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Hodges JS, Stoyanova LV, Galizzi MM. End-of-Life Preferences: A Randomized Trial of Framing Comfort Care as Refusal of Treatment in the Context of COVID-19. Med Decis Making 2023; 43:631-641. [PMID: 37199414 PMCID: PMC10196681 DOI: 10.1177/0272989x231171139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 03/23/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Rates of advance directive (AD) completion in the United Kingdom are lower than in the United States and other western European countries, which is especially concerning in light of the COVID-19 pandemic. UK residents typically complete an advance decision to refuse care (ADRT), whereas US versions of ADs present a more neutral choice between comfort-oriented or life-prolonging care. The purpose of this study is to test whether this framing affects decision making for end-of-life care and if this is affected by exposure to information about the COVID-19 pandemic. METHODS In an online experiment, 801 UK-based respondents were randomly allocated to document their preferences for end-of-life care in a 2 (US AD or UK ADRT) by 2 (presence or absence of COVID-19 prime) between-subjects factorial design. RESULTS Most (74.8%) of participants across all conditions chose comfort-oriented care. However, framing comfort care as a refusal of treatment made respondents significantly less likely to choose it (65.4% v. 84.1%, P < 0.001). This effect was exacerbated by priming participants to think about COVID-19: those completing an ADRT were significantly more likely to choose life-prolonging care when exposed to the COVID-19 prime (39.8% v. 29.6%, P = 0.032). Subgroup analyses revealed these effects differed by age, with older participants' choices influenced more by COVID-19 while younger participants were more affected by the AD framing. CONCLUSIONS The UK ADRT significantly reduced the proportion of participants choosing comfort-oriented care, an effect that was heightened in the presence of information about COVID-19. This suggests the current way end-of-life care wishes are documented in the United Kingdom could affect people's choices in a way that does not align with their preferences, especially in the context of the COVID-19 pandemic. HIGHLIGHTS Participants completing an AD framed as an advance decision to refuse treatment were significantly less likely to choose comfort-oriented care than participants completing an AD with a neutral choice between comfort-oriented and life-prolonging care.Exposure to a COVID-19 prime had an interactive effect on documented preferences in the refusal of treatment condition, with these participants even less likely to choose comfort-oriented care.Policy makers and organizations that design templates for advance care planning, particularly in the time of the COVID-19 pandemic, should be aware how the framing of these forms can influence decisions.
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Affiliation(s)
- Juliet S Hodges
- Department of Psychological and Behavioural Science, London School of Economics, London, UK
| | - Lilia V Stoyanova
- Department of Psychological and Behavioural Science, London School of Economics, London, UK
| | - Matteo M Galizzi
- Department of Psychological and Behavioural Science, London School of Economics, London, UK
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Relevant Study: Patient and Clinician Perspectives on Clinically-Meaningful Outcomes in Advanced Pancreatic Cancer. Cancers (Basel) 2023; 15:cancers15030738. [PMID: 36765698 PMCID: PMC9913496 DOI: 10.3390/cancers15030738] [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: 11/17/2022] [Revised: 01/14/2023] [Accepted: 01/21/2023] [Indexed: 01/27/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive cancer with a poor prognosis and significant symptom burden. This prospective observational study aimed to evaluate expectations and priorities of patients with advanced PDAC and their clinicians through a study survey and two quality of life (QoL) questionnaires (QLQ-C30 and PAN26) at three time-points: baseline (T1), before (T2) and after (T3) their 1st on-treatment CT scan. Over a 1-year period, 106 patients were approached, 71 patients and 12 clinicians were recruited. Choosing between treatment options, patients prioritised: 54% overall survival (OS), 26% balance between side-effects and OS, 15% could not choose and 5% favoured symptom control. These were significantly different from the clinician's answers (p < 0.001). Patients who prioritised OS had higher symptom burden (p = 0.03) and shorter OS compared to those who prioritised balance (p = 0.01). Most (86%) patients had personal goals they wanted to reach; clinicians knew of these in 12% of instances. Patient and clinicians' views regarding survival improvement from chemotherapy were significantly different: 81% of clinicians and 12% of patients thought 1-2 or 3-6 months extension, 58% of patients and 0% physicians thought 1-5 or >5 years (p < 0.001). At T1, patients had low QoL and worst symptoms were: 'Future worries', 'planning of activities', fatigue and pain. Patients were willing to accept significantly higher amounts of side-effects as a trade-off for extra time, than clinicians thought (p < 0.001). Overall, there are significant discrepancies between patient and clinicians' views about the aims, priorities and expected extension of life.
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Konishi R, Isogai J, Mukai A, Komori K, Majima T, Ito S, Kawada K. Pharmacist perceptions of a "good death" and differences in perception between patients with cancer, oncologists, and oncology nurses: a questionnaire survey. J Pharm Health Care Sci 2023; 9:5. [PMID: 36694254 PMCID: PMC9875416 DOI: 10.1186/s40780-022-00269-4] [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: 08/21/2022] [Accepted: 12/08/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND For pharmacists expected to encounter the deaths of many of their patients in the near future, it is important to understand the perception of a "good death" for patients with cancer who are likely to be aware of the circumstances of their poor prognosis. In this study, we clarified pharmacists' perceptions of a "good death" and considered the differences in perception among patients with cancer, oncologists, and oncology nurses. METHODS From April to June 2022, an anonymous questionnaire survey was conducted on pharmacists working in hospitals and pharmacies and on members of the Japanese Society for Pharmaceutical Palliative Care and Sciences. The questionnaire consisted of 57 questions, called attributes, developed by Miyashita et al. to investigate the perception of "good death" in Japanese cancer medicine. The importance of those attributes was investigated using a 7-point Likert scale. RESULTS Three thousand four hundred thirty-two pharmacists were made aware of this survey, and 207 participated in the survey. The responses of pharmacists to the 57 questions were very similar to those of the oncologists. Among them, "Fighting against disease until one's last moment" and "Not making trouble for others" had very low importance, which was the most significantly different from the responses of patients with cancer. "Fighting against disease until one's last moment" tended to be significantly underestimated by pharmacists engaged in patient guidance and interview compared to that by pharmacists not engaged in the duty (p = 0.02). Also, when we compared pharmacists with or without qualifications related to cancer and palliative care, there was no significant difference in the importance of "Fighting against disease until one's last moment." However, the importance of "Not making trouble for others" for qualified pharmacists was significantly underestimated (p = 0.04). CONCLUSION Since pharmacists understand the limits of chemotherapy, they may want to be close to the patient but may not strongly agree with the "Fighting against cancer" component that patients with cancer prefer. It may be necessary to reconsider better ways of approaching the wishes and satisfaction of patients with cancer under the care of medical professionals in the field of oncology.
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Affiliation(s)
- Reiko Konishi
- grid.412493.90000 0001 0454 7765Department of Pharmacy Practice and Science, Faculty of Pharmaceutical Sciences, Setsunan University, 45-1 Nagaotoge-cho, Hirakata, Osaka, 573-0101 Japan
| | - Junichi Isogai
- Department of Hospital Pharmacy, Tsushima City Hospital, 3-73 Tachibana-cho, Tsushima, Aichi 496-8537 Japan
| | - Akira Mukai
- grid.412493.90000 0001 0454 7765Department of Pharmacy Practice and Science, Faculty of Pharmaceutical Sciences, Setsunan University, 45-1 Nagaotoge-cho, Hirakata, Osaka, 573-0101 Japan
| | - Koji Komori
- grid.412493.90000 0001 0454 7765Department of Pharmacy Practice and Science, Faculty of Pharmaceutical Sciences, Setsunan University, 45-1 Nagaotoge-cho, Hirakata, Osaka, 573-0101 Japan
| | - Takashi Majima
- grid.472181.90000 0004 4654 0061Department of Nursing, Faculty of Allied Health Sciences, Yamato University, 2-5-1 Katayama-cho, Suita, Osaka, 564-0082 Japan
| | - Shinji Ito
- Department of Hospital Pharmacy, Tsushima City Hospital, 3-73 Tachibana-cho, Tsushima, Aichi 496-8537 Japan
| | - Kou Kawada
- grid.412493.90000 0001 0454 7765Department of Pharmacy Practice and Science, Faculty of Pharmaceutical Sciences, Setsunan University, 45-1 Nagaotoge-cho, Hirakata, Osaka, 573-0101 Japan
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Quinn KL, Krahn M, Stukel TA, Grossman Y, Goldman R, Cram P, Detsky AS, Bell CM. No Time to Waste: An Appraisal of Value at the End of Life. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:S1098-3015(22)01966-0. [PMID: 35690518 DOI: 10.1016/j.jval.2022.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 04/13/2022] [Accepted: 05/02/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES The use of economic evaluations of end-of-life interventions may be limited by an incomplete appreciation of how patients and society perceive value at end of life. The objective of this study was to evaluate how patients, caregivers, and society value gains in quantity of life and quality of life (QOL) at the end of life. The validity of the assumptions underlying the use of the quality-adjusted life-years (QALY) as a measure of preferences at end of life was also examined. METHODS MEDLINE, Embase, CINAHL, PsycINFO, and PubMed were searched from inception to February 22, 2021. Original research studies reporting empirical data on healthcare priority setting at end of life were included. There was no restriction on the use of either quantitative or qualitative methods. Two reviewers independently screened, selected, and extracted data from studies. Narrative synthesis was conducted for all included studies. The primary outcomes were the value of gains in quantity of life and the value of gains in QOL at end of life. RESULTS A total of 51 studies involving 53 981 participants reported that gains in QOL were generally preferred over quantity of life at the end of life across stakeholder groups. Several violations of the underlying assumptions of the QALY to measure preferences at the end of life were observed. CONCLUSIONS Most patients, caregivers, and members of the general public prioritize gains in QOL over marginal gains in life prolongation at the end of life. These findings suggest that policy evaluations of end-of-life interventions should favor those that improve QOL. QALYs may be an inadequate measure of preferences for end-of-life care thereby limiting their use in formal economic evaluations of end-of-life interventions.
