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Cui J, Fang P, Bai J, Tan L, Wan C, Yu L. Meta-Analysis of Effects of Early Palliative Care on Health-Related Outcomes Among Advanced Cancer Patients. Nurs Res 2023; 72:E180-E190. [PMID: 37733650 DOI: 10.1097/nnr.0000000000000687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
BACKGROUND Early palliative care (PC) has received more attention for improving health-related outcomes for advanced cancer patients in recent years, but the results of previous studies are inconsistent. OBJECTIVES This study aimed to use meta-analysis and trial sequence analysis to evaluate the effect of early PC on health-related outcomes of advanced cancer patients. METHODS All English publications were searched in PubMed, Web of Science, Embase, and the Cochrane Library from inception to March 2023, with a restriction that the study type was a randomized controlled trial. RESULTS The results showed that early PC positively affected quality of life, satisfaction with care, and symptom burden reduction. However, early PC had no significant effect on anxiety or survival. Trial sequence analysis results showed that the effect of early PC on the quality of life was stable. DISCUSSION This systematic review suggested that early PC could positively affect health-related outcomes for advanced cancer patients. Early PC can be used widely in clinical settings to improve health-related outcomes of advanced cancer. However, because of the trial sequence analysis results, further well-designed, clinical, randomized controlled trials with larger sample sizes are necessary to draw definitive conclusions.
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Levoy K, Sullivan SS, Chittams J, Myers RL, Hickman SE, Meghani SH. Don't Throw the Baby Out With the Bathwater: Meta-Analysis of Advance Care Planning and End-of-life Cancer Care. J Pain Symptom Manage 2023; 65:e715-e743. [PMID: 36764411 PMCID: PMC10192153 DOI: 10.1016/j.jpainsymman.2023.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/27/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023]
Abstract
CONTEXT There is ongoing discourse about the impact of advance care planning (ACP) on end-of-life (EOL) care. No meta-analysis exists to clarify ACP's impact on patients with cancer. OBJECTIVE To investigate the association between, and moderators of, ACP and aggressive vs. comfort-focused EOL care outcomes among patients with cancer. METHODS Five databases were searched for peer-reviewed observational/experimental ACP-specific studies that were published between 1990-2022 that focused on samples of patients with cancer. Odds ratios were pooled to estimate overall effects using inverse variance weighting. RESULTS Of 8,673 articles, 21 met criteria, representing 33,541 participants and 68 effect sizes (54 aggressive, 14 comfort-focused). ACP was associated with significantly lower odds of chemotherapy, intensive care, hospital admissions, hospice use fewer than seven days, hospital death, and aggressive care composite measures. ACP was associated with 1.51 times greater odds of do-not-resuscitate orders. Other outcomes-cardiopulmonary resuscitation, emergency department admissions, mechanical ventilation, and hospice use-were not impacted. Tests of moderation revealed that the communication components of ACP produced greater reductions in the odds of hospital admissions compared to other components of ACP (e.g., documents); and, observational studies, not experimental, produced greater odds of hospice use. CONCLUSION This meta-analysis demonstrated mixed evidence of the association between ACP and EOL cancer care, where tests of moderation suggested that the communication components of ACP carry more weight in influencing outcomes. Further disease-specific efforts to clarify models and components of ACP that work and matter to patients and caregivers will advance the field.
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Affiliation(s)
- Kristin Levoy
- Department of Community and Health Systems (K.L., R.L.M., S.E.H.), Indiana University School of Nursing, Indianapolis, Indiana; Indiana University Center for Aging Research, Regenstrief Institute (K.L., S.E.H.), Indianapolis, Indiana; Indiana University Melvin and Bren Simon Comprehensive Cancer Center (K.L., S.E.H.), Indianapolis, Indiana.
