (EORTC-QLQ-30) questionnaire at baseline immediately following a treatment decision, 2-months post-treatment decision, and 4-months post-treatment decision. The EORTC-QLQ-30 questionnaire is a validated study tool to evaluate patient functioning and provides scales in domains of physical, emotional, cognitive, social, and role functioning, with higher scores on each domain indicating better functioning. [ 13 ] Decision Satisfaction. Patients completed the Satisfaction with Decisions survey regarding their current satisfaction with their decision at baseline immediately following a treatment decision, 2-months post-treatment decision, and 4-months post-treatment decision. [ 14 ] The survey explored how patients felt they were informed (i.e., “I am satisfied that I am adequately informed about the issues important to my decision”), consistency with personal values (i.e., “I am satisfied that my decision was consistent with my personal values”), expectations to carry out decision (i.e., “I expect to successfully carry out…the decision I made”), and overall satisfaction (i.e., “I am satisfied with my decision”). Communication Preference Surveys. In addition to the responses regarding DLOC described above, participants completed surveys before leaving the clinic describing their preference for their DLOC. They were reminded of a recent treatment decision with the following prompt: “Consider a recent treatment decision that you made for your prostate cancer. Describe how you prefer to make treatment decisions”, and then provided with a modified version of the Control Preferences Scale. [ 4 , 8 , 9 ] This modified version of the 5-item scale classifies preferences for decision roles as physician-controlled (“You prefer that the doctors make the decision with little or no input from you.” or “You prefer that the doctors make the decision after seriously considering your opinion.”), SDM (“You prefer that you and your doctors made the decision together.”), or patient-controlled (“You prefer to make the decision after seriously considering your doctor's opinion.” or “You prefer to make the treatment decision with little or no input from your doctors.”). Patients also completed the Communication Assessment Tool, a 15-item survey that is reliable and valid in identifying patient perceptions of physicians’ interpersonal and communication skills. [ 15 ] The analysis was modified by asking participants to identify the five most important things that physicians can do to help them make treatment decisions, and patients’ answers were ranked in order of most commonly identified. Data Analysis Preferences. We used descriptive statistics to summarize patients’ sociodemographic characteristics, clinical factors, and participants’ preferences for DLOC. We used Fisher’s exact tests to evaluate the relationships between patients’ perceptions of DLOC and their sociodemographic characteristics including age, overall health status, and physician specialty. We used relative frequencies to rank the most identified communication techniques that physicians could use to help patients make treatment decisions. Finally, pairwise comparisons between pairs of proportions with correction for multiple testing and Fisher’s exact test were used to evaluate differences in relative frequencies of the communication techniques among DLOC preference groups. Outcomes. We used descriptive statistics to summarize patients’ perceptions of DLOC. We examined the effects of decision-making on different functional and symptom domains, overall scores, and average satisfaction using a mixed effects model. Least-squared means of QOL dimensions were compared for each time point among DLOC groups to evaluate for associations. Overall health status was evaluated as a covariate for decision satisfaction. Results Participant Characteristics Data from 101 patients in the QOL/satisfaction analysis and 103 patients in the preferences analysis were collected and are summarized in Table 1 . Most patients were White, married, living with a spouse/partner, and had insurance. Table 1 Descriptive statistics of patient demographic characteristics. Demographic Variable Preference Analysis QOL/Satisfaction Analysis Age Mean (SD) 70.0 (8.62) 69.6 (8.92) Median (range) 70.0 (49.0–89.0) 69.0 (49–92) Race White / Caucasian (not Latino / Hispanic) (n, %) 84 (81.6%) 81 (80.2%) Black / African American (not Latino / Hispanic) (n, %) 17 (16.5%) 15 (14.9%) Latino / Hispanic / Mexican-American 0 (0.0%) 1 (1.0%) Asian / Southeast Asian / Indian / Pacific Islander 0 (0.0%) 3 (4.8%) Other / Missing 2 (1.9%) 1 (1.0%) Marital Status Married (n, %) 82 (79.6%) 83 (82.2%) Single (N, %) 11 (10.7%) 7 (6.9%) Widowed (n, %) 5 (4.9%) 7 (6.9%) Divorced (n, %) 5 (4.9%) 4 (4.0%) Living Situation Alone (n, %) 10 (9.7%) 12 (11.9%) With spouse/partner (n, %) 75 (72.8%) 82 (81.2%) With others (n, %) 2 (1.9%) 6 (5.9%) Missing (n, %) 16 (15.5%) 1 (1.0%) Insurance Status Not insured (n, %) 2 (1.9%) 1 (1.0%) Insured (n, %) 99 (96.1%) 100 (99.0%) Missing (n, %) 2 (1.9%) 0 (0.0%) QOL / Patient Functioning Patients reported their DLOC for the treatment decision that had occurred during their medical visit (Fig. 1 ). Patients then reported their QOL at baseline, 2 months, and 4 months after a treatment decision was made (Fig. 2 ). At 4 months post-treatment decision, physical functioning was significantly greater among patients who experienced a shared decision or patient-directed decision than among patients who experienced a physician-directed decision (p = 0.03 and p = 0.005, respectively). This effect was not seen at 2 months post-decision. There were no significant differences among DLOC groups for the other measures of patient functioning (social, cognitive, role, or emotional functioning) at either the 2-month or 4-month timepoint. All measures of functioning, including physical functioning, were similar among DLOC groups at baseline. Decision Satisfaction Patients reported their decision satisfaction at baseline, 2 months, and 4 months after a decision was made (Fig. 3 ). At 4 months post-treatment decision, there was a trend toward increased decision satisfaction among patients who experienced a shared decision or patient-directed decision compared with patients who experienced a physician-directed decision (p = 0.097 and p = 0.056, respectively). Decision satisfaction increased over time (from baseline to 2 months to 4 months) for both the SDM group and the patient-directed group, while satisfaction decreased over time for the physician-directed group. Decision satisfaction was similar among all DLOC groups at baseline. Notably, decision satisfaction was significantly associated with overall health scores reported by patients (p < 0.001). Patient Preference for Decision Locus of Control and Physician Communication Style Patients identified their preferences for DLOC during treatment decisions (Fig. 1 ). SDM was the most common patient preference (72%). The next most common preference was for patient-directed (18%), which was more common than physician-directed (11%). No patients reported a preference for a decision made with “little to no input” from the treating physician. Patients also identified the most important communication techniques physicians