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Affiliation(s)
- Kieran L Quinn
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto and Ottawa, ON, Canada; Department of Medicine, Sinai Health System, Toronto, ON, Canada.
| | - Murray Krahn
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto and Ottawa, ON, Canada; Toronto Health Economics and Technology Assessment Collaborative, Toronto, ON, Canada
| | - Thérèse A Stukel
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto and Ottawa, ON, Canada
| | - Yona Grossman
- Arts and Science Program, McMaster University, Hamilton, ON, Canada
| | - Russell Goldman
- Interdepartmental Division of Palliative Care, Sinai Health System, Toronto, ON, Canada; Temmy Latner Centre for Palliative Care, Toronto, ON, Canada
| | - Peter Cram
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto and Ottawa, ON, Canada; Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Allan S Detsky
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Chaim M Bell
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto and Ottawa, ON, Canada; Department of Medicine, Sinai Health System, Toronto, ON, Canada
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Smith E, Huang J, Viswabandya A, Maze D, Malik S, Cheung V, Siddiq N, Claudio J, Arruda A, Kennedy J, Bankar A, Law AD, Lam W, Michelis FV, Kim D, Lipton J, Kumar R, Mattsson J, McNamara C, Sibai H, Xu W, Gupta V. Association of Factors Influencing Selection of Upfront Hematopoietic Cell Transplantation versus Nontransplantation Therapies in Myelofibrosis. Transplant Cell Ther 2021; 27:600.e1-600.e8. [PMID: 33798769 DOI: 10.1016/j.jtct.2021.03.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/11/2021] [Accepted: 03/22/2021] [Indexed: 11/29/2022]
Abstract
Despite the curative potential of allogeneic hematopoietic cell transplantation (HCT) for myelofibrosis (MF), a significant number of patients with MF do not undergo HCT. Factors influencing treatment preferences in these patients have not been well studied. This study was conducted to identify patient-, disease-, and donor-related factors influencing the decision regarding HCT in patients with MF. A secondary objective was to compare survival between patients who elected upfront HCT and those who opted for nontransplantation therapy. We conducted a retrospective chart review amongst patients meeting criteria for transplant indication, evaluating clinical characteristics, treatment preferences, and outcomes. Of the 183 study eligible patients age <70 years, 129 (70%) developed an HCT indication. Age >60 years was significantly associated with higher rates of HLA-typing refusal (13 of 72 versus 1 of 44; P = .02). Caucasian ethnicity was significantly associated with an increased rate of identifying well-matched donors compared with non-Caucasian ethnicity (75% versus 48%; P = .02). Of the 69 patients with well-matched donors, 34 (49%) preferred to not pursue upfront HCT despite an indication for transplantation. Patient preference for nontransplantation therapies was the most common reason for declining HCT. We did not find any difference in survival between patients pursuing upfront HCT and those opting for nontransplantation therapies, although more patients in the HCT arm were in remission at the last follow-up. Patients of Caucasian ethnicity were significantly more likely than non-Caucasian patients to identify a well-matched donor. Despite availability of a well-matched donor, a significant proportion of MF patients with an indication for transplantation do not pursue HCT. Patient age, donor type, and patient preference play major roles in the selection of upfront HCT. Although a survival difference was not observed between upfront HCT versus non-transplant therapy, more patients in the HCT arm were in remission at the last follow-up.
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Affiliation(s)
- Elliot Smith
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jingyue Huang
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Auro Viswabandya
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Dawn Maze
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Malik
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Verna Cheung
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Nancy Siddiq
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jaime Claudio
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Arruda
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - James Kennedy
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Aniket Bankar
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Datt Law
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Wilson Lam
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Fotios V Michelis
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Dennis Kim
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey Lipton
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Rajat Kumar
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jonas Mattsson
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Caroline McNamara
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hassan Sibai
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Vikas Gupta
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada.
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Kessous R, Wissing MD, Laskov I, Abitbol J, Bitharas J, Agnihotram VR, Yasmeen A, Salvador S, Lau S, Gotlieb WH. Multiple lines of chemotherapy for patients with high-grade ovarian cancer: Predictors for response and effect on survival. Int J Cancer 2020; 148:2304-2312. [PMID: 33197273 DOI: 10.1002/ijc.33395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 10/12/2020] [Accepted: 10/13/2020] [Indexed: 11/05/2022]
Abstract
Guidelines for the treatment of tubo-ovarian cancer patients beyond third line are lacking. We aimed to evaluate the effect of response in each line on patient's outcome as well as identify variables that predict response for additional line of chemotherapy. A cohort study was performed including all patients with advanced high-grade ovarian cancer. Survival analysis was performed using Kaplan-Meier curves and log-rank tests. Odds ratios and hazard ratios were calculated using multilevel, mixed-effects logistic regression and Cox regression, adjusting for repeated measures within individual patients. Two-hundred thirty-eight patients were included and underwent up to 10 lines of chemotherapy. The median progression-free survival was 15.6 and overall survival (OS) was 55.6 months. Response rates dropped with each additional line and by line 5, most patients (61%) became refractory and only 16% had any type of response (complete 4% or partial 12%). By line 2, whether a patient had partial disease (PR), stable disease (SD) or progressive disease (PD) did not have an effect on the OS. From line 2, whether a patient had PR, SD or PD did not have an effect on chemotherapy-free interval. Number of previous lines and time from previous line were the only variables that significantly correlated with both outcome of patients and response to the next line. In conclusion, time interval from the previous line of chemotherapy is the major clinical factor that predicts beneficial effect of another line of treatment in patients with ovarian cancer.
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Affiliation(s)
- Roy Kessous
- Division of Gynecologic Oncology, Segal Cancer Center, Lady Davis Institute of Research, Jewish General Hospital, McGill University, Quebec, Canada
| | - Michel D Wissing
- Division of Cancer Epidemiology, Gerald Bronfman Department of Oncology, McGill University, Quebec, Canada
| | - Ido Laskov
- Division of Gynecologic Oncology, Segal Cancer Center, Lady Davis Institute of Research, Jewish General Hospital, McGill University, Quebec, Canada
| | - Jeremie Abitbol
- Division of Gynecologic Oncology, Segal Cancer Center, Lady Davis Institute of Research, Jewish General Hospital, McGill University, Quebec, Canada
| | - Joanna Bitharas
- Division of Gynecologic Oncology, Segal Cancer Center, Lady Davis Institute of Research, Jewish General Hospital, McGill University, Quebec, Canada
| | - Venkata R Agnihotram
- Division of Cancer Epidemiology, Gerald Bronfman Department of Oncology, McGill University, Quebec, Canada
| | - Amber Yasmeen
- Division of Gynecologic Oncology, Segal Cancer Center, Lady Davis Institute of Research, Jewish General Hospital, McGill University, Quebec, Canada
| | - Shannon Salvador
- Division of Gynecologic Oncology, Segal Cancer Center, Lady Davis Institute of Research, Jewish General Hospital, McGill University, Quebec, Canada
| | - Susie Lau
- Division of Gynecologic Oncology, Segal Cancer Center, Lady Davis Institute of Research, Jewish General Hospital, McGill University, Quebec, Canada
| | - Walter H Gotlieb
- Division of Gynecologic Oncology, Segal Cancer Center, Lady Davis Institute of Research, Jewish General Hospital, McGill University, Quebec, Canada
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Shrime MG, Weinstein MC, Hammitt JK, Cohen JL, Salomon JA. Trading Bankruptcy for Health: A Discrete-Choice Experiment. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:95-104. [PMID: 29304947 PMCID: PMC6739632 DOI: 10.1016/j.jval.2017.07.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 07/01/2017] [Accepted: 07/16/2017] [Indexed: 05/05/2023]
Abstract
BACKGROUND Although nearly two-third of bankruptcy in the United States is medical in origin, a common assumption is that individuals facing a potentially lethal disease opt for cure at any cost. This assumption has never been tested, and knowledge of how the American population values a trade-off between cure and bankruptcy is unknown. OBJECTIVES To determine the relative importance among the general American population of improved health versus improved financial risk protection, and to determine the impact of demographics on these preferences. METHODS A discrete-choice experiment was performed with 2359 members of the US population. Respondents were asked to value treatments with varying chances of cure and bankruptcy in the presence of a lethal disease. Latent class analysis with concomitant variables was performed, weighted for national representativeness. Sensitivity analyses were undertaken to test the robustness of the results. RESULTS It was found that 31.3% of the American population values cure at all costs. Nevertheless, for 8.5% of the US population, financial solvency dominates concerns for health in medical decision making. Individuals who value cure at all costs are more likely to have had experience with serious disease and to be women. No demographic characteristics significantly predicted individuals who value solvency over cure. CONCLUSIONS Although the average American values cure more than financial solvency, a cure-at-all-costs rubric describes the preferences of a minority of the population, and 1 in 12 value financial protection over any chances of cure. This study provides empirical evidence for how the US population values a trade-off between avoiding adverse health outcomes and facing bankruptcy. These findings bring to the fore the decision making that individuals face in balancing the acute financial burden of health care access.