| | - Suzanne S Sullivan
- School of Nursing (S.S.S.), University at Buffalo, State University of New York, Buffalo, New York
| | - Jesse Chittams
- BECCA (Biostatistics, Evaluation, Collaboration, Consultation & Analysis) Lab, Office of Nursing Research (J.C.), University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Ruth L Myers
- Department of Community and Health Systems (K.L., R.L.M., S.E.H.), Indiana University School of Nursing, Indianapolis, Indiana
| | - Susan E Hickman
- Department of Community and Health Systems (K.L., R.L.M., S.E.H.), Indiana University School of Nursing, Indianapolis, Indiana; Indiana University Center for Aging Research, Regenstrief Institute (K.L., S.E.H.), Indianapolis, Indiana; Indiana University Melvin and Bren Simon Comprehensive Cancer Center (K.L., S.E.H.), Indianapolis, Indiana
| | - Salimah H Meghani
- NewCourtland Center for Transitions and Health, Department of Biobehavioral Health Sciences (S.H.M.), University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics (S.H.M.), University of Pennsylvania, Philadelphia, Pennsylvania
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Ke X, Zhu H, Zhang Y, Yang L, Shi S, Zhu F, Luo H. Willingness of patients with cancer pain to participate in end-of-life decisions: a multi-center cross-sectional study from three coastal provinces in southern China. Palliat Care 2022; 21:207. [PMID: 36434622 PMCID: PMC9700943 DOI: 10.1186/s12904-022-01108-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 11/15/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Little is known about patients' intention for participation in end-of-life decisions (EOLD) in three coastal provinces in southern China. This study aimed to explore the willingness of patients with cancer pain to participate in EOLD and potential influencing factors. METHODS A multi-center cross-sectional study was performed in three coastal provinces in southern China. Two hundred and thirty patients with cancer pain were recruited and consented to fill out the questionnaires. The patients' willingness to participate in EOLD, demographic and disease-related data was surveyed. RESULTS In total, 223 patients completed and returned the survey (response rate = 96.95%). One hundred four cases (46.64%) were willing to participate in EOLD. 119 (54.36%) cases not willing to participate in EOLD, respectively. Multivariate logistic regression analysis shows that educational level (OR: 0.683, 95% CI: 0.482-0.966), history of alcoholism (OR: 8.353, 95%CI: 2.535-27.525), Eastern Cooperative Oncology Group (ECOG) score (OR: 0.645, 95% CI: 0.450-0.925) and experience of explosive pain (OR: 6.367, 95% CI: 3.103-13.062) and clinical rescue (OR: 3.844, 95% CI: 1.722-8.577) had significant effects on EOLD intention (P < 0.05). Finally, a predictive model combined above five factors was established, which showed a good discrimination (area under receiver operating characteristic curve: 0.849, 95% CI: 0.796-0.899, P < 0.001) and calibration (Hosmer-Lemeshow Test: Chi-square = 10.103, P = 0.258) for which patients more willing to participate in EOLD. CONCLUSIONS The willingness of patients with cancer pain to participate in EOLD is at a modest level in three coastal provinces in southern China. Patients with lower educational level, history of alcoholism, better health status and experience of explosive pain and clinical rescue may be more prone to participate in EOLD.
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Affiliation(s)
- Xi Ke
- grid.415110.00000 0004 0605 1140Department of Abdominal Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuma Road 420#, Fuzhou, 350014 China
| | - Hongyu Zhu
- grid.415110.00000 0004 0605 1140Department of Abdominal Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuma Road 420#, Fuzhou, 350014 China
| | - Yu Zhang
- Department of Internal Medicine-Oncology, Shaanxi Cancer Hospital, Xian, 710061 China
| | - Ling Yang
- grid.256607.00000 0004 1798 2653Department of Gastroenterology-Oncology, Cancer Hospital Affiliated to Guangxi Medical University, Nanning, 530000 China
| | - Simei Shi
- grid.488530.20000 0004 1803 6191Department of Gastroenterology-Oncology, Sun Yat-Sen University Cancer Prevention and Treatment Center, Sun Yat-sen University Cancer Center, Guangzhou, 510060 China
| | - Fang Zhu
- grid.415110.00000 0004 0605 1140Department of thoracic oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014 China
| | - Huiyu Luo
- grid.415110.00000 0004 0605 1140Nursing management department, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuma Road 420#, Fuzhou, 350014 China
