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Eyal N. Research ethics and public trust in vaccines: the case of COVID-19 challenge trials. JOURNAL OF MEDICAL ETHICS 2024; 50:278-284. [PMID: 35595525 PMCID: PMC9157325 DOI: 10.1136/medethics-2021-108086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 05/07/2022] [Indexed: 06/15/2023]
Abstract
Despite their clearly demonstrated safety and effectiveness, approved vaccines against COVID-19 are commonly mistrusted. Nations should find and implement effective ways to boost vaccine confidence. But the implications for ethical vaccine development are less straightforward than some have assumed. Opponents of COVID-19 vaccine challenge trials, in particular, made speculative or empirically implausible warnings on this matter, some of which, if applied consistently, would have ruled out most COVID-19 vaccine trials and many non-pharmaceutical responses.
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Affiliation(s)
- Nir Eyal
- Center for Population-Level Bioethics, Department of Philosophy (SAS) and Department of HBSP (SPH), Rutgers University, New Brunswick, New Jersey, USA
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Lerner A, Eyal N. Future pandemics and the urge to 'do something'. JOURNAL OF MEDICAL ETHICS 2024:jme-2023-109791. [PMID: 38286591 DOI: 10.1136/jme-2023-109791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/27/2023] [Indexed: 01/31/2024]
Abstract
Research with enhanced potential pandemic pathogens (ePPP) makes pathogens substantially more lethal, communicable, immunosuppressive or otherwise capable of triggering a pandemic. We briefly relay an existing argument that the benefits of ePPP research do not outweigh its risks and then consider why proponents of these arguments continue to confidently endorse them. We argue that these endorsements may well be the product of common cognitive biases-in which case they would provide no challenge to the argument against ePPP research. If the case against ePPP research is strong, the views of professional experts do little to move the needle in favour of ePPP research.
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Affiliation(s)
- Adam Lerner
- Center for Population-Level Bioethics, Rutgers The State University of New Jersey, New Brunswick, New Jersey, USA
| | - Nir Eyal
- Center for Population-Level Bioethics, Department of Philosophy (SAS) and Department of HBSP (SPH), Rutgers University, New Brunswick, New Jersey, USA
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Berlin A, Ramotar M, Santiago AT, Liu Z, Li J, Wolinsky H, Wallis CJD, Chua MLK, Paner GP, van der Kwast T, Cooperberg MR, Vickers AJ, Urbach DR, Eggener SE. The influence of the "cancer" label on perceptions and management decisions for low-grade prostate cancer. J Natl Cancer Inst 2023; 115:1364-1373. [PMID: 37285311 PMCID: PMC10637044 DOI: 10.1093/jnci/djad108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/01/2023] [Accepted: 06/05/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND Grade Group 1 (GG1) prostate cancer should be managed with active surveillance (AS). Global uptake of AS remains disappointingly slow and heterogeneous. Removal of cancer labels has been proposed to reduce GG1 overtreatment. We sought to determine the impact of GG1 disease terminology on individual's perceptions and decision making. METHODS Discrete choice experiments were conducted on 3 cohorts: healthy men, canonical partners (partners), and patients with GG1 (patients). Participants reported preferences in a series of vignettes with 2 scenarios each, permuting key opinion leader-endorsed descriptors: biopsy (adenocarcinoma, acinar neoplasm, prostatic acinar neoplasm of low malignant potential [PAN-LMP], prostatic acinar neoplasm of uncertain malignant potential), disease (cancer, neoplasm, tumor, growth), management decision (treatment, AS), and recurrence risk (6%, 3%, 1%, <1%). Influence on scenario selection were estimated by conditional logit models and marginal rates of substitution. Two additional validation vignettes with scenarios portraying identical descriptors except the management options were embedded into the discrete choice experiments. RESULTS Across cohorts (194 healthy men, 159 partners, and 159 patients), noncancer labels PAN-LMP or prostatic acinar neoplasm of uncertain malignant potential and neoplasm, tumor, or growth were favored over adenocarcinoma and cancer (P < .01), respectively. Switching adenocarcinoma and cancer labels to PAN-LMP and growth, respectively, increased AS choice by up to 17%: healthy men (15%, 95% confidence interval [CI] = 10% to 20%, from 76% to 91%, P < .001), partners (17%, 95% CI = 12% to 24%, from 65% to 82%, P < .001), and patients (7%, 95% CI = 4% to 12%, from 75% to 82%, P = .063). The main limitation is the theoretical nature of questions perhaps leading to less realistic choices. CONCLUSIONS "Cancer" labels negatively affect perceptions and decision making regarding GG1. Relabeling (ie, avoiding word "cancer") increases proclivity for AS and would likely improve public health.
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Affiliation(s)
- Alejandro Berlin
- Department of Radiation Oncology, University of Toronto; Radiation Medicine Program, Princess Margaret Cancer Centre; TECHNA Institute, University Health Network, Toronto, ON, Canada
| | - Matthew Ramotar
- Department of Radiation Oncology, University of Toronto; Radiation Medicine Program, Princess Margaret Cancer Centre; TECHNA Institute, University Health Network, Toronto, ON, Canada
| | - Anna T Santiago
- Department of Biostatistics, Princess Margaret Cancer Centre; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Zhihui Liu
- Department of Biostatistics, Princess Margaret Cancer Centre; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Joyce Li
- The University of Western Ontario, London, ON, Canada
| | - Howard Wolinsky
- AnCan Active Surveillance Virtual Support Group; The Active Surveillor Newsletter, Chicago, IL, USA
| | - Christopher J D Wallis
- Division of Urology, Department of Surgery, University of Toronto, Mount Sinai Hospital, and University Hospital Network, Toronto, ON, Canada
| | - Melvin L K Chua
- Divisions of Radiation Oncology and Medical Sciences, National Cancer Centre Singapore; Oncology Academic Programme, Duke-NUS Medical School, Singapore
| | - Gladell P Paner
- Departments of Pathology and Surgery, University of Chicago. Chicago, IL, USA
| | | | - Matthew R Cooperberg
- Departments of Urology and Epidemiology and Biostatistics, University of California San Francisco Comprehensive Cancer Center, San Francisco, CA, USA
| | - Andrew J Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David R Urbach
- Institute for Clinical Evaluative Sciences (ICES), Department of Surgery, University of Toronto; Perioperative Services, Women’s College Hospital and Research Institute, Toronto, ON, Canada
| | - Scott E Eggener
- Section of Urology, Department of Surgery, The University of Chicago Comprehensive Cancer Center, Chicago, IL, USA
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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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Nickel B, McCaffery K, Jansen J, Barratt A, Houssami N, Saunders C, Spillane A, Rutherford C, Stuart K, Robertson G, Dixon A, Hersch J. Women's views about current and future management of Ductal Carcinoma in Situ (DCIS): A mixed-methods study. PLoS One 2023; 18:e0288972. [PMID: 37478123 PMCID: PMC10361483 DOI: 10.1371/journal.pone.0288972] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 07/09/2023] [Indexed: 07/23/2023] Open
Abstract
Management of low-risk ductal carcinoma in situ (DCIS) is controversial, with clinical trials currently assessing the safety of active monitoring amidst concern about overtreatment. Little is known about general community views regarding DCIS and its management. We aimed to explore women's understanding and views about low-risk DCIS and current and potential future management options. This mixed-method study involved qualitative focus groups and brief quantitative questionnaires. Participants were screening-aged (50-74 years) women, with diverse socioeconomic backgrounds and no personal history of breast cancer/DCIS, recruited from across metropolitan Sydney, Australia. Sessions incorporated an informative presentation interspersed with group discussions which were audio-recorded, transcribed and analysed thematically. Fifty-six women took part in six age-stratified focus groups. Prior awareness of DCIS was limited, however women developed reasonable understanding of DCIS and the relevant issues. Overall, women expressed substantial support for active monitoring being offered as a management approach for low-risk DCIS, and many were interested in participating in a hypothetical clinical trial. Although some women expressed concern that current management may sometimes represent overtreatment, there were mixed views about personally accepting monitoring. Women noted a number of important questions and considerations that would factor into their decision making. Our findings about women's perceptions of active monitoring for DCIS are timely while results of ongoing clinical trials of monitoring are awaited, and may inform clinicians and investigators designing future, similar trials. Exploration of offering well-informed patients the choice of non-surgical management of low-risk DCIS, even outside a clinical trial setting, may be warranted.
