Consumer impact of an interactive decision aid for rectal cancer patients offered adjuvant therapy

Experiences of Using Patient Decision Aids for Decisions About Cancer Treatment: A Meta-Aggregation of Qualitative Studies

BACKGROUND

Inconsistent results have been found regarding the effects of patient decision aids (PtDAs) in supporting patients' decision-making for cancer treatment.

OBJECTIVE

This qualitative meta-aggregation presents the experiences of using PtDAs, as perceived by adult patients with cancer, and highlights the components they perceived as important.

METHODS

We used the 3-phase process for meta-aggregation suggested by Joanna Briggs Institute to identify published studies with qualitative evidence from CINAHL, Ovid-MEDLINE, APA PsycINFO, and EMBASE databases. The selected studies involved adults with various cancer diagnoses. The phenomenon of interest and the context for this review were people's experiences of using PtDAs for decisions about first-line cancer treatment.

RESULTS

A total of 16 studies were included. The authors achieved consensus on 5 synthesized findings about PtDAs: (1) improved understanding of treatment options and patient values and preferences; (2) served as platforms for expressing concerns, obtaining support, and having meaningful conversations with healthcare providers; (3) facilitated active personal and family engagement in decision-making; (4) enabled recall of information and evaluation of satisfaction with decisions; and (5) presented potential structural barriers.

CONCLUSIONS

This study used qualitative evidence to demonstrate the usefulness of PtDAs and identify aspects patients with cancer find particularly beneficial.

IMPLICATIONS FOR PRACTICE

Nurses play a crucial role in supporting patients and family caregivers throughout the decision-making process for cancer treatment. Patient decision aids that balance complex treatment information with simple language and illustrations or graphs can enhance patients' comprehension. The integration of values clarification exercises into care can further improve patients' decisional outcomes.

The impact of decision aids in patients with colorectal cancer: a systematic review

OBJECTIVES

Our aim was to conduct a systematic review of the literature to determine the impact of patient decision aids (PDA) on patients facing treatment decisions for colorectal cancer.

DESIGN

Systematic review.

DATA SOURCES

Sources included Embase, Medline, Web of Science, CINAHL and the Cochrane Library from inception to June, 20, 2019.

ELIGIBILITY CRITERIA

We included randomised controlled trials (RCTs), cohort studies, mixed methods and case series in which a PDA for colorectal cancer treatment was used. Qualitative studies were excluded from our review.

DATA EXTRACTION AND SYNTHESIS

Following execution of the search strategy by a medical librarian, two blinded independent reviewers identified articles for inclusion. Two blinded reviewers were also responsible for data extraction, risk of bias and study quality assessments. Any conflict in article inclusion or extraction was resolved by discussion.

RESULTS

Out of 3773 articles identified, three met our inclusion criteria: one RCT, one before-and-after study and one mixed-method study. In these studies, the use of a PDA for colorectal cancer treatment was associated with increased patient knowledge, satisfaction and preparation for making a decision. On quality assessment, two of three studies were judged to be of low quality.

CONCLUSION

A paucity of evidence exists on the effect of PDA for colorectal cancer treatment with existing evidence being largely of low quality. Further investigation is required to determine the effect of decision aids for colorectal cancer treatment as well as reasons for the lack of PDA development and implementation in this area.

PROSPERO REGISTRATION NUMBER

CRD42018095153.

The desire to survive: the adaptation process of adult cancer patients undergoing radiotherapy

AIM

Radiotherapy is one of the primary treatment strategies for cancer. However, patients not only deal with the side-effects of radiotherapy, but they must also endure the psychological distress caused by cancer. This study explores how cancer patients adapt to the treatment process when receiving radiotherapy.

METHODS

This study used a grounded theory approach, and eight in-depth interviews were conducted with newly diagnosed cancer patients who received radiotherapy as a primary treatment.

RESULTS

The core category that emerged from this study was "the desire to survive". The categories and subcategories that emerged from the data include facing unknown situations (e.g. searching for relevant information and decision-making considerations, and listening to healthcare professionals' suggestions), experiencing the pain of treatment (e.g. tolerating side-effects, tolerating inconvenience during the treatment, accepting support during the treatment, and adjusting lifestyles), and chances to extend life (e.g. accepting fate, determination to undergo the treatment, and adjusting negative emotions).

