Patient decision aids for cancer treatment

Shared Decision Making in Oncology and Its Implementation in Cervical Cancer Management in the Philippines: A Narrative Review

PURPOSE

Shared decision making (SDM) is an approach where clinicians and patients make decisions together using the best available evidence. Although much studied, recognized to be ethically imperative, and recommended in international health policies, it remains poorly implemented. In the Philippines, there are limited studies on patient decision making preferences and SDM. Practical guidance on the implementation of SDM or use of patient decision aids (PtDAs) is often not detailed in existing national clinical practice guidelines in oncology.

METHODS

We performed a systematic search of Philippine literature on SDM in oncology and an iterative review of international literature on the philosophy and methods of SDM, the utility and effectiveness of PtDAs, and the facilitators and barriers to implementation or usage. We contextualized our review to the cervical cancer management and health service delivery in the Philippines.

RESULTS

Local literature is limited to five scientific publications and two registered studies. International literature encompasses patient decisional preferences, the role of PtDAs and the standards for their development and evaluation, their effectiveness, and barriers and facilitators to their use in cancer-related decision making. We discussed the implications on the management of cervical cancer in the Philippines, challenges in health service delivery and standards, and SDM research.

CONCLUSION

Local SDM research is limited. Our preliminary experience in a multicenter clinical trial in Manila on PtDA use in the framework of SDM in cervical cancer suggest good patient and clinician acceptability. Challenges to implementation such as unfavorable financial situations, urgency of clinical decisions, low patient or caregiver educational attainment, and poor integration of multidisciplinary and SDM in organizational workflows will be important when implementing SDM in different settings.

Development and initial evaluation of the usefulness of a question prompt list to promote patients' level of information about work-related medical rehabilitation: a pilot study

Introduction

The purpose of this study was to develop a question prompt list (QPL) to support patients undergoing work-related medical rehabilitation in obtaining relevant information and to explore how patients and physicians rate the QPL regarding its usefulness, practicability, and perceived (additional) effort.

Methods

An initial item pool was assessed by rehabilitation patients (N = 3) in cognitive interviews, rated by physicians and other health professionals (N = 11), and then further modified. The final QPL version (16 items) was used by patients (N = 36) in medical admission interviews in an inpatient medical rehabilitation facility and then evaluated. Physicians evaluated the QPL after each interview with a study participant (N = 6; k = 39 interviews).

Results

The QPL was used by 50% of patients who rated its usefulness and comprehensibility positively. Neither the need for information nor satisfaction with the information received was correlated with QPL use. The physicians' assessment showed a positive evaluation regarding the provision of information and structuring of the conversation, but also a higher perceived time expenditure.

Discussion

While initial testing of the QPL in work-related medical rehabilitation as a tool to support patient-provider communication generally showed a favorable evaluation by patients using it and physicians, future research should address its validity and effectiveness.

Trends and Prescriber Variation in the Duration of Oxaliplatin-Containing Adjuvant Chemotherapy for Stage III Colon Cancer From 2007 to 2019: A Population-Based Retrospective Cohort Study

INTRODUCTION

The International Duration Evaluation of Adjuvant Therapy (IDEA) collaboration in 2017 established 3 months of adjuvant therapy as an alternative to 6 months of therapy for stage III colon cancer. We determined the association between the IDEA publication, changes in clinical practice, and prescriber variation.

PATIENTS AND METHODS

Using linked databases, we identified Ontarians aged ≥18 years at diagnosis of stage III colon cancer between 2007 and 2019 who received oxaliplatin-containing adjuvant therapy. The outcome was duration of therapy, categorized as ≤25%, >25% to ≤50%, >50% to ≤75%, and >75% of a 6-month course of therapy to approximate treatment durations in the IDEA collaboration. We examined trends in duration over time using an interrupted time series regression model. We analyzed treatment duration after accounting for patient and prescriber characteristics, using multivariable mixed effects logistic regression models to quantify between-prescriber variation.

