Communication is a complex process, involving multilevel interactions, understanding of the content of discussion, and the relational aspects of cultures and behaviors, which are critical to the decision-making process and for ensuring comprehensive, quality cancer care and outcomes.7
Our data provide insight into the interaction and engagement of the patient, family member, and physician around treatment-related decisions for localized prostate cancer by race/ethnicity. Variations in communication and interaction styles among the triad of decision-makers can be important considerations for further investigations into providing culturally sensitive communication concerning prostate cancer treatment.
Results from our study show that, overall, most patients and family members felt that their physician “definitely” encouraged involvement in decision-making and that treatment options were discussed in an understandable way. Still, most patients highly regarded the opinions/recommendations of their physician, suggesting that the patient’s treatment decision may ultimately have relied on the recommendation of their urologist.9
Although our data did not directly assess this dynamic, such behavior is not unusual given that physicians are often called upon for their expertise and experience and have historically been entrusted to make medical decisions in the best interest of the patient.11
While previously, men may have taken a more passive role in selecting their treatment12
following the guidance of their physician, more recent studies suggest that men prefer greater involvement/collaboration in treatment decision-making for localized prostate cancer13
and tend to be more satisfied with their role in the decision-making given individualized information.16
Although men seem to prefer to be increasingly involved in their care, we observed that most men in our study continue to regard physician opinions highly. These interactions in the decision-making process are important to monitor as studies have shown the aggressiveness of the treatment (level of toxicity) selected for prostate cancer can often depend on the assertiveness of the managing physician and can differ from physician’s predictions for patients’ preferences.17
Additionally, treatment-specific decisions could over time increase the patient’s decisional regret following prostate cancer treatment.19
Communicating and collaborating with family members (usually spouses) and other caregivers of patients with cancer also affect the cancer diagnosis and treatment experience. Lack of communication about prostate cancer between spouses has been shown to negatively impact patient–partner satisfaction and adjustment to treatment-related issues.20
Effective communication in the level of information provided and interpersonal behaviors between the physician–patient and family members, could improve satisfaction for both the provider and patient.21
Although it is debatable to what extent family members (spouse) influence a patient’s final decision about treatment, a spouse’s presence is important for the roles they play in obtaining information, providing emotional support, and aiding in decisions. Our data support that many family members strongly perceive responsibility in providing this type of caregiving assistance to the patient, in weighing the pros and cons of each treatment option, and in helping the patient make a treatment decision.
Race/ethnicity and cultural background have critical bearing on how cancer is discussed and processed individually and in partnership.4
Our findings showed there were racial/ethnic variations in communication among the triad, although not statistically significant at P
= 0.05. African-American family members more frequently reported feeling encouraged to ask questions about treatment options and also tended to report having independent conversations with the physician compared with whites. Family members of African-American patients reported fewer discussions about treatment options with the patient and appeared to perceive a stronger role in decision-making than white family members. Comparatively, African-American patients also valued recommendations of their family member more than white patients. Although our data for this population are sparse, a similarly higher proportion of Hispanic family members compared with all other race/ethnicities “strongly agreed” their role was to support the patient by helping to arrange meetings with doctors and weigh the pros and cons of each treatment option.
Other studies that have characterized family involvement with prostate cancer treatment decisions among African-American prostate cancer survivors have also shown that men particularly value their wives’ opinions about the best treatment option and that family members generally play an important role in making decisions about the treatment the men receive.22
Our data seem to indicate similar findings. Furthermore, focus groups conducted by Williams et al found that African-American participants emphasized that effective communication involved “knowing” and “understanding” the patient and family individually so that communication could be tailored through this relationship.5
Also, African-American focus group participants (a mixture of caregivers and cancer survivors) preferred participating in the decision-making process as it equated to having a “sense of control.”5
This cultural aspect may explain the higher level of participation we observed among African-American family members in engaging with the physician.
There are several limitations to this study. First, communication among the triad is a complex process and one that is difficult to comprehensively measure and accurately attribute. Our questions only serve as a proxy to the shared decision-making process and the content, depth, and level of discussion that should have appropriately taken place. Second, the sample size was rather small for African-American and Hispanic participants and did not allow for more detailed analyses of these subpopulations, and therefore the inferences that can be concluded are limited. As such, there is a possibility of selection bias, and these results should be replicated in a larger population-based study. Third, we were unable to compare the participants who responded to our survey with those who received it but chose not to complete the survey to assess the impact of nonresponse bias. Those who agreed to participate may be different from nonparticipants in their behaviors, attitudes, and interest in engaging in decision-making. Despite these limitations, our study is one of few studies that have characterized racial/ethnic differences in communication preferences from paired surveys. We believe that the results of this study provide helpful information about communication and interaction preferences among the triad of decision-makers.
Understanding the dynamics of partner communication and physician interaction is an important part of improving outcomes in clinical practice by aiding patients and their family members in making appropriate health- and treatment-related decisions. Considering the cultural, interpersonal, and decision-making styles of patients and their family members can help clinicians facilitate improved understanding of cancer management for their patients. Burkhalter and Bromberg previously outlined and advocated for further evaluation of cultural effects on patient–family member–physician communication.21
Our results suggest variation in prostate cancer treatment-related discussions can differ by race/ethnicity and may substantiate the need for further research on how cultural influences (including faith and beliefs) and communicative behavior affect discussions and decisions about cancer treatment and outcome.