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Affiliation(s)
- Mark G Shrime
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA.
| | - Milton C Weinstein
- Center for Health Decision Science, Harvard TH Chan School of Public Health, Boston, MA, USA; Department of Health Policy and Management, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - James K Hammitt
- Center for Health Decision Science, Harvard TH Chan School of Public Health, Boston, MA, USA; Department of Health Policy and Management, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Jessica L Cohen
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Joshua A Salomon
- Department of Medicine, Stanford Medical School, Stanford, CA, USA
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8
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Khakban A, Mohammadi T, Lynd LD, Mabbott DJ, Bouffet E, Gastonguay L, Zafari Z, Malkin D, Taylor MD, Marra CA. How do parents and providers trade-off between disability and survival? Preferences in the treatment of pediatric medulloblastoma. Patient Prefer Adherence 2018; 12:2103-2110. [PMID: 30349204 PMCID: PMC6188209 DOI: 10.2147/ppa.s168739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The aim of this study was to determine the preferences of parents with children with medulloblastoma and clinicians who manage this condition and their trade-offs between survival and disability using a best-worst scaling (BWS) choice experiment. METHODS Mixed methods were used to develop a BWS tool. Health professionals involved in the care of medulloblastoma patients were contacted through oncology networks in Canada. Parents of children diagnosed with brain tumors were recruited via two clinics in Vancouver and Toronto. The profile case BWS was used with each participant completing 12 choice profiles with the respondent indicating the best and worst features of each profile. Surveys were stratified into good, moderate, and poor prognosis based on the probability of survival presented. Paired model conditional logit analysis was used to generate quantitative preferences. RESULTS Fifty-four parents (80% female) and 176 providers (36% female, 79% oncologists) participated in this study. There were many similarities in the parents' and providers' preferences for treatment although the parents tended to value survival higher than disability while providers seemed to value the opposite. Specifically, providers were willing to take more risk of recurrence in a child with good prognosis compared to intermediate and poor prognosis. Also, parents were less willing to take more survival risks than providers when they had to trade-off between mild disability and survival rate. CONCLUSION This study provides useful insights into the preferences of parents and health care providers, the stakeholders of a collaborative decision for the treatment of pediatric medullo-blastoma, and compares their values and trade-offs between different levels of survival and disability.
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Affiliation(s)
- Amir Khakban
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada
| | - Tima Mohammadi
- Centre for Health Evaluation and Outcome Sciences, University of British Columbia, St Paul's Hospital, Vancouver, BC, Canada
| | - Larry D Lynd
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada
| | - Don J Mabbott
- Department of Psychology, University of Toronto, Toronto, ON, Canada
- Department of Psychology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Eric Bouffet
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
- Department of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Louise Gastonguay
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada
| | - Zafar Zafari
- Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - David Malkin
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
- Department of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Michael D Taylor
- Departments of Surgery, Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Department of Neurosurgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Carlo A Marra
- School of Pharmacy, University of Otago, Dunedin, New Zealand,
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9
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Pedersen AF, Vedsted P. Cancer beliefs in cancer survivors, cancer relatives and persons with no cancer experience. Scand J Public Health 2017; 47:497-503. [PMID: 28673193 DOI: 10.1177/1403494817715380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims: Negative cancer beliefs have been associated with late stage at cancer diagnosis. High levels of negative cancer beliefs have been found among individuals with low socioeconomic position and ethnic minority women, but the impact of cancer experience on cancer beliefs is unexamined. The aim of this study was to examine whether cancer beliefs are associated with cancer experience. Methods: This was a cross-sectional population-based study. Telephone interviews of 2992 Danish residents (30+) were carried out using the Awareness and Beliefs about Cancer Measure (ABC). Respondents reported whether they or someone close had been diagnosed with cancer and whether they agreed/disagreed with three positively and three negatively framed cancer beliefs. Results: Respondents with someone close diagnosed was reference group. Compared with these, respondents with no cancer experience (RRadj=0.91, 95% CI=0.84-0.98) or who had had cancer themselves (RRadj=0.87, 0.77-0.98) were less likely to believe that cancer treatment is worse than the cancer itself, and respondents with no cancer experience were less likely to believe that a diagnosis of cancer is a death sentence (RRadj=0.83, 0.70-0.98), but more likely to report that they did not want to know if they had cancer (RRadj=1.31, 1.01-1.71). Conclusions: The results suggest that cancer beliefs are sensitive to cancer experience. This is an important addition to previous results focusing on the association between cancer beliefs and static factors such as socioeconomic position and ethnicity. Since cancer beliefs may determine health-related behaviour, it is important that negative cancer beliefs are addressed and possibly reframed in population-based interventions.
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Affiliation(s)
- Anette Fischer Pedersen
- Research Centre for Cancer Diagnosis in Primary Care (CaP), Research Unit for General Practice, Aarhus University, Denmark
| | - Peter Vedsted
- Research Centre for Cancer Diagnosis in Primary Care (CaP), Research Unit for General Practice, Aarhus University, Denmark
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Winther SB, Jørgensen TL, Pfeiffer P, Qvortrup C. Can we predict toxicity and efficacy in older patients with cancer? Older patients with colorectal cancer as an example. ESMO Open 2016; 1:e000021. [PMID: 27843604 PMCID: PMC5070237 DOI: 10.1136/esmoopen-2015-000021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 03/08/2016] [Accepted: 03/10/2016] [Indexed: 12/29/2022] Open
Abstract
Colorectal cancer is a disease of the elderly. As older and frail patients are under-represented in clinical trials, most of the evidence available on treatment of older metastatic colorectal patients with cancer originates from pooled analyses of the older patients included in large prospective clinical trials and from community-based studies. The aging process is highly individual and cannot be based on the chronological age alone. It is characterised by a decline in organ function with an increased risk of comorbidity and polypharmacy. These issues can result in an increased susceptibility to the complications of both the disease and treatment. Therefore, evaluation of performance status and the chronological age alone is not sufficient, and additionally assessment must be included in the treatment decision process. In the present review, we will focus on clinical aspects of treating older and frail metastatic colorectal patients with cancer, but also on the present knowledge on how to select and tailor therapy for this particular group of patients. TRIAL REGISTRATION NUMBER EudraCT 2014-000394-39, pre-results.
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Affiliation(s)
- Stine Braendegaard Winther
- Department of Oncology, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Per Pfeiffer
- Department of Oncology, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Camilla Qvortrup
- Department of Oncology, Odense University Hospital, Odense, Denmark
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Roberts MC, Weinberger M, Dusetzina SB, Dinan MA, Reeder-Hayes KE, Carey LA, Troester MA, Wheeler SB. Racial Variation in the Uptake of Oncotype DX Testing for Early-Stage Breast Cancer. J Clin Oncol 2015; 34:130-8. [PMID: 26598755 DOI: 10.1200/jco.2015.63.2489] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Oncotype DX (ODX) is a tumor gene-profiling test that aids in adjuvant chemotherapy decision-making. ODX has the potential to improve quality of care; however, if not equally accessible across racial groups, disparities in cancer care quality may persist or worsen. We examined racial disparities in ODX testing uptake. METHODS We used data from the Carolina Breast Cancer Study, phase III, a longitudinal, population-based study of 2,998 North Carolina women who received a diagnosis of breast cancer between 2008 and 2014. Our primary analysis used modified Poisson regression to determine the association between race and whether ODX testing was ordered among two strata: node-negative and node-positive breast cancer. RESULTS A total of 1,468 women with estrogen receptor-positive, human epidermal growth factor receptor-2-negative, stage I or II breast cancer met inclusion criteria. Black patients had higher-grade and larger tumors, more comorbidities, younger age at diagnosis, and lower socioeconomic status than non-black women. Overall, 42% of women had ODX test results in their pathology reports. Compared with those who did not receive ODX testing, women who received ODX testing tended to be younger and have medium tumor size and grade. Our regression analyses indicated no racial disparities in ODX uptake among node-negative patients. However, racial differences were detected among node-positive patients, with black patients being 46% less likely to receive ODX testing than non-black women (adjusted relative risk, 0.54; 95% CI, 0.35 to 0.84; P = .006). CONCLUSION We did not find racial disparities in ODX testing for node-negative patients for whom ODX testing is guideline recommended and widely covered by insurers. However, our findings suggest that a newer, non-guideline-concordant application of ODX testing for node-positive breast cancer was accessed less by black women than by non-black women, reflecting more guideline concordant care among black women.
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Affiliation(s)
- Megan C Roberts
- Megan C. Roberts, Morris Weinberger, Stacie B. Dusetzina, Katherine E. Reeder-Hayes, Lisa A. Carey, Melissa A. Troester, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill; Morris Weinberger, Durham Veterans Affairs Medical Center for Health Services Research; and Michaela A. Dinan, Duke Clinical Research Institute and Duke Cancer Institute, Durham, NC.
