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Gillman AS, Ferrer RA. Opportunities for theory-informed decision science in cancer control. Transl Behav Med 2021; 11:2055-2064. [PMID: 34850928 DOI: 10.1093/tbm/ibab141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Cancer prevention and control involves navigation of complex clinical decisions, often laden with uncertainty and/or intricate interpersonal dynamics, which have implications for both physical health and quality of life. Cancer decision-making research in recent decades has primarily focused on working to improve the quality of decisions by providing patients with detailed information about their choices and through an increased emphasis in medicine on the importance of shared decision making. This emphasis is reflective of a model of decision making that emphasizes knowledge, options, and deliberative synthesis of information as primary to decision making; yet, decades of research in psychology, decision science, and behavioral economics have taught us that our decisions are not influenced only by our objective knowledge of facts, but by our emotions, by the influence of others, and by biased cognitive processes. We present a conceptual framework for a future of research in decision science and cancer that is informed by decision science theories. Our framework incorporates greater recognition of the interpersonal dynamics of shared decision making, including the biases (including cognitive heuristics and race-based bias) that may affect multiple actors in the decision-making process, and emphasizes study of the interaction between deliberative and affective psychological processes as they relate to decision making. This work should be conducted with an eye toward informing efforts to improve decision making across the cancer care continuum, through interventions that are also informed by theory.
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Affiliation(s)
- Arielle S Gillman
- Basic Biobehavioral and Psychological Sciences Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD 20892-9761, USA
| | - Rebecca A Ferrer
- Basic Biobehavioral and Psychological Sciences Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD 20892-9761, USA
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2
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Lowe D, Ryan R, Schonfeld L, Merner B, Walsh L, Graham-Wisener L, Hill S. Effects of consumers and health providers working in partnership on health services planning, delivery and evaluation. Cochrane Database Syst Rev 2021; 9:CD013373. [PMID: 34523117 PMCID: PMC8440158 DOI: 10.1002/14651858.cd013373.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Health services have traditionally been developed to focus on specific diseases or medical specialties. Involving consumers as partners in planning, delivering and evaluating health services may lead to services that are person-centred and so better able to meet the needs of and provide care for individuals. Globally, governments recommend consumer involvement in healthcare decision-making at the systems level, as a strategy for promoting person-centred health services. However, the effects of this 'working in partnership' approach to healthcare decision-making are unclear. Working in partnership is defined here as collaborative relationships between at least one consumer and health provider, meeting jointly and regularly in formal group formats, to equally contribute to and collaborate on health service-related decision-making in real time. In this review, the terms 'consumer' and 'health provider' refer to partnership participants, and 'health service user' and 'health service provider' refer to trial participants. This review of effects of partnership interventions was undertaken concurrently with a Cochrane Qualitative Evidence Synthesis (QES) entitled Consumers and health providers working in partnership for the promotion of person-centred health services: a co-produced qualitative evidence synthesis. OBJECTIVES To assess the effects of consumers and health providers working in partnership, as an intervention to promote person-centred health services. SEARCH METHODS We searched the CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL databases from 2000 to April 2019; PROQUEST Dissertations and Theses Global from 2016 to April 2019; and grey literature and online trial registries from 2000 until September 2019. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs of 'working in partnership' interventions meeting these three criteria: both consumer and provider participants meet; they meet jointly and regularly in formal group formats; and they make actual decisions that relate to the person-centredness of health service(s). DATA COLLECTION AND ANALYSIS Two review authors independently screened most titles and abstracts. One review author screened a subset of titles and abstracts (i.e. those identified through clinical trials registries searches, those classified by the Cochrane RCT Classifier as unlikely to be an RCT, and those identified through other sources). Two review authors independently screened all full texts of potentially eligible articles for inclusion. In case of disagreement, they consulted a third review author to reach consensus. One review author extracted data and assessed risk of bias for all included studies and a second review author independently cross-checked all data and assessments. Any discrepancies were resolved by discussion, or by consulting a third review author to reach consensus. Meta-analysis was not possible due to the small number of included trials and their heterogeneity; we synthesised results descriptively by comparison and outcome. We reported the following outcomes in GRADE 'Summary of findings' tables: health service alterations; the degree to which changed service reflects health service user priorities; health service users' ratings of health service performance; health service users' health service utilisation patterns; resources associated with the decision-making