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Affiliation(s)
- Brooke Nickel
- Faculty of Medicine and Health, Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health, Sydney Health Literacy Lab, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Kirsten McCaffery
- Faculty of Medicine and Health, Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health, Sydney Health Literacy Lab, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Jesse Jansen
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Alexandra Barratt
- Faculty of Medicine and Health, Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Nehmat Houssami
- Faculty of Medicine and Health, Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health, Sydney Health Literacy Lab, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- The Daffodil Centre, The University of Sydney, a Joint Venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Christobel Saunders
- Department of Surgery, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Andrew Spillane
- Northern Clinical School, The University of Sydney, St Leonards, NSW, Australia
- Mater Hospital, Wollstonecraft, NSW, Australia
- Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Claudia Rutherford
- Faculty of Science, School of Psychology, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health, Sydney Nursing School, The University of Sydney, Sydney, NSW, Australia
| | - Kirsty Stuart
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead, NSW, Australia
- Westmead Breast Cancer Institute, Westmead, NSW, Australia
- Westmead Clinical School, The University of Sydney, Sydney, NSW, Australia
| | | | - Ann Dixon
- Faculty of Science, Sydney Neuropsychology Clinic, School of Psychology, The University of Sydney, Sydney, NSW, Australia
| | - Jolyn Hersch
- Faculty of Medicine and Health, Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health, Sydney Health Literacy Lab, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
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Lacey HP, Lacey SC, Dayal P, Forest C, Blasi D. Context Matters: Emotional Sensitivity to Probabilities and the Bias for Action in Cancer Treatment Decisions. Med Decis Making 2023; 43:417-429. [PMID: 36951184 PMCID: PMC10595072 DOI: 10.1177/0272989x231161341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
BACKGROUND Past studies have shown a commission bias for cancer treatment, a tendency to choose active treatment even when watchful waiting is less risky. This bias suggests motivations for action beyond mortality statistics, but recent evidence suggests that individuals differ in their emotional sensitivity to probabilities (ESP), the tendency to calibrate emotional reactions to probability. The current study aims to examine the role of ESP in the commission bias, specifically whether those higher in ESP are more likely to choose watchful waiting when risk probabilities align with that choice. METHODS Participants (N = 1,055) read a scenario describing a hypothetical cancer diagnosis and chose between surgery and watchful waiting, with random assignment between versions where the mortality rate was either lower for surgery or for watchful waiting. We modeled choice using the Possibility Probability Questionnaire (PPQ), a measure of ESP, and several other individual differences in a logistic regression. RESULTS We observed a commission bias as in past studies with most participants choosing surgery both when surgery was optimal (71%) and when watchful waiting was optimal (58%). An ESP × Condition interaction indicated that the predictive role of ESP depended on condition. Those higher in ESP were more likely to choose surgery when probabilities favored surgery, β = 0.57, P < 0.001, but when probabilities favored watchful waiting, ESP had a near-zero relationship with choice, β = 0.05, P < 0.99. CONCLUSIONS The role of ESP in decision making is context specific. Higher levels of ESP predict choosing action when that action is warranted but do not predict a shift away from surgery when watchful waiting offers better chances of survival. ESP does not overcome the commission bias. HIGHLIGHTS Past studies have identified a "commission bias," a tendency to choose active treatment over watchful waiting, even when mortality rate is lower for waiting.Evaluation of risk probabilities is related to individual differences in emotional sensitivity to probabilities (ESP) and has been shown to predict reactions to and decisions about health risk situations.ESP appears to be selectively factored into decision making. ESP was a robust predictor of choosing surgery when probability information supported surgery but did not predict decisions when probability information supported watchful waiting.Those who are most emotionally attuned to probabilities are just as susceptible to the commission bias as those who are less attuned.
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Affiliation(s)
- Heather P Lacey
- Department of Psychology, Center for Health and Behavioral Sciences, Bryant University, Smithfield, RI, USA
| | - Steven C Lacey
- Carroll School of Management, Boston University, Chestnut Hill, MA, USA
| | - Prerna Dayal
- Department of Psychology, Center for Health and Behavioral Sciences, Bryant University, Smithfield, RI, USA
| | - Caroline Forest
- Department of Psychology, Center for Health and Behavioral Sciences, Bryant University, Smithfield, RI, USA
| | - Dana Blasi
- Department of Psychology, Center for Health and Behavioral Sciences, Bryant University, Smithfield, RI, USA
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Duberstein PR, Hoerger M, Norton SA, Mohile S, Dahlberg B, Hyatt EG, Epstein RM, Wittink MN. The TRIBE model: How socioemotional processes fuel end-of-life treatment in the United States. Soc Sci Med 2023; 317:115546. [PMID: 36509614 DOI: 10.1016/j.socscimed.2022.115546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 03/21/2022] [Accepted: 11/13/2022] [Indexed: 11/25/2022]
Abstract
Prior interventions have repeatedly failed to decrease the prescription and receipt of treatments and procedures that confer more harm than benefit at the End-of-Life (EoL); new approaches to intervention are needed. Ideally, future interventions would be informed by a social-ecological conceptual model that explains EoL healthcare utilization patterns, but current models ignore two facts: (1) healthcare is an inherently social activity, involving clinical teams and patients' social networks, and (2) emotions influence social activity. To address these omissions, we scaffolded Terror Management Theory and Socioemotional Selectivity Theory to create the Transtheoretical Model of Irrational Biomedical Exuberance (TRIBE). Based on Terror Management Theory, TRIBE suggests that the prospect of patient death motivates healthcare teams to conform to a biomedical norm of care, even when clinicians believe that biomedical interventions will likely be unhelpful. Based on Socioemotional Selectivity Theory, TRIBE suggests that the prospect of dwindling time motivates families to prioritize emotional goals, and leads patients to consent to disease-directed treatments they know will likely be unhelpful, as moral emotions motivate deference to the perceived emotional needs of their loved ones. TRIBE is unique among models of healthcare utilization in its acknowledgement that moral emotions and processes (e.g., shame, compassion, regret-avoidance) influence healthcare delivery, patients' interactions with family members, and patients' outcomes. TRIBE is especially relevant to potentially harmful EoL care in the United States, and it also offers insights into the epidemics of overtreatment in healthcare settings worldwide. By outlining the role of socioemotional processes in the care of persons with serious conditions, TRIBE underscores the critical need for psychological innovation in interventions, health policy and research on healthcare utilization.