could use to aid decision-making. The most important techniques in descending order of frequency were discussing follow-up plans (68%), involving patients as much as they wanted (52%), understanding patients’ health concerns (51%), speaking in terms patients could understand (50%), and giving as much information as patients wanted (48%). Patients with a preference for physician-directed decisions were less likely to rank “involving patients as much as they wanted” among their top five most important techniques compared with patients who preferred shared decisions (p = 0.041) or patient-directed decisions (p = 0.007). See Supplementary Information for detailed Table S1. Discussion This study investigated the impact of patients’ locus of control during a treatment decision on their QOL and decision satisfaction over time. Patients who experienced a shared decision or a patient-directed decision had significantly better physical functioning at 4 months post-decision than patients who experienced a physician-directed decision. Importantly, there were no significant differences in physical functioning among the DLOC groups at baseline. These findings suggest that patients who are more involved in their treatment decision-making may more successfully maintain their physical functioning than those who are less actively engaged. Therefore, active engagement in decision-making can increase QOL for patients. The Federal Drug Administration considers physical functioning and other EORTC QOL metrics in the regulatory review process for novel therapeutics, which speaks to the importance of maintaining QOL in patients undergoing cancer treatment. [ 16 ] Other QOL domains (i.e., social, emotional, cognitive, and role functioning) were not significantly associated with the degree of patient engagement in decision-making in this study. The underlying reasons for physical functioning potentially being affected by DLOC are unknown, but it may be related to heightened self-efficacy empowering patients to engage in decision-making and in activities that strengthen physical functioning. It is possible that the greater levels of pain reported by patients who reported physician-directed decisions were associated with poorer disease prognosis, more advanced disease, or other factors associated with declining physical function. Other QOL domains may be less dramatically affected by disease related decline than physical functioning. However, in separate therapeutic trials, emotional/social/cognitive/role functioning domains appeared to be affected by disease progression, suggesting that DLOC may be related to the effects seen in physical functioning. [ 17 ] Over time, decision satisfaction increased among patients who experienced a shared decision or a patient-directed decision. However, patients who reported experiencing a physician-directed decision exhibited declining satisfaction with their treatment decision. This trend suggests patients may be more satisfied with their treatment decisions in the long-term if they feel they had a more active role in the decision. Many patients with mPC will have inevitable declines in general health and wellbeing, and a subset will experience decreased decision satisfaction or regret. [ 18 ] Our study similarly found a significant positive association between overall health status and decision satisfaction. For patients experiencing declining health, it is possible they may come to regret their treatment plan if they felt the decision was made primarily by the physician, even if they did not initially feel negatively toward the decision. [ 19 ] Conversely, patients who are empowered to play an active role in decision-making and feel confident they made the best choice for themselves may maintain their satisfaction in the decision, despite declining health. This study characterized patient preferences for DLOC and physician communication techniques. Most patients preferred a shared decision rather than a physician or patient-dominated decision-making process. Of those that did not prefer a shared decision, there was a greater preference for patient-directed compared with physician-directed decisions. While there is limited data regarding preferences for DLOC in mPC, our finding that the majority of patients prefer SDM is consistent with studies in other fields of oncology and beyond. [ 20 ] Other studies have suggested that younger generations value SDM more than the older populations that currently make up the majority of cancer patients. This indicates that collaborating with patients will likely become essential to the training and practice of early-career physicians. [ 21 ] The five most identified preferences for communication techniques reported by patients as important to aiding the decision-making process were as follows: discussing next steps, involving patients in decisions, understanding patients’ health concerns, speaking in patient-friendly terms, and sharing information as requested by patients. These are similar to those previously reported by patients as being helpful based on their experiences making decisions. [ 7 ] These techniques are common examples of ways for physicians to demonstrate empathy, which has been correlated to patient perception of SDM. Others have stated that a patient’s perception of shared decision making may be more about feeling that the physician has heard and processed the patient’s cognitive and emotional needs, concerns, and preferences than about the patient actively deliberating over treatment options. [ 22 ] The proportion of patients valuing communication techniques largely did not differ significantly according to DLOC preference. However, patients who preferred a physician-directed decision were less likely to value “involving patients in decisions” compared with those who preferred shared or patient-directed decisions. Our study has limitations that should be considered. First, the sample size was relatively small, particularly in patients with DLOCs other than SDM, but was identified as a sample size that was feasible to enroll and sufficient to identify clinically meaningful changes in QOL. Second, although participants were enrolled from two separate institutions, both have populations that are predominantly White and insured. Further, only patients who felt comfortable with reading English surveys were eligible to participate, which restricted participation from non-English speaking patients and limits generalizability. Finally, this study was designed as a relatively short-term longitudinal investigation. Whether these findings would change with longer follow up is unknown. Additional studies are needed to investigate these findings in larger and more diverse populations over a longer period. In conclusion, our study suggests that greater patient involvement in decision-making may provide benefits to patients in the form of improved physical functioning and greater decision satisfaction. This finding is particularly notable given the recognition by the scientific community, including the Food and Drug Administration, of the importance of physical functioning on patient outcomes. [ 22 ] Our study identified techniques, such as asking degree of involvement desired and focus on