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van der Velden NC, van Laarhoven HW, Nieuwkerk PT, Kuijper SC, Sommeijer DW, Ottevanger PB, Fiebrich HB, Dohmen SE, Creemers GJ, de Vos FY, Smets EM, Henselmans I. Attitudes Toward Striving for Quality and Length of Life Among Patients With Advanced Cancer and a Poor Prognosis. JCO Oncol Pract 2022; 18:e1818-e1830. [DOI: 10.1200/op.22.00185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE: When deliberating palliative cancer treatment, insight into patients' attitudes toward striving for quality of life (QL) and length of life (LL) may facilitate goal-concordant care. We investigated the (1) attitudes of patients with advanced cancer toward striving for QL and/or LL and whether these change over time, and (2) characteristics associated with these attitudes (over time). METHODS: We performed a secondary analysis of a randomized controlled trial on improving shared decision making (SDM), without differentiation between intervention arms. Patients (n = 173) with advanced cancer, a median life expectancy of < 12 months without anticancer treatment, and a median survival benefit of < 6 months from systemic therapy were included in seven Dutch hospitals. We used audio-recorded consultations and surveys at baseline (T0), shortly after the consultation (T2), at 3 and 6 months (T3 and T4). Primary outcomes were patients' attitudes toward striving for QL and LL (Quality Quantity Questionnaire; T2, T3, and T4). RESULTS: Overall, patients' attitudes toward striving for QL became less positive over 6 months ( P < .01); attitudes toward striving for LL did not change on group level. Studying individual patients, 76% showed changes in their attitudes toward striving for QL and/or LL at some point during the study, which occurred in various directions. More helplessness/hopelessness ( P < .001), less fighting spirit ( P < .05), less state anxiety ( P < .001), and more observed SDM ( P < .05) related to more positive attitudes toward striving for QL. Lower education, less helplessness/hopelessness, more fighting spirit, and more state anxiety ( P < .001) related to more positive attitudes toward striving for LL. CONCLUSION: Oncologists may explore patients' attitudes toward striving for QL and LL repeatedly and address patients' coping style and emotions during SDM to facilitate goal-concordant care throughout the last phase of life.
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Affiliation(s)
- Naomi C.A. van der Velden
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Hanneke W.M. van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Pythia T. Nieuwkerk
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Steven C. Kuijper
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Dirkje W. Sommeijer
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
- Department of Medical Oncology, Flevoziekenhuis, Almere, the Netherlands
| | - Petronella B. Ottevanger
- Department of Medical Oncology, Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands
| | | | - Serge E. Dohmen
- Department of Medical Oncology, BovenIJ Ziekenhuis, Amsterdam, the Netherlands
| | - Geert-Jan Creemers
- Department of Medical Oncology, Catharina Ziekenhuis, Eindhoven, the Netherlands
| | - Filip Y.F.L. de Vos
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Ellen M.A. Smets
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Inge Henselmans
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
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Gisbert-Pérez J, Martí-Vilar M, González-Sala F. Prospect Theory: A Bibliometric and Systematic Review in the Categories of Psychology in Web of Science. Healthcare (Basel) 2022; 10:healthcare10102098. [PMID: 36292546 PMCID: PMC9601776 DOI: 10.3390/healthcare10102098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/04/2022] [Accepted: 10/18/2022] [Indexed: 12/03/2022] Open
Abstract
Prospect Theory (PT) is an alternative, dynamic explanation of the phenomenon of risky decision making. This research presents an overview of PT’s history in health fields, including advancements, limitations, and bibliometric data. A systematic and bibliometric review of the scientific literature included in the psychological categories of Web of Science (WoS) was performed following the PRISMA 2020 statement for systematic reviews. A total of 37 studies (10 non-empirical and 27 empirical) were included in the sample. Bibliometric results showed thematic variability and heterogeneity regarding the production, researchers, and methodologies that are used to study PT. The systematic results highlight three main fields of PT research: preventive and screening behaviors, promotion of healthy habits, and COVID-related decision making. Personal and contextual factors which alter the usual pattern specified by PT are also described. To conclude, PT currently has an interdisciplinary character suitable for health promotion, with recent studies broadening its applicability.