RESULTS

We included 4695 patients with stage III colon cancer who received oxaliplatin-containing adjuvant chemotherapy, of whom 77.5% initiated treatment pre-IDEA and 22.5% initiated treatment post-IDEA. Post-IDEA, there was a 16.4% (95% CI, 12.5%-20.3%) absolute increase in the proportion of patients treated with ≤50% of a maximal course of therapy. This trend was greatest among patients with low-risk tumors. Prescriber variation increased pre-IDEA to 15.6% post-IDEA (variance partition coefficient 5.4% pre-IDEA and 15.6% post-IDEA).

CONCLUSION

The publication of IDEA was associated with increases in short duration adjuvant therapy and prescriber-level practice variation for stage III colon cancer. Clinicians should be better supported to make consistent recommendations about adjuvant duration under conditions of uncertainty and trade-offs.

Patient Decision Aid for Chemotherapy or Exclusion in Cisplatin-Intolerant Patients With Locally Advanced Cervical Cancer: Development, Alpha Testing, and Peer Validation

PURPOSE

In locally advanced cervical cancer (LACC), adding cisplatin to radiotherapy (RT) improves survival but increases toxicity. Among patients with cisplatin contraindications, RT compliance may be compromised by toxicity because of cisplatin or a substitute. In shared decision making, a patient decision aid (PtDA) may decrease decisional conflict and attitudinal barriers, thereby improving treatment compliance.

METHODS

Following International Patient Decision Aid Standards (IPDAS) guidelines, a steering committee of two radiation oncologists, a gynecologic oncologist, an oncology nurse, a clinical psychologist, a cancer survivor, and a caregiver developed the chemotherapy or exclusion in cisplatin-intolerant patients with LACC (CECIL) prototype, a PtDA for cisplatin-intolerant patients with LACC deciding about adding chemotherapy to RT. The prototype was alpha-tested using the e-Delphi method. The patient decision aid research group Ottawa Acceptability Questionnaire was used to evaluate comprehensibility, length, amount of information, neutrality, and overall suitability for decision making. The prototype was then independently evaluated by local internal, local external, and international reviewers using the IPDAS checklist version 4, which encompasses information, probabilities, values, guidance, development, evidence, disclosure, plain language, and evaluation.

RESULTS

Alpha testing showed high practitioner acceptability (all items with mean and median scores ≥4; overall mean score 4.70 of 5.00) and good patient acceptability (all items rated good to excellent). Content validation showed that the PtDA satisfied all IPDAS six qualifying and six certification criteria, with high overall mean score (3.63 of 4.00) for all 17 applicable quality criteria.

CONCLUSION

The CECIL prototype shows good practitioner and patient acceptability, and content validity on peer review. Clinical testing to determine its effectiveness in reducing decisional conflict is ongoing.

"The challenge is the complexity" - A qualitative study about decision-making in advanced lung cancer treatment

INTRODUCTION

The value of shared decision-making and decision aids (DA) has been well documented yet remain difficult to integrate into clinical practice. We wanted to investigate needs and challenges regarding decision-making about advanced lung cancer treatment after first-line therapy, focusing on DA applicability.

METHODS

Qualitative data from separate, semi-structured focus groups with patients/relatives and healthcare professionals were analysed using systematic text condensation. 12 patients with incurable lung cancer, seven relatives, 12 nurses and 18 doctors were recruited from four different hospitals in Norway.

RESULTS

The participants described the following needs and challenges affecting treatment decisions: 1) Continuity of clinician-patient-relationships as a basic framework for decision-making; 2) barriers to information exchange; 3) negotiation of autonomy; and 4) assessment of uncertainty and how to deal with it. Some clinicians feared DA would steal valuable time and disrupt consultations, arguing that such tools could not incorporate the complexity and uncertainty of decision-making. Patients and relatives reported a need for more information and the possibility both to decline or continue burdensome therapy. Participants welcomed interventions supporting information exchange, like communicative techniques and organizational changes ensuring continuity and more time for dialogue. Doctors called for tools decreasing uncertainty about treatment tolerance and futile therapy.

CONCLUSION

Our study suggests it is difficult to develop an applicable DA for advanced lung cancer after first-line therapy that meets the composite requirements of stakeholders. Comprehensive decision support interventions are needed to address organizational structures, communication training including scientific and existential uncertainty, and assessment of frailty and treatment toxicity.