follow-up, used by physicians that were most valued by patients to achieve shared decisions. Adoption of these often-simple techniques may improve outcomes in patients with mPC. Declarations Competing Interests: BDG reports personal fees from SureMed Compliance, KemPharm, and Elly Health, Inc. unrelated to this work. All other authors report no conflicts of interest. Ethics Approval: This study was conducted in accordance with the Declaration of Helsinki. Disclosure: This paper was presented at the American Society of Clinical Oncology Genitourinary meeting as a poster presentation with interim findings. Data Availability: The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. Funding: Department of Defense Physician Research Training Award PC150398 (PI Morgans) Author contributions: The authors confirm contribution to the paper as follows: study conception and design: AM; data collection: FS, AM, KM; analysis and interpretation of results: FS, IH, ZS, AM; draft manuscript preparation: FS, JB, LO, BG, KM, AM. All authors reviewed the results and approved the final version of the manuscript. Acknowledgements: This work was supported by the Department of Defense Physician Research Training Award PC150398. References American Cancer Society. Cancer Facts and Figures. (2022) Oswald LB, Schumacher FA, Gonzalez BD, Moses KA, Penson DF & Morgans AK. What do men with metastatic prostate cancer consider when making treatment decisions? A mixed-methods study. 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Supplementary Files Supplementary.Information.Table.S1.DLOC.Manuscript.docx Cite Share Download PDF Status: Published Journal Publication published 28 Jan, 2023 Read the published version in Prostate Cancer and Prostatic Diseases → Version 1 posted Editorial decision: revise 16 Nov, 2022 Review # 2 received at journal 04 Nov, 2022 Review # 1 received at journal 31 Oct, 2022 Reviewer # 2 agreed at journal 17 Oct, 2022 Reviewer # 1 agreed at journal 15 Oct, 2022 Reviewers invited by journal 15 Oct, 2022 Submission checks completed at journal 04 Oct, 2022 Editor assigned by journal 04 Oct, 2022 First submitted to journal 03 Oct, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2129512","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":144423659,"identity":"8603c43a-e30f-42d4-b76b-ad3c38f7a599","order_by":0,"name":"Alicia Morgans","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0002-6563-4587","institution":"Dana-Farber Cancer Institute","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Alicia","middleName":"","lastName":"Morgans","suffix":""},{"id":144423660,"identity":"67dff059-4f9a-4889-a8a3-31eca9133d83","order_by":1,"name":"Frank Schumacher","email":"","orcid":"","institution":"Feinberg School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Frank","middleName":"","lastName":"Schumacher","suffix":""},{"id":144423661,"identity":"a763813e-78a4-474e-ba98-6f65c14b98b1","order_by":2,"name":"Irene Helenowski","email":"","orcid":"","institution":"Feinberg School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Irene","middleName":"","lastName":"Helenowski","suffix":""},{"id":144423662,"identity":"54ececee-1917-45d2-b06e-647180c3c3f6","order_by":3,"name":"Zequn Sun","email":"","orcid":"","institution":"Feinberg School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Zequn","middleName":"","lastName":"Sun","suffix":""},{"id":144423663,"identity":"266067e9-ab4f-41d7-b215-14ca10d36ed7","order_by":4,"name":"Laura Oswald","email":"","orcid":"","institution":"Moffitt Cancer Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Laura","middleName":"","lastName":"Oswald","suffix":""},{"id":144423664,"identity":"378f2b06-6cfa-44b8-b8a5-703c560db40c","order_by":5,"name":"Brian Gonzalez","email":"","orcid":"","institution":"Moffitt Cancer Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Brian","middleName":"","lastName":"Gonzalez","suffix":""},{"id":144423665,"identity":"87ae4345-58c9-49d8-9647-b5829318af32","order_by":6,"name":"Kelvin Moses","email":"","orcid":"","institution":"","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kelvin","middleName":"","lastName":"Moses","suffix":""},{"id":144423666,"identity":"41156cfb-390f-49e9-9562-57e1cf16d00b","order_by":7,"name":"James Benning","email":"","orcid":"","institution":"Feinberg School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"James","middleName":"","lastName":"Benning","suffix":""}],"badges":[],"createdAt":"2022-10-03 19:20:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2129512/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2129512/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41391-023-00647-5","type":"published","date":"2023-01-28T05:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":27953916,"identity":"0fe6a047-2a5b-49f2-8e11-3a337a8e1806","added_by":"auto","created_at":"2022-10-18 18:43:53","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":113654,"visible":true,"origin":"","legend":"\u003cp\u003ePatient-reported treatment decision locus of control (Blue = perceived; Orange = preference)\u003c/p\u003e","description":"","filename":"Figure.1.DLOC.Manuscript.jpg","url":"https://assets-eu.researchsquare.com/files/rs-2129512/v1/eeb31bd3fdc113d07599520d.jpg"},{"id":27953915,"identity":"1308187b-4773-4d29-801a-f53125a1d26b","added_by":"auto","created_at":"2022-10-18 18:43:53","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":405825,"visible":true,"origin":"","legend":"\u003cp\u003ePatient functioning at baseline, 2 months, 4 months (Green = physician-directed; Blue = shared decision-making; Purple = patient-directed; error bars = 95% CI)\u003c/p\u003e","description":"","filename":"Figure.2.DLOC.Manuscript.jpg","url":"https://assets-eu.researchsquare.com/files/rs-2129512/v1/c1ed9315aae4af29e2b154f5.jpg"},{"id":27954351,"identity":"5619591c-89ba-4ceb-8ffc-502a74e4aefb","added_by":"auto","created_at":"2022-10-18 18:48:53","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1675391,"visible":true,"origin":"","legend":"\u003cp\u003eDecision satisfaction at baseline, 2 months, 4 months (Green = physician-directed; Blue = shared decision-making; Purple = patient-directed)\u003c/p\u003e","description":"","filename":"Figure.3.DLOC.Manuscript.jpg","url":"https://assets-eu.researchsquare.com/files/rs-2129512/v1/43487dfa9904eb64717d8b3f.jpg"},{"id":32167641,"identity":"66f8e3b3-0ba6-4950-9491-48630d561e0f","added_by":"auto","created_at":"2023-01-29 08:08:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":538701,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2129512/v1/6a912863-6667-42ad-ab91-dd1f87760ff2.pdf"},{"id":27953917,"identity":"7c8df7a9-d1f8-41ec-ae80-60e89d47f8fb","added_by":"auto","created_at":"2022-10-18 18:43:53","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":17940,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementary.Information.Table.S1.DLOC.Manuscript.docx","url":"https://assets-eu.researchsquare.com/files/rs-2129512/v1/3301b5186f0a685ead06114d.docx"}],"financialInterests":"\u003cb\u003eYes\u003c/b\u003e there is potential conflict of interest.","formattedTitle":"Treatment decision-making among patients with metastatic prostate cancer: Impact of decision locus of control on functional outcomes and decision satisfaction","fulltext":[{"header":"Introduction","content":"\u003cp\u003eProstate cancer remains the most common malignancy among American men and an important cause of cancer-related morbidity and mortality.