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Affiliation(s)
- Júlia Gisbert-Pérez
- Departamento de Psicología Básica, Universitat de València, Avgda. Blasco Ibañez 21, 46010 Valencia, Spain
| | - Manuel Martí-Vilar
- Departamento de Psicología Básica, Universitat de València, Avgda. Blasco Ibañez 21, 46010 Valencia, Spain
- Correspondence:
| | - Francisco González-Sala
- Departamento de Psicología Evolutiva y de la Educación, Universitat de València, Avgda. Blasco Ibañez 21, 46010 Valencia, Spain
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Bange EM, Reiss KA, Mamtani R. Reply to J. Warner-Cohen et al. JCO Oncol Pract 2020; 16:845. [PMID: 32941088 DOI: 10.1200/op.20.00603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Erin M Bange
- Erin M. Bange, MD; Kim A. Reiss, MD; and Ronac Mamtani, MD, MSCE, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Kim A Reiss
- Erin M. Bange, MD; Kim A. Reiss, MD; and Ronac Mamtani, MD, MSCE, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Ronac Mamtani
- Erin M. Bange, MD; Kim A. Reiss, MD; and Ronac Mamtani, MD, MSCE, Hospital of the University of Pennsylvania, Philadelphia, PA
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Hoerger M, Wayser GR, Schwing G, Suzuki A, Perry LM. Impact of Interdisciplinary Outpatient Specialty Palliative Care on Survival and Quality of Life in Adults With Advanced Cancer: A Meta-Analysis of Randomized Controlled Trials. Ann Behav Med 2020; 53:674-685. [PMID: 30265282 DOI: 10.1093/abm/kay077] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND In advanced cancer, patients want to know how their care options may affect survival and quality of life, but the impact of outpatient specialty palliative care on these outcomes in cancer is uncertain. PURPOSE To estimate the impact of outpatient specialty palliative care programs on survival and quality of life in adults with advanced cancer. METHODS Following PRISMA guidelines, we conducted a systematic review and meta-analysis of randomized controlled trials comparing outpatient specialty palliative care with usual care in adults with advanced cancer. Primary outcomes were 1 year survival and quality of life. Analyses were stratified to compare preliminary studies against higher-quality studies. Secondary outcomes were survival at other endpoints and physical and psychological quality-of-life measures. RESULTS From 2,307 records, we identified nine studies for review, including five high-quality studies. In the three high-quality studies with long-term survival data (n = 646), patients randomized to outpatient specialty palliative care had a 14% absolute increase in 1 year survival relative to controls (56% vs. 42%, p < .001). The survival advantage was also observed at 6, 9, 15, and 18 months, and median survival was 4.56 months longer (14.55 vs. 9.99 months). In the five high-quality studies with quality-of-life data (n = 1,398), outpatient specialty palliative care improved quality-of-life relative to controls (g = .18, p < .001), including for physical and psychological measures. CONCLUSIONS Patients with advanced cancer randomized to receive outpatient specialty palliative care lived longer and had better quality of life. Findings have implications for improving care in advanced cancer.