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Affiliation(s)
- Paul R Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers University School of Public Heath, 683 Hoes Lane West, Piscataway, NJ, 08854, United States.
| | - Michael Hoerger
- Department of Psychology, Psychiatry, and Medicine, Tulane University, 131 S. Robertson Building, 131 S Robertson St, New Orleans, LA, 70112, United States; Tulane Cancer Center, Tulane University, 1415 Tulane Ave, New Orleans, LA, 70112, United States.
| | - Sally A Norton
- School of Nursing, University of Rochester, 255 Crittenden Blvd, Rochester, NY, 14642, United States; Department of Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY, 14642, United States.
| | - Supriya Mohile
- Department of Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY, 14642, United States; James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, 90 Crittenden Blvd, Rochester, NY, 14642, United States.
| | - Britt Dahlberg
- Center for Humanism, Cooper Medical School of Rowan University, 401 South Broadway, Camden, NJ, 08103, United States.
| | - Erica Goldblatt Hyatt
- Rutgers School of Social Work, 536 George St, New Brunswick, NJ, 08901, United States.
| | - Ronald M Epstein
- Department of Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY, 14642, United States; James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, 90 Crittenden Blvd, Rochester, NY, 14642, United States; Department of Family Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY, 14642, United States.
| | - Marsha N Wittink
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY, 14642, United States.
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Ubel PA. Why Too Many Vitamins Feels Just About Right. JAMA Intern Med 2022; 182:791-792. [PMID: 35727689 DOI: 10.1001/jamainternmed.2022.0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Nickel B, Copp T, Brennan M, Farber R, McCaffery K, Houssami N. The Impact of Breast Density Information or Notification on Women's Cognitive, Psychological, and Behavioral Outcomes: A Systematic Review. J Natl Cancer Inst 2021; 113:1299-1328. [PMID: 33544867 PMCID: PMC8486329 DOI: 10.1093/jnci/djab016] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 12/31/2020] [Accepted: 02/01/2021] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Breast density (BD) is an independent risk factor for breast cancer and reduces the sensitivity of mammography. This systematic review aims to synthesize evidence from existing studies to understand the impact of BD information and/or notification on women's cognitive, psychological, and behavioral outcomes. METHODS Studies were identified via relevant database searches up to March 2020. Two authors evaluated the eligibility of studies with verification from the study team, extracted and crosschecked data, and assessed the risk of bias. RESULTS Of the 1134 titles identified, 29 studies were included. Twenty-three studies were quantitative, including only 1 randomized controlled trial of women receiving BD information, and 6 were qualitative. Twenty-seven studies were conducted in the United States, with 19 conducted post-BD legislation. The overall results in terms of BD awareness, knowledge, attitudes, perceptions, and intentions were heterogeneous across included studies, with the strongest consistency demonstrated regarding the importance of communication with and involvement of health-care professionals. Together, the studies did, however, highlight that there is still limited awareness of BD in the community, especially in more socioeconomic disadvantaged communities, and limited knowledge about what BD means and the implications for women. Importantly, BD information in the context of overall breast cancer risk has not yet been studied. CONCLUSIONS There are important gaps in the understanding of the impact of BD information or notification on women and how best to communicate BD information to women. More high-quality evidence to inform both current and future practice related to BD is still needed.
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Affiliation(s)
- Brooke Nickel
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Tessa Copp
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Meagan Brennan
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- School of Medicine Sydney, The University of Notre Dame, Sydney, Australia
| | - Rachel Farber
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Kirsten McCaffery
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Nehmat Houssami
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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Lamers RED, Cuypers M, de Vries M, van de Poll-Franse LV, Bosch JLHR, Kil PJM. Differences in treatment choices between prostate cancer patients using a decision aid and patients receiving care as usual: results from a randomized controlled trial. World J Urol 2021; 39:4327-4333. [PMID: 34272972 PMCID: PMC8602175 DOI: 10.1007/s00345-021-03782-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 07/02/2021] [Indexed: 12/12/2022] Open
Abstract
Objective To determine whether or not decision aid (DA) use influences treatment decisions in patients with low and intermediate risk prostate cancer (PC).
Patients and methods In a cluster randomized controlled trial, patients were randomized to either DA use (DA group) or no DA use (control group). Between 2014 and 2016, newly diagnosed patients with low or intermediate risk PC were recruited in 18 hospitals in the Netherlands. DA users had access to a web-based DA that provided general PC information, PC-treatment information, and values clarification exercises to elicit personal preferences towards the treatment options. Control group patients received care as usual. Differences in treatment choice were analysed using multilevel logistic regressions. Differences in eligible treatment options between groups were compared using Pearson Chi-square tests.
Results Informed consent was given by 382 patients (DA group N = 273, control group N = 109). Questionnaire response rate was 88% (N = 336). Active surveillance (AS) was an option for 38%, radical prostatectomy (RP) for 98%, external beam radiotherapy (EBRT) for 88%, and brachytherapy (BT) for 79% of patients. DA users received AS significantly more often than control group. Patients (29 vs 16%, p = 0.01), whereas the latter more often chose BT (29 vs 18%, p < 0.01). No differences were found between groups regarding RP and EBRT. DA users who were not eligible for AS, received surgery more often compared to the control group (53 vs 35%, p = 0.01). Patient and disease characteristics were evenly distributed between groups. Conclusion DA-using PC patients chose the AS treatment option more often than non-DA-using patients did.
Supplementary Information The online version contains supplementary material available at 10.1007/s00345-021-03782-7.
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Affiliation(s)
- Romy E D Lamers
- Department of Urology, University Medical Center, Utrecht, The Netherlands.
| | - Maarten Cuypers
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, Nijmegen, The Netherlands
| | - Marieke de Vries
- Institute for Computing and Information Sciences (iCIS) and Social and Cultural Psychology, Behavioural Science Institute, Radboud University, Mercator I, Toernooiveld 216, 6525, Nijmegen, The Netherlands
| | - Lonneke V van de Poll-Franse
- Department of Research, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands.,Department of Medical and Clinical Psychology, CoRPS-Center of Research on Psychology in Somatic Diseases, Tilburg University, Tilburg, The Netherlands.,Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - J L H Ruud Bosch
- University Medical Cancer Center Utrecht, Heidelberglaan 100, 3584, Utrecht, The Netherlands
| | - Paul J M Kil
- Andros Clinics, Mr. E.N. van Kleffensstraat 5, 6842 CV, Arnhem, The Netherlands
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11
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Are actions better than inactions? Positivity, outcome, and intentionality biases in judgments of action and inaction. JOURNAL OF EXPERIMENTAL SOCIAL PSYCHOLOGY 2021. [DOI: 10.1016/j.jesp.2021.104105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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12
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Schapira MM, Rodriguez KL, Chhatre S, Fraenkel L, Bastian LA, Kravetz JD, Asan O, Akers S, Vachani A, Prigge JM, Meline J, Ibarra JV, Corn B, Kaminstein D. When Is a Harm a Harm? Discordance between Patient and Medical Experts' Evaluation of Lung Cancer Screening Attributes. Med Decis Making 2021; 41:317-328. [PMID: 33554740 DOI: 10.1177/0272989x20987221] [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] [Indexed: 01/15/2023]
Abstract
BACKGROUND A shared decision-making (SDM) process for lung cancer screening (LCS) includes a discussion between clinicians and patients about benefits and potential harms. Expert-driven taxonomies consider mortality reduction a benefit and consider false-positives, incidental findings, overdiagnosis, overtreatment, radiation exposure, and direct and indirect costs of LCS as potential harms. OBJECTIVE To explore whether patients conceptualize the attributes of LCS differently from expert-driven taxonomies. DESIGN Cross-sectional study with semistructured interviews and a card-sort activity. PARTICIPANTS Twenty-three Veterans receiving primary care at a Veterans Affairs Medical Center, 55 to 73 y of age with 30 or more pack-years of smoking. Sixty-one percent were non-Hispanic African American or Black, 35% were non-Hispanic White, 4% were Hispanic, and 9% were female. APPROACH Semistructured interviews with thematic coding. MAIN MEASURES The proportion of participants categorizing each attribute as a benefit or harm and emergent themes that informed this categorization. KEY RESULTS In addition to categorizing reduced lung cancer deaths as a benefit (22/23), most also categorized the following as benefits: routine annual screening (8/9), significant incidental findings (20/23), follow-up in a nodule clinic (20/23), and invasive procedures (16/23). Four attributes were classified by most participants as a harm: false-positive (13/22), overdiagnosis (13/23), overtreatment (6/9), and radiation exposure (20/22). Themes regarding the evaluation of LCS outcomes were 1) the value of knowledge about body and health, 2) anticipated positive and negative emotions, 3) lack of clarity in terminology, 4) underlying beliefs about cancer, and 5) risk assessment and tolerance for uncertainty. CONCLUSIONS Anticipating discordance between patient- and expert-driven taxonomies of the benefits and harms of LCS can inform the development and interpretation of value elicitation and SDM discussions.
