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Home:
Educational Supplement: Appendix
Decision-Making
ProcessCommunicating Risks/Benefits:
Is There an Ideal Technique?
Mark
Norman Levine, M.D., and Timothy J. Whelan, M.Sc.
In recent years
there have been major advances in the treatment of early-stage breast
cancer, but the decisions a patient must make about treatment are
often difficult and complex. In the past, physicians tended to make
decisions for patients with little input from patients. Various
studies, however, have suggested problems in that traditional decisionmaking
process, particularly with regard to the transfer of information
from the physician to the breast cancer patient (Siminoff, Fetting,
Abeloff, 1989).
Many patients
have begun seeking more information about their disease and have
shown a desire to be actively involved in decisions about their
treatment. Researchers and clinicians have responded by investigating
ways of transferring information in ways more helpful to patients.
Decisionmaking aids have been defined as interventions designed
to help people make specific and deliberative choices among options
by providing information on the options and outcomes relevant to
the persons health status (OConnor, Fiset, DeGrasse,
et al., 1999). Such aids now take the form of printed materials,
computer-based programs, video programs, audio-guided workbooks,
and decision boards.
In general,
the patient/physician relationship involves several stages of exchange
of information, deliberation, and decisionmaking (Charles, Whelan,
Gafni, 1999). At one extreme is a paternalistic model, where information
flows in one direction from the doctor to the patient and the doctor
alone makes the decision. At the other extreme is the informed model,
where the patient alone makes the decision. The alternative to these
models is the shared model, in which the doctor and patient reach
agreement together at all stages of the decisionmaking process.
There is a two-way exchange of information in which the doctor and
patient express treatment preferences, discuss them, and come to
agreement on which treatment will be used.
OConnor
and colleagues recently conducted a systematic review of decisionmaking
aids in the treatment of various cancers (OConnor, Fiset,
DeGrasse, et al., 1999) and other conditions (OConnor, Rostom,
Fiset, et al., 1999). Studies evaluating these aids have found that
they are acceptable to patients and do not impact on patient satisfaction.
There have been
relatively few studies of decisionmaking aids for women with early-stage
breast cancer. In a trial by Goel and colleagues, women faced with
a decision regarding surgery for breast cancer were randomly directed
to an information pamphlet or an audio-guided workbook (Goel, Sawka,
Thiel, et al., 1998). The study detected no differences in knowledge
or decisional conflict between the two groups.
The decision
board was initially developed to help women with node-negative breast
cancer decide whether or not to receive adjuvant chemotherapy (Levine,
Gafni, Markham, et al., 1992). It was found to be both acceptable
and helpful in decisionmaking. A cohort study on the use of a decision
board by patients deciding whether or not to undergo postlumpectomy
radiation found that the process improved patient knowledge and
facilitated shared decisionmaking
(Whelan, Levine,
Gafni, et al., 1995). In another study, Whelan and colleagues found
that the use of a decision board by women deciding between lumpectomy
and mastectomy led to a decrease in the lumpectomy rate (Whelan,
Levine, Gafni, et al., 1999). Randomized trials are currently ongoing
to evaluate the decision board process in deciding on lumpectomy
versus mastectomy, and on adjuvant chemotherapy for node-negative
and node-positive breast cancer.
In conclusion,
both patients and physicians find decision aids helpful, but there
have been relatively few studies of their use by patients with early-stage
breast cancer. Further research is needed to determine whether decision
aids can improve such outcomes as satisfaction, downstream quality
of life, and unexplained practice variation. Research is also required
to determine whether particular decisionmaking aids are better than
others for a particular patient group or for different types of
medical intervention.
References
Charles C, Whelan
TJ, Gafni A. What do we mean by partnership in making decisions
about treatment? BMJ 1999;319:780-2. Abstract.
Goel V, Sawka
C, Thiel E, Gort E, OConnor AM. A randomized trial of a decision
aid for breast cancer surgery. Med Decis Making 1998;18:482.
Abstract.
Levine MN, Gafni
A, Markham B, MacFarlane D. A bedside decision instrument to elicit
a patients preference concerning adjuvant chemotherapy for
breast cancer. Ann Intern Med 1992;117:53-8. Abstract.
OConnor
AM, Rostom A, Fiset V, Tetroe J, Entwhistle V, Llewellyn-Thomas
H, et al. Decision aids for patients facing health treatment or
screening decision: a systematic review. BMJ 1999;319:731-4.
Abstract.
OConnor
AM, Fiset V, DeGrasse C, Graham ID, Evans W, Stacy D, et al. Decision
aids for patients considering options affecting cancer outcomes:
evidence of efficacy and policy implications. J Natl Cancer Inst
Monogr 1999;25:67-80. Abstract.
Siminoff LA,
Fetting JH, Abeloff MD. Doctor-patient communication about breast
cancer adjuvant therapy. J Clin Oncol 1989;7:1192-200. Abstract.
Whelan TJ, Levine
MN, Gafni A, Sanders K, Willan A, Mirsky D, et al. Mastectomy or
lumpectomy? Helping women make informed choices. J Clin Oncol 1999;17:1727-35.
Abstract.
Whelan TJ, Levine
MN, Gafni A, Lukka H, Mohide EA, Patel M, et al. Breast irradiation
postlumpectomy: development and evaluation of a decision instrument.
J Clin Oncol 1995;13:847-53. Abstract.
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