| | - Morris Weinberger
- Megan C. Roberts, Morris Weinberger, Stacie B. Dusetzina, Katherine E. Reeder-Hayes, Lisa A. Carey, Melissa A. Troester, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill; Morris Weinberger, Durham Veterans Affairs Medical Center for Health Services Research; and Michaela A. Dinan, Duke Clinical Research Institute and Duke Cancer Institute, Durham, NC
| | - Stacie B Dusetzina
- Megan C. Roberts, Morris Weinberger, Stacie B. Dusetzina, Katherine E. Reeder-Hayes, Lisa A. Carey, Melissa A. Troester, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill; Morris Weinberger, Durham Veterans Affairs Medical Center for Health Services Research; and Michaela A. Dinan, Duke Clinical Research Institute and Duke Cancer Institute, Durham, NC
| | - Michaela A Dinan
- Megan C. Roberts, Morris Weinberger, Stacie B. Dusetzina, Katherine E. Reeder-Hayes, Lisa A. Carey, Melissa A. Troester, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill; Morris Weinberger, Durham Veterans Affairs Medical Center for Health Services Research; and Michaela A. Dinan, Duke Clinical Research Institute and Duke Cancer Institute, Durham, NC
| | - Katherine E Reeder-Hayes
- Megan C. Roberts, Morris Weinberger, Stacie B. Dusetzina, Katherine E. Reeder-Hayes, Lisa A. Carey, Melissa A. Troester, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill; Morris Weinberger, Durham Veterans Affairs Medical Center for Health Services Research; and Michaela A. Dinan, Duke Clinical Research Institute and Duke Cancer Institute, Durham, NC
| | - Lisa A Carey
- Megan C. Roberts, Morris Weinberger, Stacie B. Dusetzina, Katherine E. Reeder-Hayes, Lisa A. Carey, Melissa A. Troester, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill; Morris Weinberger, Durham Veterans Affairs Medical Center for Health Services Research; and Michaela A. Dinan, Duke Clinical Research Institute and Duke Cancer Institute, Durham, NC
| | - Melissa A Troester
- Megan C. Roberts, Morris Weinberger, Stacie B. Dusetzina, Katherine E. Reeder-Hayes, Lisa A. Carey, Melissa A. Troester, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill; Morris Weinberger, Durham Veterans Affairs Medical Center for Health Services Research; and Michaela A. Dinan, Duke Clinical Research Institute and Duke Cancer Institute, Durham, NC
| | - Stephanie B Wheeler
- Megan C. Roberts, Morris Weinberger, Stacie B. Dusetzina, Katherine E. Reeder-Hayes, Lisa A. Carey, Melissa A. Troester, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill; Morris Weinberger, Durham Veterans Affairs Medical Center for Health Services Research; and Michaela A. Dinan, Duke Clinical Research Institute and Duke Cancer Institute, Durham, NC
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12
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Racial variation in adjuvant chemotherapy initiation among breast cancer patients receiving oncotype DX testing. Breast Cancer Res Treat 2015. [PMID: 26216535 DOI: 10.1007/s10549-015-3518-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
It is unknown whether racial differences exist in adjuvant chemotherapy initiation among women with similar oncotype DX (ODX) risk scores. We examined whether adjuvant chemotherapy initiation varied by race. Data come from the Phase III, Carolina Breast Cancer Study, a longitudinal, population-based study of North Carolina women diagnosed with breast cancer between 2008 and 2014. We used modified Poisson regression and report adjusted relative risk (aRR) and 95% confidence intervals (95%CI) to estimate the association between race and adjuvant chemotherapy initiation across ODX risk groups among women who received the test (n = 541). Among women who underwent ODX testing, 54.2, 37.5, and 8.3% of women had tumors classified as low-, intermediate-, and high-risk groups, respectively. We observed no racial variation in adjuvant chemotherapy initiation. Increasing ODX risk score (aRR = 1.39, 95%CI = 1.22, 1.58) and being married (aRR = 2.92, 95%CI = 1.12, 7.60) were independently associated with an increased likelihood of adjuvant chemotherapy in the low-risk group. Among women in the intermediate-risk group, ODX risk score (aRR = 1.15, 95%CI = 1.11, 1.20), younger age (aRR = 1.95, 95%CI = 1.35, 2.81), larger tumor size (aRR = 1.70, 95%CI = 1.22, 2.35), and higher income were independently associated with increased likelihood of adjuvant chemotherapy initiation. No racial differences were found in adjuvant chemotherapy initiation among women receiving ODX testing. As treatment decision-making becomes increasingly targeted with the use of genetic technologies, these results provide evidence that test results may drive treatment in a similar way across racial subgroups.
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Pignatti F, Jonsson B, Blumenthal G, Justice R. Assessment of benefits and risks in development of targeted therapies for cancer--The view of regulatory authorities. Mol Oncol 2015; 9:1034-41. [PMID: 25481691 PMCID: PMC5528738 DOI: 10.1016/j.molonc.2014.10.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 10/08/2014] [Accepted: 10/09/2014] [Indexed: 01/08/2023] Open
Abstract
Drug licensing and approval decisions involve the balancing of benefits against the risks (harms) in the presence of uncertainty. Typically, the benefits are estimated from primary efficacy endpoints from confirmatory (phase III) clinical trials although exceptions where promising early data from single-arm studies have led to accelerated approvals are not uncommon, particularly for cancer drugs. The challenge for regulators is to balance early evidence of efficacy that might support approval versus the need to establish clinical benefit based on conclusive evidence. Targeted agents offer the promise that knowledge about the mechanism of the disease will help identify patients with tumors likely to respond, resulting in higher efficacy and less toxicity, and earlier regulatory decisions based on convincing evidence of clinical benefit. In this paper, we describe methods and examples of benefit-risk assessment of targeted drugs, recent initiatives from EMA and FDA on improving communication about benefits and risks, and discuss future steps.
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Affiliation(s)
| | | | | | - Robert Justice
- Food and Drug Administration (FDA), Silver Spring, MD, USA
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van Veggel BAMH, Biesma B, Smit EF. Pharmacotherapy for treatment of lung cancer in the elderly. Expert Opin Pharmacother 2015; 16:1021-34. [PMID: 25797389 DOI: 10.1517/14656566.2015.1028357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The chance for elderly patients with NSCLC to receive chemotherapy decreases significantly with age. In addition, older patients are often underrepresented in clinical trials. Consequently, due to the paucity of data, evidence-based decisions with regard to chemotherapy treatment strategies in the elderly are lacking. AREAS COVERED We performed a literature search to identify mainly randomized trials focusing on treatment of NSCLC in older patients with chemotherapy and targeted therapy, toxicity and quality of life. In conclusion, the efficacy of regular chemotherapy and targeted therapy seems quite similar in older patients compared to their younger counterparts, with increased toxicity, but acceptable. However, these data are mostly derived from subgroup analyses and highly selected fit patients, which may not represent the general older population. EXPERT OPINION Further research is necessary to investigate the role of a comprehensive geriatric assessment in older patients, before the start of a chemotherapeutic treatment. Proteomic tests can have potential in the future, if these tests turn out to be able to separate patients with advanced NSCLC into groups with better or worse outcomes. It can be of special interest for the elderly population, to prevent unnecessary side effects of a possible inferior treatment.
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Affiliation(s)
- Bianca A M H van Veggel
- Jeroen Bosch Hospital, Department of Pulmonology , Henri Dunantstraat 1, 5223 GZ 's-Hertogenbosch , The Netherlands +31 0 73 5532615 ; +31 0 73 5532614 ;
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Babak MV, Plażuk D, Meier SM, Arabshahi HJ, Reynisson J, Rychlik B, Błauż A, Szulc K, Hanif M, Strobl S, Roller A, Keppler BK, Hartinger CG. Half-Sandwich Ruthenium(II) Biotin Conjugates as Biological Vectors to Cancer Cells. Chemistry 2015; 21:5110-7. [DOI: 10.1002/chem.201403974] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Revised: 01/12/2015] [Indexed: 11/07/2022]
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Hamelinck VC, Bastiaannet E, Pieterse AH, Jannink I, van de Velde CJ, Liefers GJ, Stiggelbout AM. Patients’ preferences for surgical and adjuvant systemic treatment in early breast cancer: A systematic review. Cancer Treat Rev 2014; 40:1005-18. [DOI: 10.1016/j.ctrv.2014.06.007] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 06/12/2014] [Accepted: 06/13/2014] [Indexed: 01/26/2023]
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Marta GN, Del Nero LG, Marta GN, Mangabeira A, Critchi G, Kovács MJ, Silva JLFD, Saad ED. Treatment priorities in oncology: do we want to live longer or better? Clinics (Sao Paulo) 2014; 69:509-14. [PMID: 25141108 PMCID: PMC4129550 DOI: 10.6061/clinics/2014(08)02] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 02/04/2014] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES Despite the progress achieved in the fight against cancer over the past several years, assessing the needs, goals and preferences of patients with cancer is of the utmost importance for the delivery of health care. We sought to assess priorities regarding quantity versus quality of life among Brazilian patients, comparing them with individuals without cancer. METHODS Using a questionnaire presenting four hypothetical cancer cases, we interviewed cancer patients, oncology health-care professionals and laypersons, most of whom had administrative functions in our hospital. RESULTS A total of 214 individuals participated: 101 patients, 44 health-care professionals and 69 laypersons. The mean ages in the three groups were 56, 34 and 31 years old, respectively (p<0.001). The patients had gastrointestinal (25%), breast (22%), hematologic (10%), lung (8%) or other tumors (36%) and the tumor-node- metastasis (TNM) stage was I, II, III or IV in 22%, 13%, 34% and 31% of cases, respectively. Treatment priorities differed significantly among the three groups (p = 0.005), with survival time being a higher priority for patients than for the other two groups and with opposite trends regarding quality of life. In multivariate analysis, the age and sex distributions were not associated with the choice to maximize quality of life. In this limited sample of cancer patients, there were no associations between treatment priorities and disease stages. CONCLUSIONS Both survival time and quality of life appeared to be important to cancer patients, oncology health-care professionals and laypersons, but survival time seemed to have higher priority for people diagnosed with cancer than for healthy people. Additionally, survival seemed to be more important than quality of life for all three groups assessed.
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Affiliation(s)
| | - Luís G Del Nero
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Gustavo Nader Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | | | | | - Maria J Kovács
- Psychology Institute, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
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Miyashita M, Kawakami S, Kato D, Yamashita H, Igaki H, Nakano K, Kuroda Y, Nakagawa K. The importance of good death components among cancer patients, the general population, oncologists, and oncology nurses in Japan: patients prefer "fighting against cancer". Support Care Cancer 2014; 23:103-10. [PMID: 24996829 DOI: 10.1007/s00520-014-2323-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 06/16/2014] [Indexed: 01/05/2023]
Abstract
BACKGROUND The objectives of this study were to compare the importance of components of a good death among cancer patients, the general population, oncologists, and oncology nurses, and explore which patients preferred "fighting against cancer." METHODS We conducted a cross-sectional anonymous self-reported survey of cancer patients who visited a radiation oncology outpatient clinic, oncologists, and oncology nurses at the Tokyo University Hospital and a random sample of the general population in the Tokyo metropolitan area. The outcomes were 18 previously developed components of a good death in Japanese cancer care consisting of 57 attributes. RESULTS Three hundred ten patients, 353 subjects from the general population, 109 oncologists, and 366 oncology nurses participated. The desire to "fight against cancer" was highly significantly different between patients and oncologists (effect size [ES] = -1.40; P = 0.001) and patients and oncology nurses (ES = -1.12; P = 0.001). "Physical and cognitive control" was, similarly, highly significantly different between patients and oncologists (ES = -1.30; P = 0.001) and patients and oncology nurses (ES = -1.06; P = 0.001). Patients who emphasized "maintaining hope and pleasure" (P = 0.0001), "unawareness of death" (P = 0.0001), and "good relationship with family" (P = 0.004) favored "fighting against cancer." The patients, however, who emphasized "physical and psychological comfort" did not significantly favor "fighting against cancer" (P = 0.004). CONCLUSION The importance of good death components differed between groups. Medical professionals should be aware of the diversity of values surrounding death and assess the patient's values and discuss them to support his or her quality of life. In addition, the development of care and a medical/social system to maintain hope and pleasure after failure of anticancer treatment is necessary.