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Affiliation(s)
- Marilyn M Schapira
- The Center for Health Equity Research and Promotion (CHERP) at the Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia, PA, USA.,Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Keri L Rodriguez
- CHERP, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Department of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sumedha Chhatre
- The Center for Health Equity Research and Promotion (CHERP) at the Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia, PA, USA.,The Department of Psychiatry, the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Liana Fraenkel
- VA Connecticut Healthcare System, West Haven, CT, USA.,Yale University School of Medicine, New Haven, CT, USA
| | - Lori A Bastian
- VA Connecticut Healthcare System, West Haven, CT, USA.,Yale University School of Medicine, New Haven, CT, USA
| | - Jeffrey D Kravetz
- VA Connecticut Healthcare System, West Haven, CT, USA.,Yale University School of Medicine, New Haven, CT, USA
| | - Onur Asan
- The Stevens Institute of Technology, School of Systems and Enterprises, Hoboken, NJ, USA
| | - Scott Akers
- Department of Radiology, The Michael J. Crescenz VA Medical Center and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Anil Vachani
- The Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.,Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jason M Prigge
- The Center for Health Equity Research and Promotion (CHERP) at the Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia, PA, USA
| | - Jessica Meline
- The Center for Health Equity Research and Promotion (CHERP) at the Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia, PA, USA
| | | | - Barbara Corn
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Dana Kaminstein
- The Center for Health Equity Research and Promotion (CHERP) at the Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia, PA, USA.,Organizational Dynamics, Liberal and Professional Studies, School of Arts & Sciences, University of Pennsylvania, Philadelphia, PA, USA
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Abstract
OBJECTIVES The use of more medicalised labels can increase both concern about illness and the desire for more invasive treatment. This study analyses the media's coverage of an Analysis article in The BMJ which generated a large amount of high-profile international media coverage. It aims to understand how to better communicate messages about low-risk cancers and overdiagnosis to the public. DESIGN Content analysis of media coverage. SETTING Media was identified by Isentia Media Portal, searched in Google News and cross-checked in Factiva and Proquest databases from August 2018. METHODS Media headlines, full text and open access public comments responding to the coverage on the article proposing to 'rename low-risk conditions currently labelled as cancer' were analysed to determine the main themes. RESULTS 45 original media articles and their associated public comments (n=167) were identified and included in the analysis. Overall, headlines focused on cancer generally and there was little mention of 'low-risk', 'overdiagnosis' or 'overtreatment'. The full text generally presented a more balanced view of the evidence and were supportive of the proposal, however, public responses tended to be more negative towards the idea of renaming low-risk cancers and indicated confusion. Comments seemed to focus on the headlines rather than the full article. CONCLUSIONS This study offers a novel insight into media coverage of the complex and counterintuitive problem of overdiagnosis. Continued deliberation on how to communicate similar topics to the public through the mainstream media is needed. Future work in the area of low-risk cancer communication should consider the powerful impact of people's previous experience with a cancer diagnosis and the criticism about being paternalistic and concealing the truth from patients.
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Affiliation(s)
- Brooke Nickel
- Wiser Healthcare, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Ray Moynihan
- Wiser Healthcare, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Alexandra Barratt
- Wiser Healthcare, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Juan P Brito
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Kirsten McCaffery
- Wiser Healthcare, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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14
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Shaffer VA, Scherer LD. Too Much Medicine: Behavioral Science Insights on Overutilization, Overdiagnosis, and Overtreatment in Health Care. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/2372732218786042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Overutilization—defined as the use of health care services for which the benefits do not outweigh the harms—has been identified as one of the leading contributors to the rising cost of health care in the United States. Although informational interventions designed to address overutilization have had a significant, but modest, impact on the rate of overutilization, they have not been sufficient to solve the problem. Also, various psychological mechanisms contribute to the desire for more medical tests and treatments. To effectively address overutilization, we need to better understand the psychological underpinnings of overuse in medicine. The article reviews recent findings from the behavioral science literature—including reliance on anecdotal evidence, test-related affect, the use of diagnostic labels, and medical maximizing tendencies—that lend insight into why patients sometimes seek, demand, or expect medical tests and treatments that are considered by experts to be low value.
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15
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Izadi S, Pachur T, Wheeler C, McGuire J, Waters EA. Spontaneous mental associations with the words "side effect": Implications for informed and shared decision making. PATIENT EDUCATION AND COUNSELING 2017; 100:1928-1933. [PMID: 28583721 PMCID: PMC5573624 DOI: 10.1016/j.pec.2017.05.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 04/17/2017] [Accepted: 05/21/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To gain insight into patients' medical decisions by exploring the content of laypeople's spontaneous mental associations with the term "side effect." METHODS An online cross-sectional survey asked 144 women aged 40-74, "What are the first three things you think of when you hear the words 'side effect?"' Data were analyzed using content analysis, chi-square, and Fisher's exact tests. RESULTS 17 codes emerged and were grouped into 4 themes and a Miscellaneous category: Health Problems (70.8% of participants), Decision-Relevant Evaluations (52.8%), Negative Affect (30.6%), Practical Considerations (18.1%) and Miscellaneous (9.7%). The 4 most frequently identified codes were: Risk (36.1%), Health Problems-Specific Symptoms (35.4%), Health Problems-General Terms (32.6%), and Negative Affect-Strong (19.4%). Code and theme frequencies were generally similar across demographic groups (ps>0.05). CONCLUSION The term "side effect" spontaneously elicited comments related to identifying health problems and expressing negative emotions. This might explain why the mere possibility of side effects triggers negative affect for people making medical decisions. Some respondents also mentioned decision-relevant evaluations and practical considerations in response to side effects. PRACTICE IMPLICATIONS Addressing commonly-held associations and acknowledging negative affects provoked by side effects are first steps healthcare providers can take towards improving informed and shared patient decision making.
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Affiliation(s)
- Sonya Izadi
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, USA
| | - Thorsten Pachur
- Center for Adaptive Behavior and Cognition, Max Planck Institute for Human Development, Berlin, Germany
| | - Courtney Wheeler
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, USA
| | - Jaclyn McGuire
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, USA
| | - Erika A Waters
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, USA.