\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e Despite continuing advances in care, metastatic prostate cancer (mPC) is an incurable disease, and the second leading cause of cancer death among men in the US. Recent advances have created a multitude of treatment options, each with a unique set of benefits and side effects. To date, there have been no direct comparisons of the various treatment options for mPC. This suggests differential benefit in terms of disease control, making treatment decision-making a complicated process for providers and patients. Thus, treatment decisions commonly depend on physician preferences and experience. An individualized approach to treatment decisions is preferred based on efficacy, as well as patient preferences, priorities, potential side effects, follow-up requirements, and cost of care.\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e This approach may be facilitated by shared decision-making (SDM) among patients, physicians, and caregivers, which has been identified by the National Academy of Medicine, the American Urological Association, and others as a priority method to improve the quality of cancer care in the US through patient engagement and autonomy.\u003c/p\u003e \u003cp\u003eDecision-making preferences are highly individualized and vary widely among cancer patients, with patients reporting heterogeneous preferences for decision-making roles.\u003csup\u003e[\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e The extent that decision-making roles have impacted patient functional outcomes and decision satisfaction in mPC have not been described. Therefore, the primary goal of this study was to assess the impact of decision locus of control (DLOC), whether SDM, physician- or patient-directed, on functional outcomes and decision satisfaction for mPC patients. This study also assessed patients\u0026rsquo; preferences for DLOC when making decisions regarding their treatment. We previously reported the communication techniques that patients, caregivers, and physicians felt aided decision-making, and this study further assessed patient preferences for communication techniques.\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eParticipants and Procedures\u003c/h2\u003e\n\u003cp\u003eWe assessed DLOC following a clinic visit in which a treatment decision occurred (baseline), and assessed patient-reported functional outcomes at baseline, 2-months post-treatment decision, and 4-months post-treatment decision. We evaluated patient-reported preferences for DLOC among mPC patients following a clinic visit in which a treatment decision had occurred. Treatment decisions included any decision to change the treatment approach to the prostate cancer, associated pain or comorbidities, or to maintain the current treatment approach. This study was approved by the Institutional Review Board at Vanderbilt University Medical Center (VUMC; approval #161441) and Northwestern Memorial Hospital (NMH, approval #STU00206080). Between 2018 and 2020, patients with mPC were recruited from Genitourinary Oncology clinics at VUMC and NMH. Eligible patients spoke English, were able to recall a decision at a clinic visit within the preceding 48 hours and signed informed consent to participate. There were no restrictions or requirements regarding prior local or systemic treatment exposure. Patients completed electronic surveys describing the decision-making process, decision satisfaction, and quality of life (QOL) outcomes via REDCap on tablets in clinic. Patient sociodemographic and clinical characteristics, including age, race/ethnicity, marital/partner status, self-reported health status (i.e., excellent, good, fair, or poor), and insurance status were collected by patient self-report and electronic medical record when possible to reduce missing data. The study was supported by a grant from the Department of Defense Prostate Cancer Research Program (PC150398).\u003c/p\u003e\n\u003c/div\u003e\n\u003ch2\u003eSurveys\u003c/h2\u003e\n\u003cp\u003e\u003cem\u003eDecision Locus of Control.\u003c/em\u003e Patients were enrolled after completing a physician visit in which a treatment decision was made before leaving the clinic. Participants completed a survey describing the role they played in the decision using a modified version of the Control Preferences Scale,\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e which has been used in assessments of decision making among patients with cancer and is reliable in defining decisional preferences in a unidimensional scale.\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e This modified version of the 5-item scale asks participants to describe decision roles as physician-directed (e.g., \u0026ldquo;Your doctors made the decision with little or no input from you\u0026rdquo;), SDM (e.g., \u0026ldquo;You and your doctors made the decisions together\u0026rdquo;), or patient-directed (e.g., \u0026ldquo;You made the decisions after seriously considering your doctor\u0026rsquo;s opinion\u0026rdquo;).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQuality of Life.\u003c/em\u003e Patients completed the European Organization for Research and Treatment of Cancer Quality of Life of Cancer Patients (EORTC-QLQ-30) questionnaire at baseline immediately following a treatment decision, 2-months post-treatment decision, and 4-months post-treatment decision. The EORTC-QLQ-30 questionnaire is a validated study tool to evaluate patient functioning and provides scales in domains of physical, emotional, cognitive, social, and role functioning, with higher scores on each domain indicating better functioning.\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDecision Satisfaction.\u003c/em\u003e Patients completed the Satisfaction with Decisions survey regarding their current satisfaction with their decision at baseline immediately following a treatment decision, 2-months post-treatment decision, and 4-months post-treatment decision.\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e The survey explored how patients felt they were informed (i.e., \u0026ldquo;I am satisfied that I am adequately informed about the issues important to my decision\u0026rdquo;), consistency with personal values (i.e., \u0026ldquo;I am satisfied that my decision was consistent with my personal values\u0026rdquo;), expectations to carry out decision (i.e., \u0026ldquo;I expect to successfully carry out\u0026hellip;the decision I made\u0026rdquo;), and overall satisfaction (i.e., \u0026ldquo;I am satisfied with my decision\u0026rdquo;).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCommunication Preference Surveys.\u003c/em\u003e In addition to the responses regarding DLOC described above, participants completed surveys before leaving the clinic describing their preference for their DLOC. They were reminded of a recent treatment decision with the following prompt: \u0026ldquo;Consider a recent treatment decision that you made for your prostate cancer. Describe how you prefer to make treatment decisions\u0026rdquo;, and then provided with a modified version of the Control Preferences Scale.