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Affiliation(s)
- Mitsunori Miyashita
- Department of Adult Nursing/Palliative Care Nursing, School of Health Sciences and Nursing Sciences, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan,
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Corica T, Joseph D, Saunders C, Bulsara M, Nowak AK. Intraoperative radiotherapy for early breast cancer: do health professionals choose convenience or risk? Radiat Oncol 2014; 9:33. [PMID: 24461031 PMCID: PMC3907143 DOI: 10.1186/1748-717x-9-33] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 01/20/2014] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The randomized TARGIT trial comparing experimental intra-operative radiotherapy (IORT) to up to 7 weeks of daily conventional external beam radiotherapy (EBRT) recruited participants in Western Australia between 2003 and 2012. We aimed to understand preferences for this evolving radiotherapy treatment for early breast cancer (EBC) in health professionals, and how they changed over time and in response to emerging data. Preferences for single dose IORT or EBRT for EBC were elicited in 2004 and 2011, together with factors that may be associated with these preferences. METHODS Western Australian health professionals working with breast cancer patients were invited to complete a validated, self-administered questionnaire. The questionnaire used hypothetical scenarios and trade-off methodology to determine the maximum increase in risk of local recurrence health professionals were willing to accept in order to have a single dose of IORT in the place of EBRT if they were faced with this decision themselves. RESULTS Health professional characteristics were similar across the two time points although 2011 included a higher number of nurse (49% vs. 36%) and allied health (10% vs. 4%) participants and a lower number of radiation therapists (17% vs. 32% ) compared to 2004.Health professional preferences varied, with 7.5% and 3% judging IORT unacceptable at any risk, 18% and 21% judging IORT acceptable only if offering an equivalent risk, 56% and 59% judging IORT acceptable with a low maximum increase in risk (1-3%) and 19% and 17% judging a high maximum increase in risk acceptable (4-5%), in 2004 and 2011 respectively. A significantly greater number of nurses accepted IORT as a treatment option in 2011. CONCLUSIONS Most Western Australian health professionals working with breast cancer patients are willing to accept an increase in risk of local recurrence in order to replace EBRT with IORT in a hypothetical setting. This finding was consistent over two time points spanning 7 years despite the duration of clinical experience with IORT and the publication of the early clinical results of IORT in 2010. These results need to be compared with preferences elicited from patient groups, and further investigation into the impact of personal preferences on health professionals' advice to patients is warranted.
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Affiliation(s)
- Tammy Corica
- University of Western Australia PhD Candidate, School of Medicine and Pharmacology, Comprehensive Cancer Centre, Sir Charles Gairdner Hospital, Nedlands, WA 6009, Australia
- Radiation Oncology Clinical Trials and Research Unit, Comprehensive Cancer Centre, Sir Charles Gairdner Hospital, Nedlands, WA 6009, Australia
| | - David Joseph
- School of Surgery, University of Western Australia, Comprehensive Cancer Centre, Sir Charles Gairdner Hospital, Nedlands, WA 6009, Australia
- Radiation Oncology, Comprehensive Cancer Centre, Sir Charles Gairdner Hospital, Nedlands, WA 6009, Australia
| | - Christobel Saunders
- School of Surgery, University of Western Australia, MBDP M507, Crawley, WA 6009, Australia
| | - Max Bulsara
- Institute of Health and Research, University of Notre Dame, 19 Mouat Street, P.O Box 1225, Fremantle, WA 6959, Australia
| | - Anna K Nowak
- School of Medicine and Pharmacology, University of Western Australia, MBDP M503, Crawley, WA 6009, Australia
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Long A, Ferraro D, Stockler M, Blinman P. Patient versus clinician preferences for chemotherapy in non-small-cell lung cancer. Lung Cancer Manag 2013. [DOI: 10.2217/lmt.13.60] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Decisions about systemic treatment options for non-small-cell lung cancer are becoming increasingly complex for both patients and clinicians, and involve trade-offs between the benefits, harms and inconveniences of treatments. These trade-offs result in an individual’s (e.g., a patient or clinician) preference for a treatment. Optimal clinical decision-making about an individual’s cancer treatment is ideally shared between the patient and their clinician(s), but this requires clinicians to understand their patient’s preferences, as well as their own. Patients’ preferences for chemotherapy often differ from those of clinicians’, with patients generally needing smaller survival benefits, or accepting more toxicity, to make chemotherapy worthwhile. This review summarizes and compares recent studies of patients’ and clinicians’ preferences for chemotherapy in non-small-cell lung cancer, to help clinicians and their patients make more informed and patient-centered decisions about chemotherapy.
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Affiliation(s)
- Anne Long
- Australasian Lung Cancer Trials Group, Queensland, Australia
| | - Danielle Ferraro
- Australasian Lung Cancer Trials Group, Queensland, Australia
- NHMRC Clinical Trials Centre, University of Sydney, Locked Bag 77, Camperdown, NSW 1450, Sydney, Australia
| | - Martin Stockler
- Australasian Lung Cancer Trials Group, Queensland, Australia
- NHMRC Clinical Trials Centre, University of Sydney, Locked Bag 77, Camperdown, NSW 1450, Sydney, Australia
- Royal Prince Alfred Hospital, Sydney, Australia
- Concord Repatriation General Hospital, Sydney, Australia
| | - Prunella Blinman
- Australasian Lung Cancer Trials Group, Queensland, Australia
- Concord Repatriation General Hospital, Sydney, Australia
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Kim JW, Kim YJ, Lee KW, Chang H, Lee JO, Kim KI, Bang SM, Lee JS, Kim CH, Kim JH. The early discontinuation of palliative chemotherapy in older patients with cancer. Support Care Cancer 2013; 22:773-81. [PMID: 24287502 DOI: 10.1007/s00520-013-2033-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 10/28/2013] [Indexed: 12/15/2022]
Abstract
PURPOSE Older patients with cancer may have an increased risk of early discontinuation of active treatment (ED), which results in poor outcome in curative or adjuvant settings. We aimed to determine the association between survival and ED and to identify predictors of ED in palliative setting. METHODS Ninety-eight patients older than 65 years of age who received a comprehensive geriatric assessment (CGA) before palliative first-line chemotherapy were analyzed. Clinical information and CGA results were retrieved from electronic medical record. CGA included Charlson's co-morbidity index, activities of daily living (ADL), instrumental ADL (IADL), Mini-Mental Status Examination, short-form of the geriatric depression scale, timed-get-up-and-go test (TGUG), and mini-nutritional assessment (MNA). ED was defined as no active cancer treatment (radiotherapy and/or chemotherapy) beyond palliative first-line chemotherapy. Predictors of ED were identified using clinical parameters and CGA. RESULTS Active treatment was discontinued after first-line chemotherapy in 30 patients during median follow-up period of 15.1 months. ED after first-line chemotherapy was associated with shorter overall survival (OS; median OS = 3.1 vs. 14.7 months in patients with ED compared with patients without ED, p < 0.001). Eastern Cooperative Oncology Group performance status, living alone, ADL, IADL, MNA, and TGUG were associated with ED (p = 0.001, p = 0.048, p = 0.001, p < 0.001, p < 0.001, p = 0.002, respectively). In multivariable analysis, malnutrition and dependent IADL were the independent predictive factors for ED (odds ratio = 5.03; 95 % confidence interval = 1.50-16.87: odds ratio = 3.06; confidence interval = 1.03-9.12, respectively). CONCLUSIONS ED was associated with shorter OS in older patients with cancer. Malnutrition and dependent IADL were identified as independent predictive factors for ED.
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Affiliation(s)
- Jin Won Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 463-707, South Korea
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Daniele G, Costa N, Lorusso V, Costa-Maia J, Pache I, Pirisi M. Methodological assessment of HCC literature. Ann Oncol 2013; 24 Suppl 2:ii6-14. [PMID: 23715943 DOI: 10.1093/annonc/mdt052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Despite the fact that the hepatocellular carcinoma (HCC) represents a major health problem, very few interventions are available for this disease, and only sorafenib is approved for the treatment of advanced disease. Of note, only very few interventions have been thoroughly evaluated over time for HCC patients compared with several hundreds in other, equally highly lethal, tumours. Additionally, clinical trials in HCC have often been questioned for poor design and methodological issues. As a consequence, a gap between what is measured in clinical trials and what clinicians have to face in daily practice often occurs. As a result of this scenario, even the most recent guidelines for treatment of HCC patients use low strength evidence to make recommendations. In this review, we will discuss some of the potential methodological issues hindering a rational development of new treatments for HCC patients.
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Affiliation(s)
- G Daniele
- Clinical Trials Unit, National Cancer Institute of Naples, Naples, Italy.