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16
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A Systematic Approach to Discussing Active Surveillance with Patients with Low-risk Prostate Cancer. Eur Urol 2017; 71:866-871. [PMID: 28129893 DOI: 10.1016/j.eururo.2016.12.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 12/26/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Physicians report difficulty convincing patients with prostate cancer about the merits of active surveillance (AS); as a result, a majority of patients unnecessarily choose to undergo radical treatment. OBJECTIVE To develop and evaluate a systematic approach for physicians to counsel patients with low-risk prostate cancer to increase acceptance of AS. DESIGN, SETTING, AND PARTICIPANTS A systematic counseling approach was developed and piloted in one clinic. Then five surgeons participated in a 1-h training session in which they learned about the approach. A total of 1003 patients with Gleason 3+3 prostate cancer were included in the study. We compared AS rates for 761 patients who were counseled over a 24-mo period before the training intervention with AS rates for 242 patients who were counseled over a 12-mo period afterwards, controlling for temporal trends and case mix. INTERVENTION A systematic approach for communicating the merits of AS using appropriate framing techniques derived from principles studied by negotiation scholars. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The rate of AS acceptance by patients for management of low-risk prostate cancer. RESULTS AND LIMITATIONS In the pilot phase, 81 of 86 patients (94%) accepted AS after counseling by the physician who developed the counseling approach. In the subsequent study, the cohort for the training intervention comprised 1003 consecutive patients, 80% of whom met the Epstein criteria for very low-risk disease. The proportion of patients who selected AS increased from 69% before the training intervention to 81% afterwards. After adjusting for time trends and case mix, the rate of AS after the intervention was 9.1% higher (95% confidence interval -0.4% to 19.4%) than expected, a relative reduction of approximately 30% in the risk of unnecessary curative treatment. CONCLUSIONS A systematic approach to counseling can be taught to physicians in a 1-h lecture. We found evidence that even this minimal intervention can decrease overtreatment. Our novel approach offers a framework to help address cancer screening-related overtreatment that occurs across medicine. PATIENT SUMMARY In this study, we evaluated the impact of teaching physicians how to better communicate the benefits and risks of prostate cancer treatments on the willingness of patients to choose active surveillance. Decisions related to cancer are often guided by emotions and biases that lead most patients to seek radical treatment; however, we demonstrated that if discussions are framed differently, these biases can be overcome and more patients will choose active surveillance.
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Galizzi MM, Miraldo M, Stavropoulou C, van der Pol M. Doctor-patient differences in risk and time preferences: A field experiment. JOURNAL OF HEALTH ECONOMICS 2016; 50:171-182. [PMID: 27792903 DOI: 10.1016/j.jhealeco.2016.10.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Revised: 10/04/2016] [Accepted: 10/07/2016] [Indexed: 06/06/2023]
Abstract
We conduct a framed field experiment among patients and doctors to test whether the two groups have similar risk and time preferences. We elicit risk and time preferences using multiple price list tests and their adaptations to the healthcare context. Risk and time preferences are compared in terms of switching points in the tests and the structurally estimated behavioural parameters. We find that doctors and patients significantly differ in their time preferences: doctors discount future outcomes less heavily than patients. We find no evidence that doctors and patients systematically differ in their risk preferences in the healthcare domain.
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Affiliation(s)
- Matteo M Galizzi
- Department of Social Policy, Behavioural Research Lab, LSE Health, London School of Economics, Old 2.35 Old Building, Houghton Street, London WC2A 2AE, UK; École d'Économie de Paris, Hospinnomics, Paris School of Economics, Hôtel-Dieu, 1, Parvis de Notre-Dame, Bâtiment B1, 5° étage, 75004 Paris, France.
| | - Marisa Miraldo
- École d'Économie de Paris, Hospinnomics, Paris School of Economics, Hôtel-Dieu, 1, Parvis de Notre-Dame, Bâtiment B1, 5° étage, 75004 Paris, France; Management Group, Imperial College Business School, South Kensington Campus, London SW7 2AZ, UK.
| | - Charitini Stavropoulou
- School of Health Sciences, City, University of London, Northampton Square, London EC1V 0HB, UK.
| | - Marjon van der Pol
- Health Economics Research Unit, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK.
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18
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Blumenthal-Barby JS. Biases and Heuristics in Decision Making and Their Impact on Autonomy. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:5-15. [PMID: 27111357 DOI: 10.1080/15265161.2016.1159750] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Cognitive scientists have identified a wide range of biases and heuristics in human decision making over the past few decades. Only recently have bioethicists begun to think seriously about the implications of these findings for topics such as agency, autonomy, and consent. This article aims to provide an overview of biases and heuristics that have been identified and a framework in which to think comprehensively about the impact of them on the exercise of autonomous decision making. I analyze the impact that these biases and heuristics have on the following dimensions of autonomy: understanding, intentionality, absence of alienating or controlling influence, and match between formally autonomous preferences or decisions and actual choices or actions.
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19
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Bradford A, Shinn E. Incorporating Patient Perspectives and Priorities into Clinical Trial Design. Gynecol Oncol 2016; 140:191-2. [DOI: 10.1016/j.ygyno.2016.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Accepted: 01/11/2016] [Indexed: 10/22/2022]
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20
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Nickel B, Barratt A, Hersch J, Moynihan R, Irwig L, McCaffery K. How different terminology for ductal carcinoma in situ (DCIS) impacts women's concern and management preferences: A qualitative study. Breast 2015; 24:673-9. [PMID: 26376460 DOI: 10.1016/j.breast.2015.08.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 08/14/2015] [Accepted: 08/19/2015] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE There are increasing rates of mastectomy and bi-lateral mastectomy in women diagnosed with ductal carcinoma in situ (DCIS). To help women avoid decisions that lead to unnecessary aggressive treatments, there have been recent calls to remove the cancer terminology from descriptions of DCIS. We investigated how different proposed terminologies for DCIS affect women's perceived concern and management preferences. MATERIALS AND METHODS Qualitative study using semi-structured interviews with a community sample of 26 Australian women varying by education and cancer screening experience. Women responded to a hypothetical scenario using terminology with and without the cancer term to describe DCIS. RESULTS Among a sample of women with no experience of a DCIS diagnosis, a hypothetical scenario involving a diagnosis of DCIS elicited high concern regardless of the terminology used to describe it. Women generally exhibited stronger negative reactions when a cancer term was used to describe DCIS compared to a non-cancer term, and most preferred the diagnosis be given as a description of abnormal cells. Overall women expressed interest in watchful waiting for DCIS but displayed preferences for very frequent monitoring with this management approach. CONCLUSION Communicating a diagnosis of DCIS using terminology that does not include the cancer term was preferred by many women and may enable discussions about more conservative management options. However, women's preference for frequent monitoring during watchful waiting suggests women need more education and reassurance about this management approach.
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Affiliation(s)
- Brooke Nickel
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, NSW 2006, Australia; Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, NSW 2006, Australia
| | - Alexandra Barratt
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, NSW 2006, Australia; Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, NSW 2006, Australia
| | - Jolyn Hersch
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, NSW 2006, Australia; Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, NSW 2006, Australia
| | - Ray Moynihan
- Faculty of Health Sciences and Medicine, Bond University, QLD 4229, Australia
| | - Les Irwig
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, NSW 2006, Australia
| | - Kirsten McCaffery
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, NSW 2006, Australia; Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, NSW 2006, Australia.
