Patient Decision Making

Sensemaking in the personal health space

Purpose

– Service alignment between health service provider and patient is changing. Instead of placing responsibilities into the hands of a provider, new forms of co-operation are emerging in which patients are regarded as a resource and a partner. In order to see this vision come to life, mechanisms that: first, support patient’s health decision making; and second, integrate matters of health into a wider ensemble that is health space; the overarching state of health-related affairs, are needed. In the following, these kinds of mechanisms are investigated and their applicability is discussed in relation to a national project. The paper aims to discuss these issues.

Design/methodology/approach

– The work is exploratory and conceptual, focussing more on people than on technology. In the work, findings related to a concept of a health navigator; an artefact of personal health decision support, are assembled into a framework that bases on key sociological theories. The empirical elements focus on observations made on applicability of the concept, and the underlying framework of citizen-centric electronic health services.

Findings

– The authors argue that the discussed concept, when applied to personal health decision making according to the underlying framework, has a potential to change health service provisioning. In addition to stimulating new kind of co-operation between the health service provider and the citizen, the concept gives form to, somewhat idealized, notions of patient choice and empowerment.

Research limitations/implications

– The work described here is exploratory and forward-looking. Even though the concept and the framework are tested to a degree in a national project, more practice-oriented work is needed in terms of real-world applicability. It follows from this that the work is a conceptual elaboration on the future of personal health decision making.

Originality/value

– The findings, including the discussed challenges and needs, stem from real-world observations; from the needs of citizens. As such, they indicate a direction into which the development of personal health records and health decision support aids should go.

Individualized magnetic resonance imaging-based neoadjuvant chemoradiation for middle and lower rectal carcinoma

AIM

In most institutions neoadjuvant chemoradiation for middle and lower rectal carcinoma is currently given to patients with tumours of clinical stages II or III (cT3,4 and/or N1,2). The possibility of a reduction in the use of neoadjuvant chemoradiation by an individualized magnetic resonance imaging (MRI)-based indication for neoadjuvant chemoradiation was analysed.

METHOD

Assessment of the pathological and oncological principles indicating for neoadjuvant treatment was used to determine the prognostic importance of the distance between the tumour and the circumferential resection margin and pretherapeutic assessment using modern MRI.

RESULTS

Based on the results of pretreatment MRI scanning, a proposal is presented for the treatment of middle and lower rectal carcinoma with neoadjuvant chemoradiation. Adopting this proposal, the frequency of neoadjuvant chemoradiation decreased from 70% to 35% and the early and late adverse effects of this therapy were reduced. In contrast, the expected locoregional recurrence rate increased from 6% to 11% if all quality criteria were met and to 18% if not.

CONCLUSION

An MRI-based indication for neoadjuvant chemoradiation is justified only for centres with regular quality assurance of MRI, surgery, radiotherapy and pathology. The proposal needs confirmation by long-term follow up and by prospective studies with larger numbers of patients.

Regional lymph node metastasis and locoregional recurrence of rectal carcinoma in the era of TME [corrected] surgery. Implications for treatment decisions

BACKGROUND AND AIMS

For rectal carcinoma treated according to the concept of total mesorectal excision (TME surgery), the independent influence of regional lymph node metastasis on the locoregional recurrence risk is still in discussion. A reliable assessment of this risk is important for an individualised selective indication for neoadjuvant radio-/radiochemotherapy.

METHODS

Analysis of literature, especially of the last 20 years, and consideration of pathological and oncological basic research. Multivariate analysis of data of the Erlangen Registry of Colorectal Carcinoma.

RESULTS

The clinical assessment of the pretherapeutic regional lymph node status by the present available imaging methods is still unreliable. The analysis of the association between pretherapeutic regional lymph node status and locoregional recurrence risk has to be based on follow-up data of patients treated by primary surgery and has to be distinguished between patients treated by conventional and optimised quality-assured TME surgery, respectively. Data from Erlangen show an increase of the local recurrence risk for patients with at least four involved regional lymph nodes.

CONCLUSIONS

For patients with at least four involved regional lymph nodes, a neoadjuvant radiochemotherapy may be indicated. However, today, the pretherapeutic diagnosis is uncertain and results in overtherapy in 40%. Thus, in case of positive lymph node findings by imaging methods, the benefits and risk of neoadjuvant therapy in such situations should always be discussed with the patient in the sense of informed consent and shared decision.