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Ferreira ML, Herbert RD, Ferreira PH, Latimer J, Ostelo RW, Grotle M, Barrett B. The smallest worthwhile effect of nonsteroidal anti-inflammatory drugs and physiotherapy for chronic low back pain: a benefit-harm trade-off study. J Clin Epidemiol 2013; 66:1397-404. [PMID: 24021611 DOI: 10.1016/j.jclinepi.2013.02.018] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 01/29/2013] [Accepted: 02/18/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study was to determine the smallest worthwhile effects of two treatments for nonspecific low back pain (LBP). STUDY DESIGN AND SETTING The benefit-harm trade-off method was used to estimate the smallest worthwhile effect of nonsteroidal anti-inflammatory drugs (NSAIDs) and physiotherapy for LBP. Patients seeking care for chronic LBP were interviewed by telephone before treatment commenced and 4 weeks later. RESULTS Patients need to see a median of 30% (interquartile range [IQR]: 10-40) more improvement in pain and 20% (IQR: 10-40) more improvement in disability than would occur without intervention to perceive the effect of NSAIDs are worthwhile. They would need to see 20% (IQR: 0-30) more improvement on pain and disability over natural recovery to perceive that the effect of physiotherapy was worthwhile. There was no difference in estimates of the smallest worthwhile effect elicited at baseline and 4 weeks later. CONCLUSIONS People with chronic back pain need to see larger effects on pain of NSAIDS than physiotherapy to consider the effects of these interventions worthwhile. These estimates of the smallest worthwhile effect can be used to interpret the findings of clinical trials and to design adequately powered clinical trials.
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Affiliation(s)
- Manuela L Ferreira
- The George Institute for Global Health, University of Sydney, Sydney, New South Wales, Australia.
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Brett Hauber A, Fairchild AO, Reed Johnson F. Quantifying benefit-risk preferences for medical interventions: an overview of a growing empirical literature. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2013; 11:319-29. [PMID: 23637054 DOI: 10.1007/s40258-013-0028-y] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Decisions regarding the development, regulation, sale, and utilization of pharmaceutical and medical interventions require an evaluation of the balance between benefits and risks. Such evaluations are subject to two fundamental challenges-measuring the clinical effectiveness and harms associated with the treatment, and determining the relative importance of these different types of outcomes. In some ways, determining the willingness to accept treatment-related risks in exchange for treatment benefits is the greater challenge because it involves the individual subjective judgments of many decision makers, and these decision makers may draw different conclusions about the optimal balance between benefits and risks. In response to increasing demand for benefit-risk evaluations, researchers have applied a variety of existing welfare-theoretic preference methods for quantifying the tradeoffs decision makers are willing to accept among expected clinical benefits and risks. The methods used to elicit benefit-risk preferences have evolved from different theoretical backgrounds. To provide some structure to the literature that accommodates the range of approaches, we begin by describing a welfare-theoretic conceptual framework underlying the measurement of benefit-risk preferences in pharmaceutical and medical treatment decisions. We then review the major benefit-risk preference-elicitation methods in the empirical literature and provide a brief overview of the studies using each of these methods. The benefit-risk preference methods described in this overview fall into two broad categories: direct-elicitation methods and conjoint analysis. Rating scales (6 studies), threshold techniques (9 studies), and standard gamble (2 studies) are examples of direct elicitation methods. Conjoint analysis studies are categorized by the question format used in the study, including ranking (1 study), graded pairs (1 study), and discrete choice (21 studies). The number of studies reviewed here demonstrates that this body of research already is substantial, and it appears that the number of benefit-risk preference studies in the literature will continue to increase. In addition, benefit-risk preference-elicitation methods have been applied to a variety of healthcare decisions and medical interventions, including pharmaceuticals, medical devices, surgical and medical procedures, and diagnostics, as well as resource-allocation decisions such as facility placement. While preference-elicitation approaches may differ across studies, all of the studies described in this review can be used to provide quantitative measures of the tradeoffs patients and other decision makers are willing to make between benefits and risks of medical interventions. Eliciting and quantifying the preferences of decision makers allows for a formal, evidence-based consideration of decision-makers' values that currently is lacking in regulatory decision making. Future research in this area should focus on two primary issues-developing best-practice standards for preference-elicitation studies and developing methods for combining stated preferences and clinical data in a manner that is both understandable and useful to regulatory agencies.
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Affiliation(s)
- A Brett Hauber
- RTI-Health Solutions, 200 Park Office Drive, Research Triangle Park, NC 27709, USA.
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Trade-offs associated with axillary lymph node dissection with breast irradiation versus breast irradiation alone in patients with a positive sentinel node in relation to the risk of non-sentinel node involvement: implications of ACOSOG Z0011. Breast Cancer Res Treat 2013; 138:205-13. [DOI: 10.1007/s10549-013-2418-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 01/12/2013] [Indexed: 01/17/2023]
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Hoeben KWJ, van Steenbergen LN, van de Wouw AJ, Rutten HJ, van Spronsen DJ, Janssen-Heijnen MLG. Treatment and complications in elderly stage III colon cancer patients in the Netherlands. Ann Oncol 2012; 24:974-9. [PMID: 23136227 DOI: 10.1093/annonc/mds576] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We evaluated which patient factors were associated with treatment tolerance and outcome in elderly colon cancer patients. DESIGN Population-based data from five regions included in the Netherlands Cancer Registry were used. Patients with resected stage III colon cancer aged ≥75 years diagnosed in 1997-2004 who received adjuvant chemotherapy (N = 216) were included as well as a random sample (N = 341) of patients who only underwent surgery. RESULTS The most common motives for withholding adjuvant chemotherapy were a combination of high age, co-morbidity and poor performance status (PS, 43%) or refusal by the patient or family (17%). In 57% of patients receiving chemotherapy, adaptations were made in treatment regimens. Patients who received adjuvant chemotherapy developed more complications (52%) than those with surgery alone (41%). For the selection of patients who had survived the first year after surgery, receiving adjuvant chemotherapy resulted in better 5-year overall survival (52% versus 34%), even after adjustment for differences in age, co-morbidity and PS. CONCLUSION Despite high toxicity rates and adjustments in treatment regimens, elderly patients who received chemotherapy seemed to have a better survival. Prospective studies are needed for evaluating which patient characteristics predict the risks and benefits of adjuvant chemotherapy in elderly colon cancer patients.
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Affiliation(s)
- K W J Hoeben
- Department of Medical Oncology, VieCuri Medical Centre, Venlo, the Netherlands
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Park MH, Jo C, Bae EY, Lee EK. A comparison of preferences of targeted therapy for metastatic renal cell carcinoma between the patient group and health care professional group in South Korea. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2012; 15:933-939. [PMID: 22999144 DOI: 10.1016/j.jval.2012.05.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 05/22/2012] [Accepted: 05/28/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To evaluate the preferences of health care professional groups and patient groups with respect to efficacy, adverse events, and administration method for targeted agents of metastatic renal cell carcinoma. METHODS A total of 485 respondents including cancer patients and health care professionals (medical oncologists, nurses, and pharmacists) were surveyed by using a discrete choice experiment in South Korea. Through a literature review and expert consultation, six attributes--progression-free survival, four adverse events (bone marrow suppression, hand-foot skin reaction, gastrointestinal perforation, and bleeding), and administration--were selected. This study employed the conditional logit regression model. RESULTS The six attributes are statistically significant for the patient group and health care professional group. The two groups, however, present differences in progression-free survival, hand-foot skin reaction, gastrointestinal perforation, and administration. The relative importance of adverse events is greater for the patient group, while that of efficacy and administration is greater for the health professional group. For doctors, the relative importance of efficacy is as high as 31%, compared with 7% for the patient group. If progression-free survival is prolonged by 1 month, the acceptable level of bone marrow suppression is 1.3% for the patient group and 9.6% for doctors and that of hand-foot skin reaction is 1.0% and 11.8%, respectively, for the patient group and doctors. CONCLUSIONS This study demonstrates substantial differences in the preference for a targeted drug between the patient group and the health care professional group. Doctors prefer effective and orally administered drugs while patients show more reluctant attitudes about adverse events than do health care professionals.
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Affiliation(s)
- Mi-Hai Park
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
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Saad ED, Buyse M. Overall Survival: Patient Outcome, Therapeutic Objective, Clinical Trial End Point, or Public Health Measure? J Clin Oncol 2012; 30:1750-4. [DOI: 10.1200/jco.2011.38.6359] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Marc Buyse
- International Drug Development Institute, Louvain-la-Neuve, Belgium
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Blinman P, King M, Norman R, Viney R, Stockler MR. Preferences for cancer treatments: an overview of methods and applications in oncology. Ann Oncol 2012; 23:1104-1110. [PMID: 22234737 DOI: 10.1093/annonc/mdr559] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This review provides cancer clinicians and researchers with an overview of methods for assessing preferences, with examples and recommendations for their application in oncology. Decisions about cancer treatments involve trade-offs between their relative benefits and harms. An individual's preference for a cancer treatment reflects their evaluation of the relative benefits and harms in comparison with a given alternative or alternatives. Methods of preference assessment include the ranking or rating scale, standard gamble (SG), time trade-off (TTO), visual analogue scale, discrete choice experiment (DCE), and multi-attribute utility instrument (MAUI). The choice of method depends on the purpose of preference assessment; the ranking or rating scale, SG, TTO, and DCEs are best suited to clinical decisions, whereas MAUIs are best suited to health policy decisions. Knowledge of patients' preferences for cancer treatments can better inform clinical decisions about patient management by enabling the tailoring of decisions to individual patients' values, attitudes, and priorities and health policy decisions through economic evaluations of cancer treatments and their suitability for coverage by health payers.