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21
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Ehdaie B. Words of Wisdom. Re: Perceptions of Active Surveillance and Treatment Recommendations for Low-risk Prostate Cancer: Results from a National Survey of Radiation Oncologists and Urologists. Eur Urol 2015; 67:1188-9. [PMID: 25944036 DOI: 10.1016/j.eururo.2015.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Behfar Ehdaie
- Department of Surgery, Urology Service, Department of Biostatistics and Epidemiology, Health Outcomes Group, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Blumenthal-Barby JS, Krieger H. Cognitive biases and heuristics in medical decision making: a critical review using a systematic search strategy. Med Decis Making 2014; 35:539-57. [PMID: 25145577 DOI: 10.1177/0272989x14547740] [Citation(s) in RCA: 288] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 07/26/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND The role of cognitive biases and heuristics in medical decision making is of growing interest. The purpose of this study was to determine whether studies on cognitive biases and heuristics in medical decision making are based on actual or hypothetical decisions and are conducted with populations that are representative of those who typically make the medical decision; to categorize the types of cognitive biases and heuristics found and whether they are found in patients or in medical personnel; and to critically review the studies based on standard methodological quality criteria. METHOD Data sources were original, peer-reviewed, empirical studies on cognitive biases and heuristics in medical decision making found in Ovid Medline, PsycINFO, and the CINAHL databases published in 1980-2013. Predefined exclusion criteria were used to identify 213 studies. During data extraction, information was collected on type of bias or heuristic studied, respondent population, decision type, study type (actual or hypothetical), study method, and study conclusion. RESULTS Of the 213 studies analyzed, 164 (77%) were based on hypothetical vignettes, and 175 (82%) were conducted with representative populations. Nineteen types of cognitive biases and heuristics were found. Only 34% of studies (n = 73) investigated medical personnel, and 68% (n = 145) confirmed the presence of a bias or heuristic. Each methodological quality criterion was satisfied by more than 50% of the studies, except for sample size and validated instruments/questions. Limitations are that existing terms were used to inform search terms, and study inclusion criteria focused strictly on decision making. CONCLUSIONS Most of the studies on biases and heuristics in medical decision making are based on hypothetical vignettes, raising concerns about applicability of these findings to actual decision making. Biases and heuristics have been underinvestigated in medical personnel compared with patients.
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Affiliation(s)
- J S Blumenthal-Barby
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX (JSBB)
| | - Heather Krieger
- Department of Social Psychology, University of Houston, Houston, TX (HK)
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Weernink MGM, Janus SIM, van Til JA, Raisch DW, van Manen JG, IJzerman MJ. A Systematic Review to Identify the Use of Preference Elicitation Methods in Healthcare Decision Making. Pharmaceut Med 2014. [DOI: 10.1007/s40290-014-0059-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Meertens RM, Van de Gaar VMJ, Spronken M, de Vries NK. Prevention praised, cure preferred: results of between-subjects experimental studies comparing (monetary) appreciation for preventive and curative interventions. BMC Med Inform Decis Mak 2013; 13:136. [PMID: 24344779 PMCID: PMC3878324 DOI: 10.1186/1472-6947-13-136] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Accepted: 12/04/2013] [Indexed: 12/02/2022] Open
Abstract
Background 'An ounce of prevention is worth a pound of cure’ is a common saying, and indeed, most health economic studies conclude that people are more willing to pay for preventive measures than for treatment activities. This may be because most health economic studies ask respondents to compare preventive measures with treatment, and thus prompt respondents to consider other uses of resources. However, psychological theorizing suggests that, when methods do not challenge subjects to consider other uses of resources, curative treatment is favored over prevention. Could it be that while prevention is praised, cure is preferred? Methods In two experimental studies, we investigated, from a psychological perspective and using a between-subjects design, whether prevention or treatment is preferred and why. In both studies, participants first read a lung cancer prevention or treatment intervention scenario that varied on the prevention-treatment dimension, but that were the same on factors like 'costs per saved life’ and kind of disease. Then participants completed a survey measuring appreciation (general and monetary) as well as a number of potential mediating variables. Results Both studies clearly demonstrated that, when the design was between-subjects, participants had greater (general and monetary) appreciation for treatment interventions than for preventive interventions with perceived urgency of the intervention quite consistently mediating this effect. Differences in appreciation of treatment over preventive treatment were shown to be .59 (Study 1) and .45 (Study 2) on a 5-point scale. Furthermore, participants thought that health insurance should compensate more for the treatment than for preventive measures, differences of 16% (Study 1), and 22% (Study 2). When participants were asked to directly compare both interventions on the basis of a short description, they preferred the preventive intervention. Conclusion It appears that people claim to prefer prevention when they are asked to consider other use of resources, but otherwise they prefer treatment. This preference is related to perceived urgency. The preference for treatment may be related to the prevention-treatment dimension itself, but also to variations on other dimensions that are inherently linked to prevention and treatment (like different efficacy rates and costs per treatment).
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Affiliation(s)
- Ree M Meertens
- Department of Health Education and Promotion, Maastricht University, P,O, Box 616, 6200, MD Maastricht, The Netherlands.
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Kutikov A, Egleston BL, Canter D, Smaldone MC, Wong YN, Uzzo RG. Competing risks of death in patients with localized renal cell carcinoma: a comorbidity based model. J Urol 2012; 188:2077-83. [PMID: 23083850 DOI: 10.1016/j.juro.2012.07.100] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE Multiple risks compete with cancer as the primary cause of death. These factors must be considered against the benefits of treatment. We constructed a model of competing causes of death to help contextualize treatment trade-off analyses in patients with localized renal cell carcinoma. MATERIALS AND METHODS We identified 6,655 individuals 66 years old or older with localized renal cell carcinoma in the linked SEER (Surveillance, Epidemiology and End Results)-Medicare data set for 1995 to 2005. We used Fine and Gray competing risks proportional hazards regression to predict probabilities of competing mortality outcomes. Prognostic markers included race, gender, tumor size, age and the Charlson comorbidity index score. RESULTS At a median followup of 43 months, age and comorbidity score strongly correlated with patient mortality and were most predictive of nonkidney cancer death, as measured by concordance statistics. Patients with localized, node negative kidney cancer had a low 3 (4.7%), 5 (7.5%) and 10-year (11.9%) probability of cancer specific death but a significantly higher overall risk of death from competing causes within 3 (10.9%), 5 (20.1%) and 10 years (44.4%) of renal cell carcinoma diagnosis, depending on comorbidity score. CONCLUSIONS Informed treatment decisions regarding patients with solid tumors must integrate not only cancer related variables but also factors that predict noncancer death. We established a comorbidity based predictive model that may assist in patient counseling by allowing quantification and comparison of competing risks of death in patients 66 years old or older with localized renal cell carcinoma who elect to proceed with surgery.
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Affiliation(s)
- Alexander Kutikov
- Department of Urological Oncology, Fox Chase Cancer Center, Temple University School of Medicine, Philadelphia, Pennsylvania 19111, USA
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Dale W, Hemmerich J, Moliski E, Schwarze ML, Tung A. Effect of specialty and recent experience on perioperative decision-making for abdominal aortic aneurysm repair. J Am Geriatr Soc 2012; 60:1889-94. [PMID: 23016733 DOI: 10.1111/j.1532-5415.2012.04157.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine whether recent experience and specialty choice would affect physician adherence to evidence-based guidelines. DESIGN In a series of computer-simulated encounters, participants weighed the risk of spontaneous abdominal aortic aneurysm (AAA) rupture against the risk of perioperative death to determine timing for elective repair. Guideline recommendations and statistical information on the risks of rupture and surgical death were provided. SETTING Annual meetings of the American Geriatrics Society, American College of Surgeons, and American Society of Anesthesiologists. PARTICIPANTS Physicians. INTERVENTION Before the simulation, each participant was randomly exposed to one of three simulated outcomes: death during watchful waiting (WWD), perioperative death (PD), or successful outcome (SO). MEASUREMENTS Adherence to recommended guidelines for AAA treatment. RESULTS Against guideline recommendations, 67% of geriatricians, 74% of anesthesiologists, and 77% of surgeons chose surgery when the rupture risk was lower than the risk of perioperative death (P < .05). Surgeons exposed to the WWD experience chose surgery significantly earlier than if they were exposed to a PD or SO experience (P < .001). Anesthesiologist choices did not differ with recent experience. CONCLUSION Geriatrician decisions more closely followed guideline recommendations for AAA management than those of two other specialties typically involved in AAA care. A prior WWD affected surgeons most, geriatricians next, and anesthesiologists least. Geriatricians referring patients for AAA surgery should be aware of specialty-specific differences in perioperative decision behavior.