\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e This modified version of the 5-item scale classifies preferences for decision roles as physician-controlled (\u0026ldquo;You prefer that the doctors make the decision with little or no input from you.\u0026rdquo; or \u0026ldquo;You prefer that the doctors make the decision after seriously considering your opinion.\u0026rdquo;), SDM (\u0026ldquo;You prefer that you and your doctors made the decision together.\u0026rdquo;), or patient-controlled (\u0026ldquo;You prefer to make the decision after seriously considering your doctor's opinion.\u0026rdquo; or \u0026ldquo;You prefer to make the treatment decision with little or no input from your doctors.\u0026rdquo;). Patients also completed the Communication Assessment Tool, a 15-item survey that is reliable and valid in identifying patient perceptions of physicians\u0026rsquo; interpersonal and communication skills.\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e The analysis was modified by asking participants to identify the five most important things that physicians can do to help them make treatment decisions, and patients\u0026rsquo; answers were ranked in order of most commonly identified.\u003c/p\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003eData Analysis\u003c/h2\u003e\n\u003cp\u003e\u003cem\u003ePreferences.\u003c/em\u003e We used descriptive statistics to summarize patients\u0026rsquo; sociodemographic characteristics, clinical factors, and participants\u0026rsquo; preferences for DLOC. We used Fisher\u0026rsquo;s exact tests to evaluate the relationships between patients\u0026rsquo; perceptions of DLOC and their sociodemographic characteristics including age, overall health status, and physician specialty. We used relative frequencies to rank the most identified communication techniques that physicians could use to help patients make treatment decisions. Finally, pairwise comparisons between pairs of proportions with correction for multiple testing and Fisher\u0026rsquo;s exact test were used to evaluate differences in relative frequencies of the communication techniques among DLOC preference groups.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOutcomes.\u003c/em\u003e We used descriptive statistics to summarize patients\u0026rsquo; perceptions of DLOC. We examined the effects of decision-making on different functional and symptom domains, overall scores, and average satisfaction using a mixed effects model. Least-squared means of QOL dimensions were compared for each time point among DLOC groups to evaluate for associations. Overall health status was evaluated as a covariate for decision satisfaction.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n\u003ch2\u003eParticipant Characteristics\u003c/h2\u003e\n\u003cp\u003eData from 101 patients in the QOL/satisfaction analysis and 103 patients in the preferences analysis were collected and are summarized in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Most patients were White, married, living with a spouse/partner, and had insurance.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eDescriptive statistics of patient demographic characteristics.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDemographic Variable\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePreference Analysis\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eQOL/Satisfaction Analysis\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMean (SD)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e70.0 (8.62)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e69.6 (8.92)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedian (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e70.0 (49.0\u0026ndash;89.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e69.0 (49\u0026ndash;92)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eRace\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWhite / Caucasian (not Latino / Hispanic) (n, %)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e84 (81.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e81 (80.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBlack / African American (not Latino / Hispanic) (n, %)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e17 (16.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e15 (14.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLatino / Hispanic / Mexican-American\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1 (1.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAsian / Southeast Asian / Indian / Pacific Islander\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3 (4.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOther / Missing\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2 (1.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1 (1.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMarital Status\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMarried (n, %)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e82 (79.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e83 (82.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSingle (N, %)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e11 (10.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7 (6.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWidowed (n, %)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e5 (4.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7 (6.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDivorced (n, %)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e5 (4.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4 (4.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eLiving Situation\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAlone (n, %)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e10 (9.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e12 (11.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWith spouse/partner (n, %)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e75 (72.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e82 (81.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWith others (n, %)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2 (1.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6 (5.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMissing (n, %)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e16 (15.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1 (1.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eInsurance Status\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNot insured (n, %)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2 (1.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1 (1.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInsured (n, %)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e99 (96.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e100 (99.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMissing (n, %)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2 (1.