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Affiliation(s)
- Michael Hoerger
- Departments of Psychology, Psychiatry, and Medicine, Tulane University, New Orleans, LA
| | | | - Gregory Schwing
- Department of Biology, University of New Orleans, New Orleans, LA
| | - Ayako Suzuki
- Department of Epidemiology, Tulane University, New Orleans, LA
| | - Laura M Perry
- Department of Psychology, Tulane University, New Orleans, LA
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Narayanan S, Nagengast A, Hussain A, Badugu P, Elnazeir M, Jones CM. Palliative Considerations Regarding Enteral Access in Surgical Patients. CURRENT SURGERY REPORTS 2020. [DOI: 10.1007/s40137-020-00249-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Yip KF, Wong TH, Alhamid SM, Nadkarni N, Tan CKG, Pang A, Seow CCD. Integrating advance care planning as part of comprehensive geriatric assessment for hospitalised frail elderly patients: findings of a cross-sectional study. Singapore Med J 2019; 61:254-259. [PMID: 31423542 DOI: 10.11622/smedj.2019098] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The integration of advance care planning (ACP) as part of the comprehensive geriatric assessment (CGA) of hospitalised frail elderly patients, together with the clinical and demographic factors that determine successful ACP discussion, has not been previously explored. METHODS A cross-sectional study on patients and family caregivers admitted under the geriatric medicine department of a tertiary hospital was conducted from October 2015 to December 2016. RESULTS Among 311 eligible patients, 116 (37.3%) patients completed ACP discussion while 166 (53.4%) patients declined, with 62 (37.3%) of the decliners providing reasons for refusal. Univariate logistic regression analysis showed that older age, higher Charlson Comorbidity Index, poorer functional status and cognitive impairment had statistically significant associations with agreeing to ACP discussion (p < 0.05). On multivariate logistic regression analysis, only poorer functional status was significantly associated (odds ratio 2.22 [95% confidence interval 1.27-3.87]; p = 0.005). Among those who completed ACP discussion, a majority declined cardiopulmonary resuscitation (79.3%), preferred limited medical intervention or comfort care (82.8%), and opted for blood transfusion (62.9%), antibiotics (73.3%) and intravenous fluid (74.1%) but declined haemodialysis (50.9%). Decision-making was divided for enteral feeding. Among decliners, the main reasons for refusal were 'not keen' (33.9%), 'deferring to doctors' decision' (11.3%) and 'lack of ACP awareness' (11.3%). CONCLUSION The feasibility and utility of integrating ACP as part of CGA has been demonstrated. Poorer functional status is significantly associated with successful ACP discussion. Greater public education on end-of-life care choices (besides cardiopulmonary resuscitation) and follow-up with decliners are recommended.
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Affiliation(s)
- King Fan Yip
- Department of Geriatric Medicine, Singapore General Hospital, Singapore
| | - Ting Hway Wong
- Department of General Surgery, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | | | - Nivedita Nadkarni
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | | | - Amanda Pang
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore
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Shrestha A, Martin C, Burton M, Walters S, Collins K, Wyld L. Quality of life versus length of life considerations in cancer patients: A systematic literature review. Psychooncology 2019; 28:1367-1380. [PMID: 30838697 PMCID: PMC6619389 DOI: 10.1002/pon.5054] [Citation(s) in RCA: 179] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 02/24/2019] [Accepted: 02/25/2019] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Patients with cancer face difficult decisions regarding treatment and the possibility of trading quality of life (QoL) for length of life (LoL). Little information is available regarding patients' preferences and attitudes toward their cancer treatment and the personal costs they are prepared to exchange to extend their life. The aim of this review is to determine the complex trade-offs and underpinning factors that make patients with cancer choose quality over quantity of life. METHODS A systematic review of the literature was conducted using MeSH terms: cancer, longevity or LoL, QoL, decision making, trade-off, and health utility. Articles retrieved were published between 1942 and October 2018. RESULTS Out of 4393 articles, 30 were included in this review. Older age, which may be linked to declining physical status, was associated with a preference for QoL over LoL. Younger patients were more likely to undergo aggressive treatment to increase survival years. Preference for QoL and LoL was not influenced by gender, education, religion, having children, marital status, or type of cancer. Patients with better health valued LoL and inversely those with poorer physical status preferred QoL. CONCLUSION Baseline QoL and future expectations of life seem to be key determinants of preference for QoL versus LoL in cancer patients. In-depth studies are required to understand these trade-offs and the compromises patients are willing to make regarding QoL or LoL, especially in older patients with naturally limited life expectancy.
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Affiliation(s)
- Anne Shrestha
- Department of Oncology and MetabolismUniversity of SheffieldSheffield
| | - Charlene Martin
- Department of Oncology and MetabolismUniversity of SheffieldSheffield
| | - Maria Burton
- Faculty of Health and WellbeingSheffield Hallam UniversitySheffield
| | - Stephen Walters
- School of Health and Related ResearchUniversity of SheffieldSheffield
| | - Karen Collins
- Faculty of Health and WellbeingSheffield Hallam UniversitySheffield
| | - Lynda Wyld
- Department of Oncology and MetabolismUniversity of SheffieldSheffield
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