Engaging Patients with Late-Stage Non-Small Cell Lung Cancer in Shared Decision Making about Treatment

Few treatment decision support interventions (DSIs) are available to engage patients diagnosed with late-stage non-small cell lung cancer (NSCLC) in treatment shared decision making (SDM). We designed a novel DSI that includes care plan cards and a companion patient preference clarification tool to assist in shared decision making. The cards answer common patient questions about treatment options (chemotherapy, chemotherapy plus immunotherapy, targeted therapy, immunotherapy, clinical trial participation, and supportive care). The form elicits patient treatment preference. We then conducted interviews with clinicians and patients to obtain feedback on the DSI. We also trained oncology nurse educators to implement the prototype. Finally, we pilot tested the DSI among five patients with NSCLC at the beginning of an office visit scheduled to discuss treatment with an oncologist. Analyses of pilot study baseline and exit survey data showed that DSI use was associated with increased patient awareness of the alternatives' treatment options and benefits/risks. In contrast, patient concern about treatment costs and uncertainty in treatment decision making decreased. All patients expressed a treatment preference. Future randomized controlled trials are needed to assess DSI implementation feasibility and efficacy in clinical care.

Cancer patients' perspective on shared decision-making and decision aids in oncology

Purpose

Shared Decision-Making (SDM) enhances patients’ satisfaction with a decision, which in turn increases compliance with and adherence to cancer treatment. SDM requires a good patient-clinician relationship and communication, patients need information matching their individual needs, and clinicians need support on how to best involve the individual patient in the decision-making process. This survey assessed oncological patients’ information needs and satisfaction, their preferred information in patient decision aids (PDAs), and their preferred way of making decisions regarding their treatment.

Methods

Questionnaires were distributed among attendees of a lecture program on complementary and alternative medicine in oncology of which 220 oncological patients participated.

Results

Participants reported a generally high need for information—correlating with level of education—but also felt overwhelmed by the amount. The latter proved particularly important during consultation. Use of PDAs increased satisfaction with given information but occurred in less than a third of the cases. Most requested contents for PDAs were pros and cons of treatment options and lists of questions to ask. The vast majority of patients preferred SDM to deciding alone. None wanted their physician to decide for them.

Conclusions

There is a high demand for SDM but a lack of conclusive evidence on the specific information needs of different types of patients. Conversation between patients and clinicians needs encouragement and support. PDAs are designed for this purpose and have the potential to increase patient satisfaction. Their scarce use in consultations calls for easier access to and better information on PDAs for clinicians.

Evaluation of a National Comprehensive Cancer Network Guidelines-Based Decision Support Tool in Patients With Non-Small Cell Lung Cancer: A Nonrandomized Clinical Trial

IMPORTANCE

The association of guideline-based decision support with the quality of care in patients with non-small cell lung cancer (NSCLC) is not known.

OBJECTIVE

To evaluate the association of exposure to the National Comprehensive Cancer Center (NCCN) guidelines with guideline-concordant care and patients' decisional conflict.

DESIGN, SETTING, AND PARTICIPANTS

A nonrandomized clinical trial, conducted at a tertiary care academic institution, enrolled patients from February 23, 2015, to September 28, 2017. Data analysis was conducted from July 19, 2019, to April 22, 2020. A cohort of 76 patients with NSCLC seen at diagnosis or disease progression and a retrospective cohort of 157 patients treated before the trial were included. Adherence to 6 NCCN recommendations were evaluated: (1) smoking cessation counseling, (2) adjuvant chemotherapy for patients with stage IB to IIB NSCLC after surgery, (3) pathologic mediastinal staging in patients with stage III NSCLC before surgery, (4) pathologic mediastinal staging in patients with stage III NSCLC before nonsurgical treatment, (5) definitive chemoradiotherapy for patients with stage III NSCLC not having surgery, and (6) molecular testing for epidermal growth factor receptor and anaplastic lymphoma kinase alterations for patients with stage IV NSCLC. Subgroup analysis was conducted to compare the rates of guideline concordance between the prospective and retrospective cohorts. Secondary end points included decisional conflict and satisfaction.

INTERVENTIONS

An online tool customizing the NCCN guidelines to patients' clinical and pathologic features was used during consultation, facilitated by a trained coordinator.