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Affiliation(s)
- P Blinman
- NHMRC Clinical Trials Centre, University of Sydney, Sydney.
| | - M King
- Psycho-oncology Co-operative Research Group (PoCoG), School of Psychology, University of Sydney, Sydney
| | - R Norman
- Centre for Health Economics Research and Evaluation (CHERE), University of Technology Sydney (UTS), Sydney
| | - R Viney
- Centre for Health Economics Research and Evaluation (CHERE), University of Technology Sydney (UTS), Sydney
| | - M R Stockler
- NHMRC Clinical Trials Centre, University of Sydney, Sydney; Sydney Cancer Centre, Royal Prince Alfred and Concord Hospitals, Sydney, Australia
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Brotherston DC, Poon I, Le T, Leung M, Kiss A, Ringash J, Balogh J, Lee J, Wright JR. Patient preferences for oropharyngeal cancer treatment de-escalation. Head Neck 2012; 35:151-9. [PMID: 22431201 DOI: 10.1002/hed.22930] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2011] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The excellent prognosis of human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinomas (SCCs) against severe chemoradiotherapy (CRT) toxicities has opened discussion of deintensification trials. The purpose of this study was to describe the perspective of patients with HPV-positive and HPV-negative disease toward such studies. METHODS Fifty-one patients with oropharyngeal SCC (post-CRT) underwent semistructured interviews contrasting toxicities of radiotherapy (RT) alone and CRT. Patients were asked what potential difference in cancer survival was acceptable to prefer RT over CRT. Initially, survival rate was the same for both treatments, then the RT rate was reduced until the preference switched. Treatment experience and preference for deintensified CRT were collected. RESULTS Ninety-percent of patients initially selected RT, but 69% switched to CRT after 0% to 5% reduction in survival. Patients that rated their treatment experience as mild would accept lower survival versus severe treatment (p = .02). Eighty-one percent of patients (33 of 40) indicated they preferred reduced chemotherapy in CRT. CONCLUSION Patients accept little difference in survival between treatments to avoid toxicity.
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Affiliation(s)
- Drew C Brotherston
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Soubeyran P, Henriques de Figueiredo B, Soubeyran I, Mertens C, Cazeau A. Therapeutic strategies in elderly and very elderly patients. Best Pract Res Clin Haematol 2012; 25:91-100. [DOI: 10.1016/j.beha.2012.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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de Vries M, Leget CJ. Ethical Dilemmas in Elderly Cancer Patients: A Perspective From the Ethics of Care. Clin Geriatr Med 2012; 28:93-104. [DOI: 10.1016/j.cger.2011.10.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Women prefer adjuvant endocrine therapy to chemotherapy for breast cancer treatment. Breast Cancer 2011; 20:67-74. [PMID: 22109640 DOI: 10.1007/s12282-011-0310-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2011] [Accepted: 10/18/2011] [Indexed: 10/15/2022]
Abstract
BACKGROUND We attempted to determine the preferences of women regarding the benefits they considered necessary to make adjuvant therapy worthwhile, and to compare preferences for adjuvant endocrine therapy, chemotherapy, and trastuzumab therapy. We also investigated the effect of information about cost on women's treatment preferences. PATIENTS AND METHODS Consecutive women who had a medical examination at the Breast Clinic, Ota General Hospital, were included in our study. We collected a questionnaire from a total of 365 women; 297 completed responses were included in the study. RESULTS Among 297 women, 105 had breast cancer that had been treated and 192 did not have breast cancer; 38% of women judged that a 5% or less gain in the probability of survival was sufficient to make endocrine therapy worthwhile; 28% of participants judged that chemotherapy was worthwhile; 24% of participants judged that trastuzumab therapy was worthwhile. Women indicated that they were more likely to receive adjuvant endocrine therapy than chemotherapy or trastuzumab therapy, for the same gains in the probability of survival. Cost information about treatments did not affect women's treatment preferences. Younger women tended to judge improvements in survival sufficient to make adjuvant endocrine and chemotherapy worthwhile, as compared to older women. The comparisons were statistically significant in the 10 and 20% categories for endocrine therapy and chemotherapy. CONCLUSION Women prefer endocrine therapy to chemotherapy or trastuzumab therapy, given the same projected treatment benefits. Younger women prefer both chemotherapy and endocrine therapy as compared with older woman.
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Ferreira ML, Herbert RD, Ferreira PH, Latimer J, Ostelo RW, Nascimento DP, Smeets RJ. A critical review of methods used to determine the smallest worthwhile effect of interventions for low back pain. J Clin Epidemiol 2011; 65:253-61. [PMID: 22014888 DOI: 10.1016/j.jclinepi.2011.06.018] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Revised: 05/19/2011] [Accepted: 06/08/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To critically and systematically review methods used to estimate the smallest worthwhile effect of interventions for nonspecific low back pain. STUDY DESIGN AND SETTING A computerized search was conducted of MEDLINE, CINAHL, LILACS, and EMBASE up to May 2011. Studies were included if they were primary reports intended to measure the smallest worthwhile effect of a health intervention (although they did not need to use this terminology) for nonspecific low back pain. RESULTS The search located 31 studies, which provided a total of 129 estimates of the smallest worthwhile effect. The estimates were given a variety of names, including the Minimum Clinically Important Difference, Minimum Important Difference, Minimum Worthwhile Reductions, and Minimum Important Change. Most estimates were obtained using anchor- or distribution-based methods. These methods are not (or not directly) based on patients' perceptions, are not intervention-specific, and are not formulated in terms of differences in outcomes with and without intervention. CONCLUSION The methods used to estimate the smallest worthwhile effect of interventions for low back pain have important limitations. We recommend that the benefit-harm trade-off method be used to estimate the smallest worthwhile effects of intervention because it overcomes these limitations.
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Affiliation(s)
- Manuela L Ferreira
- The George Institute for Global Health, Missenden Road, NSW 2050, Australia.
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Strohschein FJ, Bergman H, Carnevale FA, Loiselle CG. Patient decision making among older individuals with cancer. QUALITATIVE HEALTH RESEARCH 2011; 21:900-926. [PMID: 21343431 DOI: 10.1177/1049732311399778] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Patient decision making is an area of increasing inquiry. For older individuals experiencing cancer, variations in health and functional status, physiologic aspects of aging, and tension between quality and quantity of life present unique challenges to treatment-related decision making. We used the pragmatic utility method to analyze the concept of patient decision making in the context of older individuals with cancer. We first evaluated its maturity in existing literature and then posed analytical questions to clarify aspects found to be only partially mature. In this context, we found patient decision making to be an ongoing process, changing with time, reflecting individual and relational components, as well as analytical and emotional ones. Assumptions frequently associated with patient decision making were not consistent with the empirical literature. Careful attention to the multifaceted components of patient decision making among older individuals with cancer provides guidance for research, supportive interventions, and targeted follow-up care.
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Biesma B, Wymenga A, Vincent A, Dalesio O, Smit H, Stigt J, Smit E, van Felius C, van Putten J, Slaets J, Groen H. Quality of life, geriatric assessment and survival in elderly patients with non-small-cell lung cancer treated with carboplatin–gemcitabine or carboplatin–paclitaxel: NVALT-3 a phase III study. Ann Oncol 2011; 22:1520-1527. [DOI: 10.1093/annonc/mdq637] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Decisions for lung cancer chemotherapy: the influence of physician and patient factors. Support Care Cancer 2011; 19:1261-6. [DOI: 10.1007/s00520-011-1176-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Accepted: 04/25/2011] [Indexed: 11/25/2022]
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Lung cancer clinicians’ preferences for adjuvant chemotherapy in non-small-cell lung cancer: What makes it worthwhile? Lung Cancer 2011; 72:213-8. [DOI: 10.1016/j.lungcan.2010.08.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Revised: 07/30/2010] [Accepted: 08/08/2010] [Indexed: 10/19/2022]
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van Steenbergen L, Rutten H, Creemers G, Pruijt J, Coebergh J, Lemmens V. Large age and hospital-dependent variation in administration of adjuvant chemotherapy for stage III colon cancer in southern Netherlands. Ann Oncol 2010; 21:1273-1278. [DOI: 10.1093/annonc/mdp482] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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van Steenbergen LN, Elferink MAG, Krijnen P, Lemmens VEPP, Siesling S, Rutten HJT, Richel DJ, Karim-Kos HE, Coebergh JWW. Improved survival of colon cancer due to improved treatment and detection: a nationwide population-based study in The Netherlands 1989-2006. Ann Oncol 2010; 21:2206-2212. [PMID: 20439339 DOI: 10.1093/annonc/mdq227] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND We described changes in treatment of colon cancer over time and the impact on survival in The Netherlands in the period 1989-2006. PATIENTS AND METHODS All 103,744 patients with invasive colon cancer during 1989-2006 in The Netherlands were included. Data were extracted from The Netherlands Cancer Registry. Trends in treatment over time were analysed and multivariable relative survival analysis was carried out. RESULTS The administration of adjuvant chemotherapy in stage III patients <75 years increased from 19% in 1989-1993 to 79% in 2004-2006 and from 1% to 19% in stage III patients ≥75 years. Among stage IV patients, resection rates of the primary tumour decreased from 72% to 63%, while chemotherapy administration increased from 23% to 64% in those <75 years. Survival increased from 52% to 58% in males and from 55% to 58% among females. Stage III patients with adjuvant chemotherapy exhibited a relative excess risk of 0.4 (95% confidence interval 0.4-0.4) compared with those without. Among stage IV patients, resection of primary tumour, palliative chemotherapy, and metastasectomy were important prognostic factors. CONCLUSIONS There were substantial improvements in management and survival of colon cancer from 1989 to 2006. Stage III disease patients with colon cancer experienced the largest improvement in survival, most likely related to the increased administration of adjuvant chemotherapy.