CONCLUSION

The study results provide a better understanding of the experiences of cancer patients undergoing radiotherapy. Healthcare professionals should provide effective medical management for side-effects and psychological support to cancer patients during the journey of radiotherapy.

Adjuvant chemotherapy for colorectal cancer: age differences in factors influencing patients' treatment decisions

PURPOSE

Older colorectal cancer patients are significantly less likely than younger patients to receive guideline-recommended adjuvant chemotherapy. Previous research has indicated that patient refusal of treatment is a contributing factor. This study aimed to identify potential barriers to adjuvant chemotherapy use in older patients by examining the associations between patient age, factors influencing chemotherapy treatment decisions, and preferences for information and decision-making involvement.

PATIENTS AND METHODS

Sixty-eight patients who underwent surgery for colorectal cancer in Sydney, Australia, within the previous 24 months completed a self-administered survey.

RESULTS

Fear of dying, health status, age, quality of life, and understanding treatment procedures and effects were significantly more important to older patients (aged ≥65 years) than younger patients in deciding whether to accept chemotherapy (all P < 0.05). Reducing the risk of cancer returning and physician trust were important factors for all patients. Practical barriers such as traveling for treatment and cost were rated lowest. Older patients preferred less information and involvement in treatment decision making than younger patients. However, 60% of the older group wanted detailed information about chemotherapy, and 83% wanted some involvement in decision making. Those preferring less information and involvement still rated many factors as important in their decision making, including understanding treatment procedures and effects.

CONCLUSION

A range of factors appears to influence patients' chemotherapy decision making, including, but not limited to, survival benefits and treatment toxicity. For older patients, balancing the risks and benefits of treatment may be made more complex by the impact of emotional motivators, greater health concerns, and conflicts between their need for understanding and their information and decision-making preferences. Through greater understanding of perceived barriers to treatment and unique motivators for treatment choice, physicians may be better able to support older patients to make informed decisions about their care.

Information needs across the colorectal cancer care continuum: scoping the literature

Because cancer care requires a multifaceted approach, providing useful and timely information to people with colorectal cancer may be fragmented and inconsistent. Our interest was in examining what has and has not captured the attention of researchers speaking to the information needs of people with colorectal cancer. We followed Arksey and O'Malley's framework for the methodology of scoping review. Focusing solely on colorectal cancer, we analysed 239 articles to get a picture of which information needs and sources of information, as well as the timing of providing information, were attended to. Treatment-related information received the most mentions (26%). Healthcare professionals (49%) were mentioned as the most likely source of information. Among articles focused on one stage of the care continuum, post-treatment (survivorship) received the most attention (16%). Only 27% of the articles consulted people with colorectal cancer and few attended to diet/nutrition and bowel management. This study examined the numerical representation of issues to which researchers attend, not the quality of the mentions. We ponder, however, on the relationship between the in/frequency of mentions and the actual information needs of people with colorectal cancer as well as the availability, sources and timing of information.

Older patients and adjuvant therapy for colorectal cancer: surgeon knowledge, opinions, and practice

BACKGROUND

Increasing patient age independently predicts nonreferral and nonreceipt of adjuvant therapy among patients with colorectal cancer.

OBJECTIVE

This study aimed to identify factors affecting surgeons' decisions to refer older patients for adjuvant therapy.

DESIGN/SETTINGS/PARTICIPANTS

A self-administered survey was sent to all Australian and New Zealand colorectal surgeons (n = 146).

MAIN OUTCOME MEASURES

The survey consisted of 3 sections: 1) knowledge of research evidence, 2) opinions on evidence and adjuvant therapy in older patients, and 3) self-reported practice, or likelihood of patient referral in different scenarios. Demographic information was also obtained.

RESULTS

Seventy percent of surgeons responded. Surgeons were significantly less likely to refer older patients than younger patients for adjuvant therapy in all scenarios (P < .001). The difference in referral recommendations was greatest when patients lived a long way from treatment, had a comorbid condition, or had little social support. There was greater variation in referral recommendations for older patients, and marked disagreement between surgeons in knowledge and opinion questions. Surgeon age was the only significant predictor of survey responses. Greater knowledge and more positive opinions predicted similar referral recommendations for older and younger patients (P = .02, P = .01).