MAIN OUTCOMES AND MEASURES

Concordance of practice with 6 NCCN treatment recommendations on NSCLC and patients' decisional conflict.

RESULTS

Of the 76 patients with NSCLC, 44 were men (57.9%), median age at diagnosis was 68 years (interquartile range [IQR], 41-87 years), and 59 patients (77.6%) had adenocarcinoma. In the retrospective cohort, 91 of 157 patients (58.0%) were men, median age at diagnosis was 66 years (IQR, 61-65 years), and 105 patients (66.9%) had adenocarcinoma. After the intervention, patients received more smoking cessation counseling (4 of 5 [80.0%] vs 1 of 24 [4.2%], P < .001) and less adjuvant chemotherapy (0 of 7 vs 7 of 11 [63.6%]; P = .012). There was no significant change in mutation testing of non-squamous cell stage IV disease (20 of 20 [100%] vs 48 of 57 [84.2%]; P = .10). There was no significant change in pathologic mediastinal staging or initial chemoradiotherapy for patients with stage III disease. After consultation with the tool, decisional conflict scores improved by a median of 20 points (IQR, 3-34; P < .001).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that exposure to the NCCN guidelines is associated with increased guideline-concordant care for 2 of 6 preselected recommendations and improvement in decisional conflict.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03982459.

Cancer Patients Numeracy and Preferences for Information Presentation-a Survey Among German Cancer Patients

Numeracy is highly relevant for therapy safety and effective self-management. Worse numeracy leads to poor health outcome. Most medical information is expressed in numbers. Considering the complexity of decisions, more information on the patient's ability to understand information is needed. We used a standardized questionnaire. Content was self-perception of numeracy, preferences regarding decision-making with respect to medical issues, and preferred content of information from four possible answers on side effect of cancer therapies (insomnia) within two scenarios. Overall, 301 participants answered the questionnaire. Presentation of facts in numbers was rated as helpful or very helpful (59.4%). Higher numeracy was associated with higher appreciation for presentation in numbers (p = 0.002). Although participants indicated presentation of facts in numbers as helpful in general, the favored answer in two concrete scenarios was verbal and descriptive instead of numerical. Numeracy is highly relevant for therapy safety and effective self-management. Health professionals need more knowledge about patient's ability and preferences with respect to presentation of health information. An individualized patient communication might be the best strategy to discuss treatment plans. We need to understand in which situations patients benefit from numerical presentation and how managing numerical data might influence decision processes.

Kidney cancer survivorship care: Patient experiences in a Canadian setting

INTRODUCTION

The incidence of kidney cancer (KCa) in Canada is rising. Despite this, there is a shortage of research assessing KCa care experiences. This study aims to explore the current experiences of KCa survivors related to treatment and management, information provision, and barriers to care.

METHODS

A cross-sectional, descriptive study of KCa patients was conducted online and through various cancer centers across Canada. English- and French-speaking adults who received a KCa diagnosis and were currently undergoing treatment or had completed treatment in Canada were eligible to participate.

RESULTS

In total, 368 surveys were completed. Ten percent of respondents had not yet received treatment, 29% were receiving treatment, and 56% had completed treatment. Most respondents (72%) had localized KCa (stage 0-3) at diagnosis. Sixty-one percent of respondents reported that their doctors discussed various treatment options with them and 24% reported discussing applicable clinical trials. Most (85%) respondents received information about their KCa and 36% discussed where to get information about their disease and support. The most commonly reported barriers to care were side effects (26%), system delays (26%), not having access to certain treatments (25%), and financial burden (24%). More participants in Central Region and Quebec (p=0.004) and rural/suburban (p=0.014) areas reported lacking access to certain treatments and KCa experts.

CONCLUSIONS

This was the first large-scale study to explore access to care experiences of Canadian KCa survivors. Results show examples of good patient-centered care and provide new practical information that can inform efforts to improve patient-centered care for KCa patients.