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Affiliation(s)
- L N van Steenbergen
- Department of Research, Eindhoven Cancer Registry, Comprehensive Cancer Centre South, Eindhoven.
| | - M A G Elferink
- Department of Research, Comprehensive Cancer Centre North East, Enschede/Groningen
| | - P Krijnen
- Comprehensive Cancer Centre West, Leiden
| | - V E P P Lemmens
- Department of Research, Eindhoven Cancer Registry, Comprehensive Cancer Centre South, Eindhoven; Department of Public Health, Erasmus MC University Medical Centre, Rotterdam
| | - S Siesling
- Department of Research, Comprehensive Cancer Centre North East, Enschede/Groningen; Department of Health Technology and Services Research, Twente University, Enschede
| | - H J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven
| | - D J Richel
- Department of Internal Medicine, Academic Medical Centre Amsterdam, The Netherlands
| | - H E Karim-Kos
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam
| | - J W W Coebergh
- Department of Research, Eindhoven Cancer Registry, Comprehensive Cancer Centre South, Eindhoven; Department of Public Health, Erasmus MC University Medical Centre, Rotterdam
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Clough-Gorr KM, Stuck AE, Thwin SS, Silliman RA. Older breast cancer survivors: geriatric assessment domains are associated with poor tolerance of treatment adverse effects and predict mortality over 7 years of follow-up. J Clin Oncol 2009; 28:380-6. [PMID: 20008637 DOI: 10.1200/jco.2009.23.5440] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE To evaluate geriatric assessment (GA) domains in relation to clinically important outcomes in older breast cancer survivors. METHODS Six hundred sixty women diagnosed with primary breast cancer in four US geographic regions (Los Angeles, CA; Minnesota; North Carolina; and Rhode Island) were selected with disease stage I to IIIA, age >or= 65 years at date of diagnosis, and permission from attending physician to contact. Data were collected over 7 years of follow-up from consenting patients' medical records, telephone interviews, physician questionnaires, and the National Death Index. Outcomes included self-reported treatment tolerance and all-cause mortality. Four GA domains were described by six individual measures, as follows: sociodemographic by adequate finances; clinical by Charlson comorbidity index (CCI) and body mass index; function by number of physical function limitations; and psychosocial by the five-item Mental Health Index (MHI5) and Medical Outcomes Study Social Support Survey (MOS-SSS). Associations were evaluated using t tests, chi(2) tests, and regression analyses. RESULTS In multivariable regression including age and stage, three measures from two domains (clinical and psychosocial) were associated with poor treatment tolerance; these were CCI >or= 1 (odds ratio [OR] = 2.49; 95% CI, 1.18 to 5.25), MHI5 score less than 80 (OR = 2.36; 95% CI, 1.15 to 4.86), and MOS-SSS score less than 80 (OR = 3.32; 95% CI, 1.44 to 7.66). Four measures representing all four GA domains predicted mortality; these were inadequate finances (hazard ratio [HR] = 1.89; 95% CI, 1.24 to 2.88; CCI >or= 1 (HR = 1.38; 95% CI, 1.01 to 1.88), functional limitation (HR = 1.40; 95% CI, 1.01 to 1.93), and MHI5 score less than 80 (HR = 1.34; 95% CI, 1.01 to 1.85). In addition, the proportion of women with these outcomes incrementally increased as the number of GA deficits increased. CONCLUSION This study provides longitudinal evidence that GA domains are associated with poor treatment tolerance and predict mortality at 7 years of follow-up, independent of age and stage of disease.
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Affiliation(s)
- Kerri M Clough-Gorr
- Section of Geriatrics, Boston University School of Medicine, Boston, MA, USA.
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Carretier J, Bataillard A, Fervers B. La place du patient dans la médecine factuelle. ACTA ACUST UNITED AC 2009; 146:537-44. [DOI: 10.1016/j.jchir.2009.10.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Demez PH, Moreau PR. Perception of head and neck cancer quality of life within the medical world: a multicultural study. Head Neck 2009; 31:1056-67. [PMID: 19340871 DOI: 10.1002/hed.21069] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Physician's perception of quality of life of patients with cancer is unclear. No reports have evaluated its influence on patient management. METHODS Five hundred otolaryngologists completed a questionnaire regarding the quality of life of patients with head and neck cancer. RESULTS Seventy-eight percent of responders thought that quality of life must be considered when choosing treatment, even if this meant decreased survival. Seventy-five percent thought it justified to withhold curative treatment if this would lead to impaired quality of life. Pain and breathing were the most important symptoms to consider. The perception was worse for physicians practicing in Latin culture, working in private practice, or with no personal acquaintance with a head and neck cancer victim and was better after radiotherapy than after surgery and chemotherapy. CONCLUSION Quality of life is important for physicians and is considered as essential as survival by many physicians. The perception of patient's quality of life influences the treatment choice.
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Affiliation(s)
- Pierre H Demez
- Otorhinolaryngology-Head and Neck Surgery Department, C.H.U. Liege, Domaine Universitaire du Sart Tilman, Bâtiment B 35, B-4000 Liège 1, Belgium.
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Hirose T, Yamaoka T, Ohnishi T, Sugiyama T, Kusumoto S, Shirai T, Okuda K, Ohmori T, Adachi M. Patient willingness to undergo chemotherapy and thoracic radiotherapy for locally advanced non-small cell lung cancer. Psychooncology 2009; 18:483-9. [PMID: 18942662 DOI: 10.1002/pon.1450] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To determine how Japanese patients with lung cancer weigh the chance of cure and potential survival against the potential toxicity of different treatment strategies for locally advanced non-small cell lung cancer (NSCLC). METHODS We used a questionnaire describing a hypothetical situation involving locally advanced NSCLC. Seventy-three patients with lung cancer who had received chemotherapy and a control group of 120 patients without cancer were asked to state the minimal benefit that would make two hypothetical treatments acceptable. RESULTS Patients with lung cancer were significantly more likely than were patients without cancer to accept either intensive or less-intensive chemoradiotherapy for a potentially small benefit for 'chance of cure' and 'response but not cure'. The percentages of patients who would accept intensive or less-intensive chemoradiotherapy to prolong survival did not differ significantly between the two groups. When the chance of cure was 20%, 56 and 64% of patients with lung cancer were willing to receive intensive and less-intensive chemoradiotherapy, respectively. If their lives were prolonged by 6 months, 20 and 30% of patients with lung cancer would choose to receive intensive and less-intensive chemoradiotherapy, respectively. The chance of cure and the survival advantage that patients require for accepting chemoradiotherapy varied widely. No factors were associated with the choice of chemoradiotherapy in patients with lung cancer. CONCLUSIONS Physicians must consider the substantial range of attitudes to chemoradiotherapy among patients when selecting treatment and give patients opportunities to be included in the treatment-selection process.
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Affiliation(s)
- Takashi Hirose
- The First Department of Internal Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, Japan.
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Estimation of an optimal chemotherapy utilisation rate for head and neck carcinoma: Setting an evidence-based benchmark for the best-quality cancer care. Eur J Cancer 2009; 45:2150-9. [DOI: 10.1016/j.ejca.2009.02.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2008] [Revised: 01/17/2009] [Accepted: 02/04/2009] [Indexed: 11/22/2022]
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The role of palliative care in the lung cancer patient: can we improve quality while limiting futile care? Curr Opin Pulm Med 2009; 15:321-6. [DOI: 10.1097/mcp.0b013e32832b8a5d] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Westerman MJ, Hak T, Sprangers MAG, Groen HJM, van der Wal G, The AM. Listen to their answers! Response behaviour in the measurement of physical and role functioning. Qual Life Res 2008; 17:549-58. [PMID: 18389384 PMCID: PMC2358935 DOI: 10.1007/s11136-008-9333-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2007] [Accepted: 03/13/2008] [Indexed: 12/02/2022]
Abstract
Background Quality of life (QoL) is considered to be an indispensable outcome measure of curative and palliative treatment. However, QoL research often yields findings that raise questions about what QoL measurement instruments actually assess and how the scores should be interpreted. Objective To investigate how patients interpret and respond to questions on the EORTC-QLQ-C30 over time and to find explanations to account for counterintuitive findings in QoL measurement. Methods Qualitative investigation was made of the response behaviour of small-cell lung cancer patients (n = 23) in the measurement of QoL with the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30). Focus was on physical functioning (PF, items 1 to 5), role functioning (RF, items 6 and 7), global health and QoL rating (GH/QOL, items 29 and 30). Interviews were held at four points: at the start of the chemotherapy, 4 weeks later, at the end, and 6 weeks after the end of chemotherapy. Patients were asked to ‘think aloud’ when filling in the questionnaire. Results Patients used various response strategies when answering questions about problems and limitations in functioning, which impacted the accuracy of the scale. Patients had scores suggesting they were less limited than they actually were by taking the wording of questions literally, by guessing their functioning in activities that they did not perform, and by ignoring or excluding certain activities that they could not perform. Conclusion Terminally ill patients evaluate their functioning in terms of what they perceive to be normal under the circumstances. Their answers can be interpreted in terms of change in the appraisal process (Rapkin and Schwartz 2004; Health and Quality of Life Outcomes, 2, 14). More care should be taken in assessing the quality of a set of questions about physical and role functioning.
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Affiliation(s)
- Marjan J Westerman
- Department of Public and Occupational Health, EMGO Institute, VU University Medical Centre, Amsterdam, The Netherlands.
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Abstract
Patients face difficult decisions about chemotherapy near the end of life. Such treatment might prolong survival or reduce symptoms but cause adverse effects, prevent the patient from engaging in meaningful life review and preparing for death, and preclude entry into hospice. Palliative care and oncology clinicians should be logical partners in caring for patients with serious cancers for which symptom control, medically appropriate goal setting, and communication are paramount, but some studies have shown limited cooperation. We illustrate how clinicians involved in palliative care and oncology can more effectively work together with the story of Mr L, a previously healthy 56-year-old man, who wanted to survive his lung cancer at all costs. He lived 14 months with 3 types of chemotherapy, received chemotherapy just 6 days before his death, and resisted entering hospice until his prognosis and options were explicitly communicated. Approaches to communication about prognosis and treatment options and questions that patients may want to ask are discussed.
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Affiliation(s)
- Sarah Elizabeth Harrington
- Department of Internal Medicine and the Thomas Palliative Care Program, Massey Cancer Center, Virginia Commonwealth University, Richmond, VA 23298, USA
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Affiliation(s)
- Jeffrey D. Clough
- Department of Health Policy, Jefferson Medical College, Philadelphia, PA
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