LIMITATIONS

Although decreased referral and receipt of adjuvant therapy among older patients is most likely multifactorial, this survey focused on the views of one physician group and a number of specific scenarios.

CONCLUSIONS

Chronological age alone appears to impact colorectal surgeons' decisions to refer patients for adjuvant therapy. Sociodemographic and physiological factors further decrease the likelihood of referral of older patients. A lack of consensus among surgeons suggests that more research is needed both to predict how older patients with cancer will react to treatment, and to determine how information from emerging evidence can be best used to assist physicians' treatment decisions.

Sharing vs. caring--the relative impact of sharing decisions versus managing emotions on patient outcomes

OBJECTIVE

To assess the relative impact of cognitive and emotional aspects of shared decision making (SDM) on patient outcomes.

METHODS

Cognitive and emotional aspects of SDM in consultations between 20 oncologists and 55 early breast cancer patients were coded using the Observing Patient Involvement (OPTION) scale and the Response to Emotional Cues and Concerns (RECC) coding system, plus blocking and facilitating behaviour scales. Patient outcomes including anxiety, decisional conflict, and satisfaction with: (i) the decision, (ii) the consultation, and (iii) doctor SDM skills, were assessed. Relationships between cognitive and emotional aspects of SDM, and patient outcomes were examined using hierarchical regression.

RESULTS

The OPTION score predicted satisfaction with doctor SDM skills 2 weeks post-consultation (p=.010), and with the treatment decision 4 months post-consultation (p=.004). Emotional blocking predicted decisional conflict (p=.039), while the number of emotional cues emitted (p=.003), and the degree of empathy provided (p=.011), predicted post-consultation anxiety.

CONCLUSION

Cognitive and emotional aspects of SDM in oncology consultations have different effects on various patient outcomes.

PRACTICE IMPLICATIONS

It is important that doctors focus on both sharing decisions and managing emotions in consultations. Communication skills training addressing both these areas may be an effective way to improve diverse patient outcomes.

Shared decision making coding systems: how do they compare in the oncology context?

OBJECTIVE

The current study aimed to evaluate three coding systems which have been used to assess shared decision making in oncology consultations (OPTION, Decision Support Analysis Tool (DSAT) and Decision Analysis System for Oncology (DAS-O)): (i) comparing their ability to identify competencies of shared decision making, and (ii) determining their ability to predict patient outcomes in a single data set.

METHOD

Twenty oncologists from Australia and New Zealand participated in the IBCSG Trial 33-03. The consultations of 55 women with early stage breast cancer were audio-taped, transcribed and then coded using the OPTION, DAS-O and DSAT coding systems by three different raters. Women completed the questionnaires 2 weeks and 4 months after their consultation.

RESULTS

DAS-O was strongly correlated with OPTION (r=0.73). DSAT was moderately correlated with DAS-O and OPTION (r<0.6). Decisional satisfaction and satisfaction with doctor SDM skills were significantly correlated with OPTION (r=0.39 and 0.42 respectively) and the latter variable was correlated with DAS-O (r=0.40). These relationships persisted in multiple linear regression analyses.

CONCLUSIONS

OPTION may be the most efficient and sensitive coding system for research purposes; however, DSAT appeared to document behaviours reducing decisional conflict and both DSAT and DAS-O offer more detailed feedback to doctors.

PRACTICE IMPLICATIONS

Optimal coding system will depend on research goals and training purposes.

Using patient and physician perspectives to develop a shared decision-making framework for colorectal cancer

BACKGROUND

Colorectal cancer is the third leading cause of death from cancer worldwide with over 900,000 diagnoses and 639,000 deaths each year. Although shared decision making is broadly advocated as a mechanism by which to achieve patient-centred care, there has been little investigation of patient and physician shared decision-making preferences and practices or the outcomes associated with shared decision making in the context of colorectal cancer.

AIM

The aim of this study is to determine patient and physician attitudes towards the use of shared decision making in the setting of colorectal cancer.

METHODS

Standard principles of qualitative research will be used to sample and interview 20 colorectal cancer patients in each of three tertiary care hospitals (n = 60) and 15 surgeons, radiation oncologists, and medical oncologists (n = 45) affiliated with cancer centres. The interview questions will be guided by a conceptual framework defining patient and physician factors that influence the shared decision-making process and associated outcomes in the setting of colorectal cancer. An inductive, grounded approach will be used by two investigators to independently analyze the interview transcripts. These investigators will meet to compare and achieve consensus on themes that will be tabulated to compare barriers, enablers, and outcomes of shared decision making by patient, physician, and contextual factors.