Patient-Specific Actual-Size Three-Dimensional Printed Models for Patient Education in Glioma Treatment: First Experiences

BACKGROUND

Patients with cancer need high-quality information about disease stage, treatment options, and side effects. High-quality information can also improve health literacy, shared decision making, and satisfaction. We created patient-specific three-dimensional (3D) models of tumors including surrounding functional areas and assessed what patients with glioma value (or fear) about the models when they are used to educate them about the relationship between their tumor and specific brain parts, the surgical procedure, and risks.

METHODS

This exploratory study included adult patients with glioma who underwent functional magnetic resonance imaging and diffusion tensor imaging as part of preoperative work-up. All participants received an actual-size 3D model printed based on functional magnetic resonance imaging and diffusion tensor imaging. Semistructured interviews were conducted to identify facilitators and barriers for using the model and perceived effects.

RESULTS

Models were successfully created for all 11 participants. There were 18 facilitators and 8 barriers identified. The model improved patients' understanding about their situation; patients reported that it was easier to ask their neurosurgeon questions based on their model and that it supported their decision about preferred treatment. A perceived barrier for using the 3D model was that it could be emotionally confronting, particularly in an early phase of the disease. Positive effects were related to psychological domains, including coping, learning effects, and communication.

CONCLUSIONS

Patient-specific 3D models are promising and simple tools that could help patients with glioma better understand their situation, treatment options, and risks. These models have the potential to improve shared decision making.

Understandability of Patient Information Booklets for Patients with Cancer

The improvement of health literacy in general and the information of individual patient is a major concern of the German national cancer plan and similar initiatives in other western countries. The aim of our study was to assess the readability and understandability of information booklets for cancer patients available at German Web sites. A support vector machine (SVM) was used to discriminate between laymen- and expert-centric patient information booklets about nine most common tumor types. All booklets had to be available for free at the Internet. A total of 52 different patient booklets were downloaded and assessed. Overall, the assessment of all booklets showed that an understandability level L of 4.6 and therefore increased medical background knowledge is required to understand a random text selected from the sample. The assessed information booklets on cancer show very limited suitability for laymen. We were able to demonstrate that a medical background is necessary to understand the examined booklets. The current study highlights the need to create information material adjusted to the needs of laymen. Assessing understandability before publication, especially for laymen with low health literacy, could ensure the suitability and thus quality of the information material.

The Experience of Persons With Hematological Malignancy When Communicating With Health Care Professionals

This study aimed to elucidate the experiences of Japanese persons with hematological malignancy (PHMs) in communicating with health care professionals (HCPs), from diagnosis to the end of life, as recalled by their families. We interviewed 14 bereaved families and analyzed the data using the basic techniques of grounded theory. We found that PHMs lived to the fullest possible when they experienced ownership of their illness process despite their disease. The ownership was made possible by active communication from HCPs: first, acknowledging the PHM's way of life, including reaching out from the HCPs and appreciating sincerely PHMs' hopes and will; and second, paving the way ahead, including giving prospects and offering choices. The study underlines that rather than just providing information about the disease, HCPs need to actively ask about and show respect for the PHM's way of life. Only after achieving this can HCPs communicate possible future pathways with PHMs.

A Review of Shared Decision-Making and Patient Decision Aids in Radiation Oncology

Cancer treatment decisions are complex and may be challenging for patients, as multiple treatment options can often be reasonably considered. As a result, decisional support tools have been developed to assist patients in the decision-making process. A commonly used intervention to facilitate shared decision-making is a decision aid, which provides evidence-based outcomes information and guides patients towards choosing the treatment option that best aligns with their preferences and values. To ensure high quality, systematic frameworks and standards have been proposed for the development of an optimal aid for decision making. Studies have examined the impact of these tools on facilitating treatment decisions and improving decision-related outcomes. In radiation oncology, randomized controlled trials have demonstrated that decision aids have the potential to improve patient outcomes, including increased knowledge about treatment options and decreased decisional conflict with decision-making. This article provides an overview of the shared-decision making process and summarizes the development, validation, and implementation of decision aids as patient educational tools in radiation oncology. Finally, this article reviews the findings from decision aid studies in radiation oncology and offers various strategies to effectively implement shared decision-making into clinical practice.

Parallel multicentre randomised trial of a clinical trial question prompt list in patients considering participation in phase 3 cancer treatment trials

OBJECTIVE

To evaluate the effect of a clinical trial question prompt list in patients considering enrolment in cancer treatment trials.