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Affiliation(s)
- William Dale
- Section of Geriatrics and Palliative Medicine, Department of Medicine, University of Chicago, Chicago, IL 60637, USA
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Elmore JG, Fenton JJ. Ductal Carcinoma In Situ (DCIS): Raising Signposts on an Ill-Marked Treatment Path. J Natl Cancer Inst 2012; 104:569-71. [DOI: 10.1093/jnci/djs184] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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Charise A, Witteman H, Whyte S, Sutton EJ, Bender JL, Massimi M, Stephens L, Evans J, Logie C, Mirza RM, Elf M. Questioning context: a set of interdisciplinary questions for investigating contextual factors affecting health decision making. Health Expect 2011; 14:115-32. [PMID: 21029277 PMCID: PMC5060568 DOI: 10.1111/j.1369-7625.2010.00618.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To combine insights from multiple disciplines into a set of questions that can be used to investigate contextual factors affecting health decision making. BACKGROUND Decision-making processes and outcomes may be shaped by a range of non-medical or 'contextual' factors particular to an individual including social, economic, political, geographical and institutional conditions. Research concerning contextual factors occurs across many disciplines and theoretical domains, but few conceptual tools have attempted to integrate and translate this wide-ranging research for health decision-making purposes. METHODS To formulate this tool we employed an iterative, collaborative process of scenario development and question generation. Five hypothetical health decision-making scenarios (preventative, screening, curative, supportive and palliative) were developed and used to generate a set of exploratory questions that aim to highlight potential contextual factors across a range of health decisions. FINDINGS We present an exploratory tool consisting of questions organized into four thematic domains - Bodies, Technologies, Place and Work (BTPW) - articulating wide-ranging contextual factors relevant to health decision making. The BTPW tool encompasses health-related scholarship and research from a range of disciplines pertinent to health decision making, and identifies concrete points of intersection between its four thematic domains. Examples of the practical application of the questions are also provided. CONCLUSIONS These exploratory questions provide an interdisciplinary toolkit for identifying the complex contextual factors affecting decision making. The set of questions comprised by the BTPW tool may be applied wholly or partially in the context of clinical practice, policy development and health-related research.
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Affiliation(s)
- Andrea Charise
- Health Care, Technology and Place CIHR Strategic Training Program, University of Toronto, Toronto, Canada.
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Elmore JG, Ganschow PS, Geller BM. Communication between patients and providers and informed decision making. J Natl Cancer Inst Monogr 2011; 2010:204-9. [PMID: 20956831 DOI: 10.1093/jncimonographs/lgq038] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Women with ductal carcinoma in situ (DCIS) need to comprehend the meaning of the diagnosis and the potential benefits and harms of treatment options. Full and understandable information is a requirement, not an option. However, with DCIS, as with many areas of medicine, a high level of uncertainty about the disease remains. In this article, we define informed medical decision making, review challenges to its implementation, and provide suggestions on how to improve communication with women about the diagnosis and treatment of DCIS.
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Affiliation(s)
- Joann G Elmore
- Department of Medicine, School of Medicine, University of Washington, Seattle, WA 98104-2499, USA.
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Gavaruzzi T, Lotto L, Rumiati R, Fagerlin A. What Makes a Tumor Diagnosis a Call to Action? On the Preference for Action versus Inaction. Med Decis Making 2010; 31:237-44. [DOI: 10.1177/0272989x10377116] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. Many studies have shown an omission bias, but when the context is cancer, people seem to prefer active treatments to watchful waiting. Objective. First, to investigate whether the preference for active treatment for cancer could depend on the associations attached to the inaction option, and second, to explore the kind of diagnosis that gives rise to the preference for action, by comparing scenarios differing in the status of the illness (already present v. could arise in the future), the kind of diagnosis (malign tumor, benign tumor, or nontumor), and the possible development of the tumor (growth v. degeneration). Design. Between-subjects design with 8 hypothetical scenarios. Participants. A total of 735 students participated in an Internet survey. Measurements. Choice between watchful waiting and surgery, perceived severity of the diagnosis. Results. Active treatment was preferred only when the scenario described watchful waiting as excluding surgery in the future. The critical aspect for participants’ preference for active treatment was the malignancy of the tumor currently diagnosed. Perceived severity was also a significant predictor of treatment choice. Limitations. Inability to infer causation in the relationship between choice and perceived severity. Conclusions. Action is preferred to inaction when a malignant tumor is currently diagnosed and active treatments are not allowed in the future; under other conditions, participants prefer inaction (e.g., when active treatments are allowed in the future, or when the tumor is benign) or exhibit no preference (e.g., when it is not specified whether active treatments are allowed in the future).
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Affiliation(s)
- Teresa Gavaruzzi
- Department of Developmental Psychology and Socialization (DPSS), University of Padova, Italy (TG, LL, RR)
- Ann Arbor VA HSR&D Center for Practice Management and Outcome Research, Ann Arbor, Michigan (AF)
- Division of General Internal Medicine and Center for Behavioral and Decision Sciences in Medicine, University of Michigan, Ann Arbor, Michigan (AF)
| | - Lorella Lotto
- Department of Developmental Psychology and Socialization (DPSS), University of Padova, Italy (TG, LL, RR)
- Ann Arbor VA HSR&D Center for Practice Management and Outcome Research, Ann Arbor, Michigan (AF)
- Division of General Internal Medicine and Center for Behavioral and Decision Sciences in Medicine, University of Michigan, Ann Arbor, Michigan (AF)
| | - Rino Rumiati
- Department of Developmental Psychology and Socialization (DPSS), University of Padova, Italy (TG, LL, RR)
- Ann Arbor VA HSR&D Center for Practice Management and Outcome Research, Ann Arbor, Michigan (AF)
- Division of General Internal Medicine and Center for Behavioral and Decision Sciences in Medicine, University of Michigan, Ann Arbor, Michigan (AF)
| | - Angela Fagerlin
- Department of Developmental Psychology and Socialization (DPSS), University of Padova, Italy (TG, LL, RR)
- Ann Arbor VA HSR&D Center for Practice Management and Outcome Research, Ann Arbor, Michigan (AF)
- Division of General Internal Medicine and Center for Behavioral and Decision Sciences in Medicine, University of Michigan, Ann Arbor, Michigan (AF)
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Salz T, Brewer NT. Offering Chemotherapy and Hospice Jointly: One Solution to Hospice Underuse. Med Decis Making 2009; 29:521-31. [DOI: 10.1177/0272989x09333123] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose . Patients with advanced lung cancer typically receive chemotherapy at the cost of receiving care that may promote quality of life more effectively. The authors examined whether offering chemotherapy and hospice concurrently, a clinically appropriate but often unavailable option, might resolve this problem. Method. Adult smokers (N = 198) completed an Internet-based survey in which they imagined having advanced lung cancer. Participants rated the effectiveness of 4 treatments (supportive care alone, chemotherapy with supportive care, hospice, and chemotherapy with hospice) at achieving 4 goals of treatment (extending survival, controlling symptoms, avoiding side effects, and promoting quality of life at the end of life). Results. Reflecting utilization patterns of lung cancer patients, few respondents preferred supportive care alone (10%) or hospice (19%), and many preferred chemotherapy (29%). The most common choice was concurrent chemotherapy and hospice (42%). Treatments that involved chemotherapy were seen as the most effective at extending survival, whereas treatments that involved hospice were seen as most effective at promoting quality of life. Effectiveness ratings were weakly related to preferences for hospice, moderately related to preferences for chemotherapy with supportive care, and strongly related to preferences for chemotherapy and hospice together. Conclusions. These findings suggest that interest in hospice may be low because, offered without chemotherapy, hospice is perceived as ineffective at controlling symptoms and avoiding side effects. Chemotherapy and hospice together may be a preferred option for treating advanced lung cancer. Furthermore, preferences for chemotherapy and hospice together best reflect the values people placed on the goals of treatment.
