Thinking, Feeling, Choosing: The Affective Architecture of Low to Intermediate Risk Prostate Cancer Treatment Decision Making

Background. Shared decision-making (SDM) emphasizes informed, value-aligned choices, yet affect has not been a primary focus and is rarely addressed explicitly in cancer treatment decision-making. Among men with low- to intermediate-risk prostate cancer (LIRPC), active treatment (AT) can trigger fears of significant side effects, whereas active surveillance (AS) often evokes persistent anxiety, uncertainty, and fear of progression. These affective challenges can shape risk perceptions, increase decisional conflict, and reduce satisfaction. Aims. To address the gap, this study examined how affective-cognitive-psychosocial processes shape LIRPC treatment decisions, guided by SDM and affective science frameworks. Methods. We conducted in-depth, semi-structured interviews with 28 men with LIRPC across three treatment pathways: AS, AT, and AS-AT transition. Interviews explored a) how participants learned and interpreted diagnostic information; b) how thoughts, emotions, values, and relation dynamics influenced decision-making; and c) how men reflected on preferred roles. Themes and illustrative quotes were extracted. Participants completed the Control Preferences Scale. Results. Eleven themes emerged across domains. Information understanding was shaped by the clarity of medical information and the relational context of its delivery. Decision-making unfolded from initial shock to greater stability as men balanced evidence with personal values, navigated uncertainty, and drew on identity, prior experiences, physician trust, and family support. Post-treatment reflections emphasized autonomy, value alignment. Men engaged in coping to regulate affect and maintain control. Conclusions . Findings suggest that LIRPC decisions are affectively informed. Within SDM, men valued autonomy and deliberately balanced medical information with personal values, yet this rational stance unfolded alongside affective dynamics. Affect shaped what mattered most through value weighting, identity protection, and relational trust. Integrating affect-informed psychosocial approaches into decision support may improve SDM, treatment satisfaction, and HRQOL.