SETTING

Tertiary cancer referral hospitals in three state capital cities in Australia.

PARTICIPANTS

88 patients with cancer attending three cancer centres in Australia, who were considering enrolment in phase 3 treatment trials, were invited to enrol in an unblinded randomised trial of provision of a clinical trial question prompt list (QPL) before consenting to enrol in the treatment trial.

INTERVENTIONS

We developed and pilot tested a targeted QPL for patients with cancer considering clinical trial participation (the clinical trial QPL). Consenting patients were randomised to receive the clinical trial QPL or not before further discussion with their oncologist and/or trial nurse about the treatment trial.

PRIMARY AND SECONDARY OUTCOMES

Questionnaires were completed at baseline and within 3 weeks of deciding on treatment trial participation.

MAIN OUTCOME MEASURE

scores on the Quality of Informed Consent questionnaire (QuIC).

RESULTS

88 patients of 130 sought for the study were enrolled (43 males), and 45 received the clinical trial QPL. 49% of trials were chemotherapy interventions for patients with advanced disease, 35% and 16% were surgical adjuvant and radiation adjuvant trials respectively. 70 patients completed all relevant questionnaires. 28 of 43 patients in the control arm compared with 39 of 45 patients receiving the clinical trial QPL completed the QuIC (p=0.0124). There were no significant differences in the QuIC scores between the randomised groups (QuIC part A p=0.08 and QuIC part B p=0.92). There were no differences in patient satisfaction with decisions or in anxiety levels between the randomised groups.

CONCLUSIONS

Use of a question prompt list did not significantly change the QuIC scores in this randomised trial. ANZCTR 12606000214538 prospectively registered 31/5/2006.

TRIAL REGISTRATION NUMBER

Results, ACTRN12606000214538.

Breast cancer patients' information seeking during surgical consultations: A qualitative, videotape-based analysis of patients' questions

BACKGROUND

Despite data on breast cancer patients' information needs and their association with patient outcomes, there are currently no data on what U.S. patients actually ask surgeons during primary consultations.

METHODS

Working from transcripts of videotaped, treatment decision making consultations between breast cancer patients and surgeons, we identify all questions (by patients and companions) and then use grounded theory techniques to determine the most recurrent question-asking themes.

RESULTS

Sample includes 132 recently diagnosed (M = 8.9 days), late-middle-aged (M = 61.2 years), female patients with predominantly early stage (0-1; 78%), first-time breast cancer (92.4%) consulting with one of nine surgeons in community based offices. Transcripts contained 2,781 questions (1,929 by patients, 852 by companions; Cohen's Kappa = 0.90), which generated 15 patient question asking themes that were represented (i.e., asked about) at least once in >20% of all consultations.

CONCLUSION

Question asking themes are a concrete index of what patients want to know more about prior to treatment. Identified themes specify, modify, and extend prior findings based on self-report data. Findings potentially increase surgeons' levels of patient centered care by improving surgeons' abilities to satisfactorily address patients' information needs, which has the potential to improve both patient outcomes and clinical practice guidelines. J. Surg. Oncol. 2016;114:922-929. © 2016 Wiley Periodicals, Inc.

A review of question prompt lists used in the oncology setting with comparison to the Patient Concerns Inventory

A question prompt list (QPL) is a simple and inexpensive communication tool used to facilitate patient participation in medical consultations. The QPL is composed of a structured list of questions and has been shown to be an effective way of helping ensure patients' individual information needs are appropriately met. This intervention has been investigated in a variety of settings but not specifically head and neck cancer (HNC). The aim of this paper was to perform a narrative review of literature reporting the use of a QPL for oncology patients and to draw comparison to the Patient Concerns Inventory (PCI-HN). The databases Scopus, PubMed and MEDLINE were searched using the key terms 'question prompt list', 'question prompt sheet', 'cancer' and 'oncology'. Of 98 articles hand searched, 30 of which were found to meet all inclusion criteria, and described in a tabulated summary. The studies concluded that the QPL was an effective intervention, enabling active patient participation in medical consultations. The PCI-HN is specific for HNC and differs from many QPLs, which are more general cancer tools. The QPL approach should prove to be a useful intervention for HNC sufferers, however further research into the clinical utility is required.