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Affiliation(s)
- Talya Salz
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY,
| | - Noel T. Brewer
- Department of Health Behavior and Health Education, University of North Carolina, School of Public Health, Chapel Hill, NC
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Wang J, Kuo YF, Freeman J, Markowitz AB, Goodwin JS. Temporal trends and predictors of perioperative chemotherapy use in elderly patients with resected nonsmall cell lung cancer. Cancer 2008; 112:382-90. [PMID: 18041068 DOI: 10.1002/cncr.23181] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The authors assessed patterns of perioperative chemotherapy use in elderly patients with resected stage I, II, or IIIA nonsmall cell lung cancer (NSCLC) from 1992 to 2002. METHODS By using data from the Surveillance, Epidemiology, and End Results Program, 11,807 patients were identified who had resected stage I, II, or IIIA NSCLC between 1992 and 2002 and survived >or=120 days beyond diagnosis. The rate of perioperative chemotherapy use was measured by calendar year, and the association between clinical/demographic characteristics and the receipt of chemotherapy was examined by using logistic regression. RESULTS In total, 957 patients with stage I, II, or IIIA NSCLC (8.1% of the study population) received perioperative chemotherapy. The proportion of patients receiving chemotherapy for stage I NSCLC changed little during the study period. Of 3230 patients with stage II and IIIA NSCLC, 609 patients (18.9%) received chemotherapy, 423 patients (13%) received chemotherapy combined with radiation. 452 patients (15.6%) received adjuvant chemotherapy, and 66 patients (2.3%) received neoadjuvant chemotherapy. The use of chemotherapy increased significantly among patients who were diagnosed after 1994 relative to patients who were diagnosed in 1992 after controlling for sociodemographic and treatment characteristics (P< .001). There was significantly increased use of new-generation chemotherapy agents, such as carboplatin and taxanes (P< .001). The proportion of patients receiving combined-modality therapy also increased significant (P< .001). Younger age, being married, having advanced-stage tumor or adenocarcinoma, having a later diagnosis year, receiving radiation, and seeing an oncologist were predictors for the receipt of chemotherapy (P< .001). CONCLUSIONS A substantial proportion of Medicare beneficiaries with NSCLC received perioperative chemotherapy. Specifically designed prospective trials that focus on older patients are needed.
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Affiliation(s)
- Jue Wang
- Department of Internal Medicine, Section of Oncology-Hematology, University of Nebraska Medical Center, Omaha, Nebraska 68198-7680, USA.
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CARDEN CP, ROSENTHAL MA. Immediate versus delayed chemotherapy in patients with asymptomatic incurable metastatic cancer. Asia Pac J Clin Oncol 2007. [DOI: 10.1111/j.1743-7563.2007.00113.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hemmerich JA, Ghini EA, Schwarze ML, Dale W. Vivid bad outcome influences the decisions of older adults about treatment timing: a randomized field experiment with an abdominal aortic aneurysm analog. Transl Res 2007; 150:139-46. [PMID: 17761364 DOI: 10.1016/j.trsl.2007.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2007] [Revised: 04/20/2007] [Accepted: 04/25/2007] [Indexed: 11/20/2022]
Abstract
In balancing the risk of rupture from an asymptomatic abdominal aortic aneurysm (AAA) against the risk of perioperative mortality, data-based guidelines recommend surgical repair when the AAA diameter reaches 5.5 cm, whereas smaller AAAs should be followed with periodic surveillance. Previous work with vascular surgeon subjects and a computer-based AAA analog simulation showed that, even when constantly updated with the relevant statistics, experiencing a prior bad watchful waiting outcome shortened the time until they made the decision to operate. Using the same simulation, this field experiment enrolled healthy older volunteers (n = 107). Participants were randomly assigned to experience either a bad outcome demonstration with an expanding balloon that bursts (experimental) or an expanding, nonbursting balloon (control). Participants then made decisions about how many times to allow the balloon to expand before opting-out of the simulation. The main outcome measure was the amount of time participants continued watchful waiting before opting-out. A Cox-regression analysis assessed the likelihood of opting-out after each expansion while controlling for censoring and important covariates, including baseline anxiety, uncertainty attitudes, and risk preferences. The bad outcome demonstration group ended the simulation significantly earlier than did the control subjects (Hazard ratio: 1.98; 95% CI: 1.05-3.74). These results extend previous findings from vascular surgeons to older adults at higher risk for AAA. The preceding bad outcome influenced subsequent decisions, even when statistical risk information was readily available. The influence of recent experience on medical decision making by patients with life-threatening conditions may be under-appreciated.
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Affiliation(s)
- Joshua A Hemmerich
- Section of Geriatrics and Department of Decision Sciences, University of Chicago, Chicago, IL 60637, USA
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Abstract
A health policy decision often requires a balancing of risks, costs, and benefits. In this paper we illustrate that there is no uniform answer in the United States to the question of who decides the risk-benefit balance. We use a wide range of case examples from medicine and public health to show the different approaches that are used to allocate decision-making responsibility. Our ultimate purpose is to urge the U.S. health policy community to develop a more consistent way of thinking about how risk-benefit decisions could be guided by general principles.
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Affiliation(s)
- John Graham
- Frederick S. Pardee RAND Graduate School, Santa Monica, California, USA.
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Volk ML, Marrero JA, Lok AS, Ubel PA. Who decides? Living donor liver transplantation for advanced hepatocellular carcinoma. Transplantation 2007; 82:1136-9. [PMID: 17102762 DOI: 10.1097/01.tp.0000245670.75583.3d] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Few effective treatment options are available for patients with advanced hepatocellular carcinoma (HCC). Some transplant centers have begun offering living donor liver transplantation (LDLT) for selected patients whose HCC exceeds Milan criteria by a small margin. However, this remains a controversial subject. In this article, we weigh the arguments for and against LDLT for advanced HCC. Because donor autonomy forms the crux of this dilemma, the real question becomes: to whom does the decision belong, the individual donors or the medical community? We argue that donor autonomy should not be paramount in settings where the recipient benefit is uncertain.
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Affiliation(s)
- Michael L Volk
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI 48109-0362, USA.
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Iglseder S. [Palliative chemotherapy and CUP-syndrome: medical intentions versus patients' attitudes in decision making]. Wien Med Wochenschr 2006; 156:283-7. [PMID: 16830247 DOI: 10.1007/s10354-006-0290-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2006] [Accepted: 03/08/2006] [Indexed: 11/28/2022]
Abstract
The following case report is about a 55 year old male patient with CUP-syndrome. After developing a malignant bowel obstruction he received five cycles of a palliative chemotherapy with oxaliplatin and irinotecan. The focus is on medical intentions and goals concerning palliative chemotherapy and on discussing patients' attitudes towards chemotherapy. Communication is identified as fundamental skill in shared decision making. On the one hand it improves Patients' satisfaction and palliative care and on the other hand it reduces psychological and existential suffering. In tumors of unknown primary site regimens with different combinations of Platin, Taxol, Etoposide, Irinotecan and Gemcitabine showed responses up to 46% and a survival benefit with an overall median survival up to 12 months and even long term survival.
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Affiliation(s)
- Stephan Iglseder
- Palliativstation, Krankenhaus der Elisabethinen, Linz, Osterreich.
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