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Saturday, September 2, 2017

Bargaining With Cancer Patients About Treatment 09-02

Bargaining With Cancer Patients About Treatment

Doctors at Memorial Sloan Kettering Cancer Center borrowed negotiating tactics from Harvard Business School

Surgeons at Memorial Sloan Kettering Cancer Center in New York are enlisting techniques taught at Harvard Business School to advise men facing tough decisions about prostate cancer.

Behfar Ehdaie liked giving his prostate-cancer patients hopeful news: While they had a low-grade version of the illness, they wouldn’t need immediate treatment, let alone major surgery. Instead, they could be monitored through a process known as active surveillance. But Dr. Ehdaie, a surgeon at Sloan Kettering, found that many men insisted on having radical surgery or radiation—treatments that sometimes had devastating side effects.

“It was very frustrating,” Dr. Ehdaie said. “They didn’t see active surveillance as a viable option.”
In recent years, a growing body of evidence indicates that men with low-grade early-stage prostate cancer don’t need radical treatment, such as removing or radiating the prostate. The medical consensus is that active surveillance often is the appropriate treatment for small early tumors. Yet despite the data showing that this approach is safe, about 50% of eligible men don’t get it either because they turn it down or their physicians don’t embrace it. Medical experts say many men have been overtreated, as their cancers probably posed little immediate danger.

Dr. Ehdaie worried that too many patients were making the wrong decision. While surgery or radiation can be effective for early prostate cancer, potential side effects include sexual dysfunction, urinary incontinence and bowel problems.

Dr. Ehdaie confided his frustration to his research mentor and the two men decided to search outside the institution and even outside medicine for experts in behavioral economics and psychology.

“It was a very left-field idea to say let’s use behavioral economics to help a doctor explain to a patient what is important,” said Andrew Vickers, a biostatistician who advises Dr. Ehdaie on his research. “But we knew that this was a problem and that surgeons weren’t dealing with it. Doctors often use the completely wrong words.”

Dr. Ehdaie’s wife, who has an M.B.A., thought an expert in negotiation theory might help. After hearing about a Harvard Business School professor named Deepak Malhotra who specializes in tough negotiations, Dr. Ehdaie emailed him in December 2013.

Professor Malhotra says he was intrigued. He also believed that many doctor-patient conversations were in fact negotiations—and that doctors had no idea how to negotiate. He had co-authored an article with his brother, an emergency physician, in the Harvard Business Review about the need for doctors and hospitals to negotiate with patients to help them make better care decisions. The piece, published in 2013, said doctors and hospitals had “a dearth of negotiation skills and acumen.”

The professor traveled to Manhattan in 2014 to observe Dr. Ehdaie with his patients. The two hammered out pointers adapted from negotiation theory that doctors could use. For example, Dr. Ehdaie, like many surgeons, would first tell newly diagnosed prostate-cancer patients about surgery as a treatment option, and then discuss radiation; he left active surveillance for last.

Professor Malhotra advised flipping the order. “Instead of going on and on about surgery, and then going on and on about radiation, you give the prominence and salience to active surveillance” he said. The rejiggering was critical to making surveillance—not surgery—the “default option.”

It also was important to explain what active surveillance entailed. While the cancer is left untreated, patients follow a rigorous program of MRI’s, tests and biopsies. Dr. Ehdaie told his patients he would see them every six months. But far from being reassured, patients worried “the cancer could spread in six months.”

Professor Mahotra advised reframing the time period. The doctor should emphasize that a patient’s cancer was growing very slowly, if at all, and it would be safe for him to see them in about five years. But under active surveillance, he would examine them every six months—making some patients feel they were being closely monitored. Finally, Professor Malhotra advised giving patients a concise message to keep in mind when talking with family and friends who might “start questioning” the decision.

As Dr. Ehdaie changed his approach, he saw striking results. Nearly all his patients began accepting active surveillance and rejecting aggressive treatments. That set the stage for a study on the business-school techniques. The study had two goals: to determine whether the approach could be taught to other doctors, and to discover if it improved active-surveillance rates at Sloan Kettering.

The initial challenge was getting half-a-dozen busy cancer surgeons to participate. “If you started going to doctors saying, ‘You have to study up on negotiation theory,’ they would say, ‘Oh, come on,’ ” Dr. Vickers said.

That is why the study was built around a one-hour lecture. Five surgeons attended a talk by Dr. Ehdaie with Professor Malhotra on hand. The number of patients who chose active surveillance afterward was tracked.

Among the participants was Peter Scardino, who was Sloan Kettering’s chairman of surgery for more than a decade. Dr. Scardino was an early believer in active surveillance—back when many physicians didn’t embrace it. Five to 10 years ago, he said, it was hard to get patients on board. Even now, with active surveillance more common, men still agonize.

“The majority take an hour discussion and some an hour-long meeting and an hour phone call,” Dr. Scardino said.

Another hurdle: Active surveillance isn’t risk-free. Dr. Scardino tells patients “it is possible the cancer could get out of control before we realize it.” But he notes that surgery and radiation also have risks, including “urinary incontinence and impotence, so it isn’t a question” of an alternative without risk.

The Harvard Business School pointers have brought “more clarity and definition and concise thinking” to how doctors discuss these risks with patients, Dr. Scardino said.

In a report published in June in the journal European Urology, the Sloan Kettering team, along with Professor Malhotra, analyzed the decisions of 1,003 prostate-cancer patients eligible for active surveillance. When they compared 761 patients in a two-year period before the doctors were taught the Harvard methods, with 242 patients who were counseled with the business-school pointers, they found the percentage that chose active surveillance rose to 81% from 69%. In other words, there was a decrease of 30% in “the risk of unnecessary curative treatment.” Even a “minimal intervention can decrease overtreatment,” the paper concluded.

Richard Saler, a patient of Dr. Ehdaie who was diagnosed with low-grade prostate cancer in 2014, admits he is “a worrier” and was inclined to have surgery. “My mindset was ‘Get it out, cut it out,’” he recalled.

He spoke with Dr. Ehdaie and recalls when the doctor said, “I would be happy to do your surgery”—but he wouldn’t advise it. After carefully reviewing the data on treatments, Mr. Saler chose active surveillance.

Mr. Saler, who has an M.B.A., didn’t realize his doctor was using classic negotiating tactics and said the conversations with Dr. Ehdaie “never feel like a negotiation.”

“It is not supposed to feel like a negotiation,” Dr. Ehdaie said. “You want to empower patients to make the best decisions for themselves.” Professor Malhotra wrote about the experience with Sloan Kettering in a chapter in his book “Negotiating the Impossible.”

James Eastham, chief of the urology service at Sloan Kettering, said his department incorporates Professor Malhotra’s techniques. “Acceptance rates have increased significantly,” he said. About 90% of eligible Sloan Kettering prostate-cancer patients now select active surveillance.

David Miller, a professor of urology at the University of Michigan in Ann Arbor, said Dr. Ehdaie is changing how doctors can talk to prostate-cancer patients. He wonders if the approach can work beyond Sloan Kettering. “The challenge is how do you bring Deepak Malhotra to care settings in rural parts of the United States,” he said. “What happens at Memorial isn’t necessarily what happens” in clinics across the country.

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