2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer

BACKGROUND

Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the American Thyroid Association's (ATA's) guidelines for the management of these disorders were revised in 2009, significant scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid nodules and differentiated thyroid cancer.

METHODS

The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles on adults were eligible for inclusion. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations for therapeutic interventions. We developed a similarly formatted system to appraise the quality of such studies and resultant recommendations. The guideline panel had complete editorial independence from the ATA. Competing interests of guideline task force members were regularly updated, managed, and communicated to the ATA and task force members.

RESULTS

The revised guidelines for the management of thyroid nodules include recommendations regarding initial evaluation, clinical and ultrasound criteria for fine-needle aspiration biopsy, interpretation of fine-needle aspiration biopsy results, use of molecular markers, and management of benign thyroid nodules. Recommendations regarding the initial management of thyroid cancer include those relating to screening for thyroid cancer, staging and risk assessment, surgical management, radioiodine remnant ablation and therapy, and thyrotropin suppression therapy using levothyroxine. Recommendations related to long-term management of differentiated thyroid cancer include those related to surveillance for recurrent disease using imaging and serum thyroglobulin, thyroid hormone therapy, management of recurrent and metastatic disease, consideration for clinical trials and targeted therapy, as well as directions for future research.

CONCLUSIONS

We have developed evidence-based recommendations to inform clinical decision-making in the management of thyroid nodules and differentiated thyroid cancer. They represent, in our opinion, contemporary optimal care for patients with these disorders.

Practical Implications of the Publication of Consensus Guidelines by the American Society for Radiation Oncology: Accelerated Partial Breast Irradiation and the National Cancer Data Base

PURPOSE

To examine utilization trends of accelerated partial breast irradiation (APBI) in the American College of Surgeons' National Cancer Database and changes in APBI use after the 2009 publication of the American Society for Radiation Oncology (ASTRO) guidelines.

METHODS AND MATERIALS

A total of 399,705 women were identified who were diagnosed from 2004 to 2011 with nonmetastatic invasive breast cancer or ductal carcinoma in situ who were treated with breast-conserving surgery and radiation therapy to the breast. Patients were divided by the type of treatment received (whole breast irradiation or APBI) and by suitability to receive APBI as defined by the ASTRO guidelines. Logistic regression was applied to study APBI use overall and within guideline categorization, and a multivariable model was created to determine predictors of treatment with brachytherapy-based APBI based on guideline categorization.

RESULTS

For all patients, APBI use increased, from 3.8% in 2004 to 10.6% in 2011 (P<.0001). Overall rates of APBI utilization were higher among "suitable" than "cautionary"/"unsuitable" patients (14.8% vs 7.1%, P<.0001). The majority of APBI treatment was delivered using brachytherapy, for which use peaked in 2008. Starting in 2009, among "suitable" patients, utilization of APBI via brachytherapy plateaued, whereas for "cautionary"/"unsuitable" patients, treatment with brachytherapy-based APBI declined and then plateaued.

CONCLUSION

Use of APBI across all patient groups increased from 2004 through 2008. After publication of the ASTRO APBI guidelines in 2009, rates of brachytherapy-based APBI treatment plateaued among "suitable" patients and declined and then plateaued among "cautionary"/"unsuitable" patients. Our study highlights how large national databases can be used to assess national trends in radiation use in response to the publication of guidelines.

Primary systemic therapy for breast cancer: Does the patient's involvement in decision-making create a new future?

OBJECTIVE

Primary systemic therapy (PST) followed by surgery is the standard initial treatment for locally advanced breast cancer (LABC). However, some patients are averse to mastectomy or breast-conserving surgery and do not consent to these procedures. The reasons for this controversial decision, the factors influencing the decision-making and optimal solutions for decision aiding need to be investigated.

METHODS

We addressed these questions by a review of literature on the possibilities associated with different patient choices and subsequent treatment options in relation to LABC.

RESULTS

A total of 5 reviews and 22 clinical studies were summarized in relation to decision making and the most successful decision aids. A discussion is given of the issues of those few patients who cannot be convinced to undergo surgery.