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n\u003ch2\u003eQOL / Patient Functioning\u003c/h2\u003e\n\u003cp\u003ePatients reported their DLOC for the treatment decision that had occurred during their medical visit (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Patients then reported their QOL at baseline, 2 months, and 4 months after a treatment decision was made (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). At 4 months post-treatment decision, physical functioning was significantly greater among patients who experienced a shared decision or patient-directed decision than among patients who experienced a physician-directed decision (p\u0026thinsp;=\u0026thinsp;0.03 and p\u0026thinsp;=\u0026thinsp;0.005, respectively). This effect was not seen at 2 months post-decision. There were no significant differences among DLOC groups for the other measures of patient functioning (social, cognitive, role, or emotional functioning) at either the 2-month or 4-month timepoint. All measures of functioning, including physical functioning, were similar among DLOC groups at baseline.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n\u003ch2\u003eDecision Satisfaction\u003c/h2\u003e\n\u003cp\u003ePatients reported their decision satisfaction at baseline, 2 months, and 4 months after a decision was made (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). At 4 months post-treatment decision, there was a trend toward increased decision satisfaction among patients who experienced a shared decision or patient-directed decision compared with patients who experienced a physician-directed decision (p\u0026thinsp;=\u0026thinsp;0.097 and p\u0026thinsp;=\u0026thinsp;0.056, respectively). Decision satisfaction increased over time (from baseline to 2 months to 4 months) for both the SDM group and the patient-directed group, while satisfaction decreased over time for the physician-directed group. Decision satisfaction was similar among all DLOC groups at baseline. Notably, decision satisfaction was significantly associated with overall health scores reported by patients (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n\u003ch2\u003ePatient Preference for Decision Locus of Control and Physician Communication Style\u003c/h2\u003e\n\u003cp\u003ePatients identified their preferences for DLOC during treatment decisions (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). SDM was the most common patient preference (72%). The next most common preference was for patient-directed (18%), which was more common than physician-directed (11%). No patients reported a preference for a decision made with \u0026ldquo;little to no input\u0026rdquo; from the treating physician.\u003c/p\u003e\n\u003cp\u003ePatients also identified the most important communication techniques physicians could use to aid decision-making. The most important techniques in descending order of frequency were discussing follow-up plans (68%), involving patients as much as they wanted (52%), understanding patients\u0026rsquo; health concerns (51%), speaking in terms patients could understand (50%), and giving as much information as patients wanted (48%). Patients with a preference for physician-directed decisions were less likely to rank \u0026ldquo;involving patients as much as they wanted\u0026rdquo; among their top five most important techniques compared with patients who preferred shared decisions (p\u0026thinsp;=\u0026thinsp;0.041) or patient-directed decisions (p\u0026thinsp;=\u0026thinsp;0.007). See Supplementary Information for detailed Table S1.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study investigated the impact of patients\u0026rsquo; locus of control during a treatment decision on their QOL and decision satisfaction over time. Patients who experienced a shared decision or a patient-directed decision had significantly better physical functioning at 4 months post-decision than patients who experienced a physician-directed decision. Importantly, there were no significant differences in physical functioning among the DLOC groups at baseline. These findings suggest that patients who are more involved in their treatment decision-making may more successfully maintain their physical functioning than those who are less actively engaged. Therefore, active engagement in decision-making can increase QOL for patients. The Federal Drug Administration considers physical functioning and other EORTC QOL metrics in the regulatory review process for novel therapeutics, which speaks to the importance of maintaining QOL in patients undergoing cancer treatment.\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOther QOL domains (i.e., social, emotional, cognitive, and role functioning) were not significantly associated with the degree of patient engagement in decision-making in this study. The underlying reasons for physical functioning potentially being affected by DLOC are unknown, but it may be related to heightened self-efficacy empowering patients to engage in decision-making and in activities that strengthen physical functioning. It is possible that the greater levels of pain reported by patients who reported physician-directed decisions were associated with poorer disease prognosis, more advanced disease, or other factors associated with declining physical function. Other QOL domains may be less dramatically affected by disease related decline than physical functioning. However, in separate therapeutic trials, emotional/social/cognitive/role functioning domains appeared to be affected by disease progression, suggesting that DLOC may be related to the effects seen in physical functioning.\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOver time, decision satisfaction increased among patients who experienced a shared decision or a patient-directed decision. However, patients who reported experiencing a physician-directed decision exhibited declining satisfaction with their treatment decision. This trend suggests patients may be more satisfied with their treatment decisions in the long-term if they feel they had a more active role in the decision. Many patients with mPC will have inevitable declines in general health and wellbeing, and a subset will experience decreased decision satisfaction or regret.\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e Our study similarly found a significant positive association between overall health status and decision satisfaction. For patients experiencing declining health, it is possible they may come to regret their treatment plan if they felt the decision was made primarily by the physician, even if they did not initially feel negatively toward the decision.\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e Conversely, patients who are empowered to play an active role in decision-making and feel confident they made the best choice for themselves may maintain their satisfaction in the decision, despite declining health.\u003c/p\u003e \u003cp\u003eThis study characterized patient preferences for DLOC and physician communication techniques. Most patients preferred a shared decision rather than a physician or patient-dominated decision-making process. Of those that did not prefer a shared decision, there was a greater preference for patient-directed compared with physician-directed decisions. While there is limited data regarding preferences for DLOC in mPC, our finding that the majority of patients prefer SDM is consistent with studies in other fields of oncology and beyond.