DISCUSSION

This study is the first to examine both patient and physician perspectives on the use of shared decision making for colorectal cancer in North America or elsewhere. It will provide a framework that can be used to describe the shared decision-making process and its outcomes, and evaluate strategies to facilitate this process for patients with colorectal cancer.

Implementing patient decision support tools: moving beyond academia?

OBJECTIVE

To ascertain the feasibility of implementing three decision support tools (DSTs) for people with rectal cancer within the surgical consultation.

METHODS

Twenty colorectal surgeons participated in a focus group or individual interviews. Colorectal surgeons were also asked to complete a self-administered questionnaire.

RESULTS

All surgeons responded encouragingly to the concept of DSTs. However, for every positive statement an accompanying caveat was made and these were either a criticism of each tool or a barrier to their implementation. Surgeons stated DSTs should be used by patients and surgeons together (80%). The majority (70-75%) thought each tool was 'useful' or 'extremely useful'. However, there were strong views that in their current form the DSTs would not feasible to be used within the surgical consultation. Time restraints, personal and clinical characteristics of the patient, the content of each tool, the potential negative impact on the doctor-patient relationship were noted as real barriers to their implementation.

CONCLUSION

Surgeons have identified a number of barriers that may limit implementation of DSTs into routine clinical practice.

PRACTICE IMPLICATIONS

Feasibility and implementation studies have the potential to provide important information to help guide development, evaluation and implementation of DSTs.

Colorectal cancer patients' attitudes towards involvement in decision making

OBJECTIVES

To design and administer an attitude rating scale, exploring colorectal cancer patients' views of involvement in decision making. To examine the impact of socio-demographic and/or treatment-related factors on decision making. To conduct principal components analysis to determine if the scale could be simplified into a number of factors for future clinical utility.

METHODS

An attitude rating scale was constructed based on previous qualitative work and administered to colorectal cancer patients using a cross-sectional survey approach.

RESULTS

375 questionnaires were returned (81.7% response). For patients it was important to be informed and involved in the decision-making process. Information was not always used to make decisions as patients placed their trust in medical expertise. Women had more positive opinions on decision making and were more likely to want to make decisions. Written information was understood to a greater degree than verbal information. The scale could be simplified to a number of factors, indicating clinical utility.

CONCLUSION

Few studies have explored the attitudes of colorectal cancer patients towards involvement in decision making. This study presents new insights into how patients view the concept of participation; important when considering current policy imperatives in the UK of involving service users in all aspects of care and treatment.

Improving informed consent: pilot of a decision aid for women invited to participate in a breast cancer prevention trial (IBIS-II DCIS)

BACKGROUND

Patients and clinicians report difficulties with the process of informed consent to clinical trials and audiotape audits show that critical information is often omitted or poorly presented. Decision aids (DAs) may assist in improving consent.

AIMS

This study piloted a DA booklet for a high priority breast cancer prevention trial, IBIS-II DCIS, which compares the efficacy of an aromatase inhibitor (anastrozole) with tamoxifen in women who have had surgery for ductal carcinoma in situ (DCIS).

METHOD

Thirty-one Australian women participating in the IBIS-I breast cancer prevention trial and who are currently in follow-up agreed to read the IBIS-II DCIS participant information sheet and the DCIS DA booklet, complete a set of standardized questionnaires, and provide feedback on the DA via a semi-structured phone interview.

RESULTS

Women found the DA helpful in deciding about trial participation, reporting that it aided their understanding over and above the approved IBIS-II DCIS participant information sheet and was not anxiety provoking. Women's understanding of the rationale and methods of clinical trials and the IBIS-II DCIS trial was very good; with more than 80% of items answered correctly. The only areas that were not understood well were the concepts of randomization and blinding.

CONCLUSIONS

This study suggests that the DA will be acceptable to and valued by potential participants in the IBIS-II DCIS study. The revised DA is currently being evaluated prospectively in a randomized controlled trial. If successful, such DAs could transform the consent process to large clinical trials and may also reduce dropout rates.