CONCLUSION

Currently there is no guideline for the treatment of patients who reject the surgical procedures after PST. Medical oncologists should be able to apply decision aid modalities in a personalized manner to give all needed information to their patients thereby ensuring a deliberate decision-making process, facilitating acceptance of a need for surgery, and thus improving the chances of prolonged survival.

PRACTICE IMPLICATIONS

Currently multidisciplinary tumor boards are the most suitable decision aids in oncological practice.

Shared decision-making and comparative effectiveness research for patients with chronic conditions: an urgent synergy for better health

Chronic conditions are the most important cause of morbidity, mortality and health expense in the USA. Comparative effectiveness research (CER) seeks to provide evidence supporting the relative value of alternative courses of action. This research often concludes with estimates of the likelihood of desirable and undesirable outcomes associated with each option. Patients with chronic conditions should engage with their clinicians in deciding which of these options best fits their goals and context. In practicing shared decision-making (SDM), clinicians and patients should make use of CER to inform their deliberations. In these ways, SDM and CER are interrelated. SDM translates CER into patient-centered practice, while CER provides the backbone evidence about options and outcomes in SDM interventions. In this review, we explore the potential for a SDM-CER synergy in improving healthcare for patients with chronic conditions.

Do parents of children with attention-deficit/hyperactivity disorder (ADHD) receive adequate information about the disorder and its treatments? A qualitative investigation

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is the most prevalent pediatric neurodevelopmental condition, commonly treated using pharmacological agents such as stimulant medicines. The use of these agents remains contentious, placing parents in a difficult position when deciding to initiate and/or continue their child's treatment. Parents refer to a range of information sources to assist with their treatment decision-making. This qualitative study aimed to investigate 1) parents' ADHD-related knowledge pre- and post-diagnosis, 2) the information sources accessed by parents, 3) whether parents' information needs were met post-diagnosis, and 4) parents' views about strategies to meet their information needs.

METHODS

Three focus groups (n=16 parents), each lasting 1.0-1.5 hours were conducted. Focus groups were audio-recorded and transcribed verbatim. Transcripts were analyzed using the framework method, coded, and categorized into themes.

RESULTS

Generally, parents had limited ADHD-related knowledge prior to their child's diagnosis and perceived prescription medicines indicated for ADHD in a negative context. Parents reported improved knowledge after their child's diagnosis; however, they expressed dissatisfaction with information that they accessed, which was often technical and not tailored to their child's needs. Verbal information sought from health care professionals was viewed to be reliable but generally medicine-focused and not necessarily comprehensive. Parents identified a need for concise, tailored information about ADHD, the medicines used for its treatment, and changes to their child's medication needs with age. They also expressed a desire for increased availability of support groups and tools to assist them in sourcing information from health care professionals during consultations, such as question prompt lists.

CONCLUSION

There are gaps in parents' knowledge about ADHD and its treatment, and an expressed need for tailored and reliable information. Future research needs to focus on providing parents with avenues to access concise, reliable, and relevant information and support in order to empower them to make the best treatment decision for their child.

Women's perceptions of their involvement in treatment decision making for early stage breast cancer

PURPOSE

This study aimed to describe the perceptions of women with early stage breast cancer regarding their involvement in treatment decision making (TDM).

METHODS

Eligible women with early stage breast cancer were recruited immediately after their first consultation with a specialist. Semistructured personal interviews were held prior to treatment. Interviews were audiotaped, transcribed, and analyzed.

RESULTS

Nineteen women with early stage breast cancer considering surgery (n = 6) or adjuvant therapy (n = 13) participated. Women described being involved in various stages of TDM and interacting with informal networks and specialists. Women's descriptions suggest that (1) the concept of involvement in TDM may have a broader meaning for patients than strictly their decisional role and (2) inclusion of significant others in TDM contributes to the patient's sense of involvement.

CONCLUSIONS

Conceptualization and measurement of patient involvement in TDM have often been framed within the context of the medical encounter and the patient's perceived or actual role in this process. Our findings raise questions about what involvement means to patients with early stage breast cancer and suggest that the focus on patient involvement in TDM within the medical encounter may be too narrow to capture the meaning of involvement from the patient's perspective.