\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e Other studies have suggested that younger generations value SDM more than the older populations that currently make up the majority of cancer patients. This indicates that collaborating with patients will likely become essential to the training and practice of early-career physicians.\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe five most identified preferences for communication techniques reported by patients as important to aiding the decision-making process were as follows: discussing next steps, involving patients in decisions, understanding patients\u0026rsquo; health concerns, speaking in patient-friendly terms, and sharing information as requested by patients. These are similar to those previously reported by patients as being helpful based on their experiences making decisions.\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e These techniques are common examples of ways for physicians to demonstrate empathy, which has been correlated to patient perception of SDM. Others have stated that a patient\u0026rsquo;s perception of shared decision making may be more about feeling that the physician has heard and processed the patient\u0026rsquo;s cognitive and emotional needs, concerns, and preferences than about the patient actively deliberating over treatment options.\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e The proportion of patients valuing communication techniques largely did not differ significantly according to DLOC preference. However, patients who preferred a physician-directed decision were less likely to value \u0026ldquo;involving patients in decisions\u0026rdquo; compared with those who preferred shared or patient-directed decisions.\u003c/p\u003e \u003cp\u003eOur study has limitations that should be considered. First, the sample size was relatively small, particularly in patients with DLOCs other than SDM, but was identified as a sample size that was feasible to enroll and sufficient to identify clinically meaningful changes in QOL. Second, although participants were enrolled from two separate institutions, both have populations that are predominantly White and insured. Further, only patients who felt comfortable with reading English surveys were eligible to participate, which restricted participation from non-English speaking patients and limits generalizability. Finally, this study was designed as a relatively short-term longitudinal investigation. Whether these findings would change with longer follow up is unknown. Additional studies are needed to investigate these findings in larger and more diverse populations over a longer period.\u003c/p\u003e \u003cp\u003eIn conclusion, our study suggests that greater patient involvement in decision-making may provide benefits to patients in the form of improved physical functioning and greater decision satisfaction. This finding is particularly notable given the recognition by the scientific community, including the Food and Drug Administration, of the importance of physical functioning on patient outcomes.\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e Our study identified techniques, such as asking degree of involvement desired and focus on follow-up, used by physicians that were most valued by patients to achieve shared decisions. Adoption of these often-simple techniques may improve outcomes in patients with mPC.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u0026nbsp;\u003c/strong\u003eBDG reports personal fees from SureMed Compliance, KemPharm, and Elly Health, Inc. unrelated to this work. All other authors report no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval:\u0026nbsp;\u003c/strong\u003eThis study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure:\u0026nbsp;\u003c/strong\u003eThis paper was presented at the American Society of Clinical Oncology Genitourinary meeting as a poster presentation with interim findings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability:\u003c/strong\u003e The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eDepartment of Defense Physician Research Training Award PC150398 (PI Morgans)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u0026nbsp;\u003c/strong\u003eThe authors confirm contribution to the paper as follows: study conception and design: AM; data collection: FS, AM, KM; analysis and interpretation of results: FS, IH, ZS, AM; draft manuscript preparation: FS, JB, LO, BG, KM, AM. All authors reviewed the results and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eThis work was supported by the Department of Defense Physician Research Training Award PC150398.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAmerican Cancer Society. Cancer Facts and Figures. (2022)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOswald LB, Schumacher FA, Gonzalez BD, Moses KA, Penson DF \u0026amp; Morgans AK. What do men with metastatic prostate cancer consider when making treatment decisions? A mixed-methods study. Patient Prefer Adherence \u003cb\u003e14\u003c/b\u003e, 1949\u0026ndash;1959 (2020)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElkin EB, Kim SHM, Casper ES, Kissane DW \u0026amp; Schrag D. Desire for information and involvement in treatment decisions: elderly cancer patients' preferences and their physicians' perceptions. J Clin Oncol \u003cb\u003e25\u003c/b\u003e, 5275\u0026ndash;5280 (2007)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDegner LF \u0026amp; Sloan JA. Decision making during serious illness: what role do patients really want to play?J Clin Epidemiol \u003cb\u003e45\u003c/b\u003e, 941\u0026ndash;950 (1992)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKeating NL, Guadagnoli E, Landrum MB, Borbas C \u0026amp; Weeks JC.Treatment decision making in early-stage breast cancer: should surgeons match patients' desired level of involvement?J Clin Oncol \u003cb\u003e20\u003c/b\u003e,1473\u0026ndash;1479 (2002)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOswald LB, Kasimer R, Rappazzo K, Fought AJ, Penson DF \u0026amp; Morgans AK. Patient expectations of benefit from systemic treatments for metastatic prostate cancer.Cancer Med \u003cb\u003e9\u003c/b\u003e, 980\u0026ndash;987 (2020)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchumacher FA, Helenowski IB, Oswald LB, Gonzalez BD, Benning JT \u0026amp; Morgans AK. Treatment decision-making in metastatic prostate cancer: perceptions of locus of control among patient, caregiver, and physician triads. Patient Prefer Adherence \u003cb\u003e16\u003c/b\u003e, 235\u0026ndash;244 (2022)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHawley ST, Lantz PM, Janz NK, Salem B, Morrow M, Schwartz K, et al. Factors associated with patient involvement in surgical treatment decision making for breast cancer. Patient Educ Couns \u003cb\u003e65\u003c/b\u003e, 387\u0026ndash;395 (2007)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKehl KL, Landrum MB, Arora NK, Ganz PA, van Ryn M, Mack JW, et al. Association of actual and preferred decision roles with patient-reported quality of care: shared decision making in cancer care. JAMA Oncol \u003cb\u003e1\u003c/b\u003e, 50\u0026ndash;58 (2015)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDegner LF, Kristjanson LJ, Bowman D, Sloan JA, Carriere KC, O'Neil J, et al. Information needs and decisional preferences in women with breast cancer. JAMA \u003cb\u003e277\u003c/b\u003e,1485\u0026ndash;1492 (1997)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeaver K, Luker KA, Owens RG, Leinster SJ, Degner LF \u0026amp; Sloan JA.Treatment decision making in women newly diagnosed with breast cancer.Cancer Nurs. \u003cb\u003e19\u003c/b\u003e, 8\u0026ndash;19 (1996)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, et al. The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst \u003cb\u003e85\u003c/b\u003e, 365\u0026ndash;376 (1993)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolmes-Rovner M, Kroll J, Schmitt N, Rovner DR, Breer ML, Rothert ML, et al. Patient satisfaction with health care decisions: the Satisfaction with Decision scale. Med Decis Making \u003cb\u003e16\u003c/b\u003e, 58\u0026ndash;64 (1996)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBilodeau BA \u0026amp; Degner LF. Information needs, sources of information, and decisional roles in women with breast cancer. Oncol Nurs Forum \u003cb\u003e23\u003c/b\u003e, 691\u0026ndash;696 (1996)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKluetz PG, O'Connor DJ \u0026amp; Soltys K.Incorporating the patient experience into regulatory decision making in the USA, Europe, and Canada. 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Patient Educ Couns \u003cb\u003e84\u003c/b\u003e, 386\u0026ndash;392 (2011)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eU.S. Department of Health and Human Services FDA Center for Drug Evaluation and Research, U.S. Department of Health and Human Services FDA Center for Biologics Evaluation abd Research \u0026amp; U.S. Department of Health and Human Services FDA Center for Devices and Radiological Health. Guidance for industry: Patient-reported outcome measures: use in medical product development to support labeling claims: draft guidance. Health Qual Life Outcomes \u003cb\u003e4\u003c/b\u003e, 79 (2006)\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"prostate-cancer-and-prostatic-diseases","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"pcan","sideBox":"Learn more about [Prostate Cancer and Prostatic Diseases](http://www.nature.com/pcan/)","snPcode":"41391","submissionUrl":"https://mts-pcan.nature.com/cgi-bin/main.plex","title":"Prostate Cancer and Prostatic Diseases","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-2129512/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2129512/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eShared decision-making (SDM) for metastatic prostate cancer (mPC) engages patients in the decision-making process and may be associated with better outcomes relative to physician- or patient-directed decision-making. We assessed the association between decision locus of control (DLOC) and patient-reported quality of life (QOL), functional outcomes, and decision satisfaction among mPC patients.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAfter a clinic visit in which a treatment decision was made (baseline), mPC patients completed DLOC and QOL surveys. QOL was re-assessed at 2- and 4-months post-baseline. Mean scores for each QOL dimension (physical, emotional, cognitive, social, and role functioning) were compared by DLOC group using mixed effects models. Patient preferences for DLOC and provider communication techniques were similarly collected via survey.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMedian age of participants (N\u0026thinsp;=\u0026thinsp;101) was 69 years (range: 49\u0026ndash;92); most were White (80%) and married (82%). 62% reported using SDM. At baseline, there were no differences in QOL dimensions between DLOC groups. At 4 months, patient-directed (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01) and SDM (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.03) were associated with better physical functioning than physician-directed decision-making, and there was a trend toward greater decision satisfaction among patients who reported patient-directed (p\u0026thinsp;=\u0026thinsp;0.06) or SDM (p\u0026thinsp;=\u0026thinsp;0.10). SDM was the most reported preferred DLOC.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003emPC patients reporting SDM had better physical functioning and a trend toward greater decision satisfaction at 4 months than physician- or patient-directed decision-making, suggesting measurable benefit from patient involvement in decision-making. Future investigations of these associations in larger, more diverse populations can further clarify these previously unmeasured benefits of patient engagement in treatment decisions.\u003c/p\u003e","manuscriptTitle":"Treatment decision-making among patients with metastatic prostate cancer: Impact of decision locus of control on functional outcomes and decision satisfaction","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-10-18 18:43:51","doi":"10.21203/rs.3.rs-2129512/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"revise","date":"2022-11-16T12:50:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"This content is not available.","date":"2022-11-04T11:21:18+00:00","index":2,"fulltext":"This content is not available."},{"type":"editorInvitedReview","content":"This content is not available.","date":"2022-10-31T16:50:03+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2022-10-17T13:00:37+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2022-10-15T22:46:19+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewersInvited","content":"","date":"2022-10-15T06:00:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-10-04T10:23:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-10-04T10:23:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"Prostate Cancer and Prostatic Diseases","date":"2022-10-03T19:16:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"prostate-cancer-and-prostatic-diseases","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"pcan","sideBox":"Learn more about [Prostate Cancer and Prostatic Diseases](http://www.nature.com/pcan/)","snPcode":"41391","submissionUrl":"https://mts-pcan.nature.com/cgi-bin/main.plex","title":"Prostate Cancer and Prostatic Diseases","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"eb97f0ab-0423-47b8-a3bf-f1ae3b3e1ec0","owner":[],"postedDate":"October 18th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-01-29T08:08:11+00:00","versionOfRecord":{"articleIdentity":"rs-2129512","link":"https://doi.org/10.1038/s41391-023-00647-5","journal":{"identity":"prostate-cancer-and-prostatic-diseases","isVorOnly":false,"title":"Prostate Cancer and Prostatic Diseases"},"publishedOn":"2023-01-28 05:00:00","publishedOnDateReadable":"January 28th, 2023"},"versionCreatedAt":"2022-10-18 18:43:51","video":"","vorDoi":"10.1038/s41391-023-00647-5","vorDoiUrl":"https://doi.org/10.1038/s41391-023-00647-5","workflowStages":[]},"version":"v1","identity":"rs-2129512","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2129512","identity":"rs-2129512","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}