process; resources associated with implementing decisions; and adverse events. MAIN RESULTS We included five trials (one RCT and four cluster-RCTs), with 16,257 health service users and more than 469 health service providers as trial participants. For two trials, the aims of the partnerships were to directly improve the person-centredness of health services (via health service planning, and discharge co-ordination). In the remaining trials, the aims were indirect (training first-year medical doctors on patient safety) or broader in focus (which could include person-centredness of health services that targeted the public/community, households or health service delivery to improve maternal and neonatal mortality). Three trials were conducted in high income-countries, one was in a middle-income country and one was in a low-income country. Two studies evaluated working in partnership interventions, compared to usual practice without partnership (Comparison 1); and three studies evaluated working in partnership as part of a multi-component intervention, compared to the same intervention without partnership (Comparison 2). No studies evaluated one form of working in partnership compared to another (Comparison 3). The effects of consumers and health providers working in partnership compared to usual practice without partnership are uncertain: only one of the two studies that assessed this comparison measured health service alteration outcomes, and data were not usable, as only intervention group data were reported. Additionally, none of the included studies evaluating this comparison measured the other primary or secondary outcomes we sought for the 'Summary of findings' table. We are also unsure about the effects of consumers and health providers working in partnership as part of a multi-component intervention compared to the same intervention without partnership. Very low-certainty evidence indicated there may be little or no difference on health service alterations or health service user health service performance ratings (two studies); or on health service user health service utilisation patterns and adverse events (one study each). No studies evaluating this comparison reported the degree to which health service alterations reflect health service user priorities, or resource use. Overall, our confidence in the findings about the effects of working in partnership interventions was very low due to indirectness, imprecision and publication bias, and serious concerns about risk of selection bias; performance bias, detection bias and reporting bias in most studies. AUTHORS' CONCLUSIONS The effects of consumers and providers working in partnership as an intervention, or as part of a multi-component intervention, are uncertain, due to a lack of high-quality evidence and/or due to a lack of studies. Further well-designed RCTs with a clear focus on assessing outcomes directly related to partnerships for patient-centred health services are needed in this area, which may also benefit from mixed-methods and qualitative research to build the evidence base.
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Affiliation(s)
- Dianne Lowe
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Rebecca Ryan
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Lina Schonfeld
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Bronwen Merner
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Louisa Walsh
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | | | - Sophie Hill
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
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Gillman AS, Vo JB, Nohria A, Ferrer RA. Decision Science Can Inform Clinical Trade-Offs Regarding Cardiotoxic Cancer Treatments. JNCI Cancer Spectr 2021; 5:pkab053. [PMID: 34350379 PMCID: PMC8328021 DOI: 10.1093/jncics/pkab053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 02/19/2021] [Accepted: 04/30/2021] [Indexed: 12/22/2022] Open
Abstract
Cancer treatment-related cardiotoxicity (ie, heart failure, coronary artery disease, vascular diseases, arrhythmia) is a growing cancer survivorship concern within oncology practice; heart disease is the leading cause of noncancer death in cancer survivors and surpasses cancer as the leading cause of death for some cancers with higher survival rates. The issue of cardiotoxicity introduces a critical tradeoff that must be acknowledged and reconciled in clinical oncology practice: treating cancer aggressively and effectively in the present vs preventing future cardiotoxicity. Although many cancers must be treated as aggressively as possible, for others, multiple treatment options are available. Yet even when effective and less cardiotoxic treatments are available, they are not always chosen. Wariness to choose equally effective but less cardiotoxic treatment options may result in part from providers' and patients' reliance on "cognitive heuristics," or mental shortcuts that people (including, research shows, medical professionals) use to simplify complex judgments. These heuristics include delay discounting, availability and affect heuristics, and default bias. In the current commentary, we describe relevant research that illuminates how use of heuristics leads to biased medical decision making and translate how this research may apply when the tradeoff between aggressive cancer treatment and preventing future cardiotoxicity is considered. We discuss the implications of these biases in oncology practice, offer potential solutions to reduce bias, and call for future research in this area.
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Affiliation(s)
- Arielle S Gillman
- Division of Cancer Control and Population Sciences, Cancer Prevention Fellowship Program, Basic Biobehavioral and Psychological Sciences Branch, Behavioral Research Program, National Cancer Institute, Bethesda, MD, USA
| | - Jacqueline B Vo
- Division of Cancer Epidemiology and Genetics, Cancer Prevention Fellowship Program, Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA
| | - Anju Nohria
- Cardio-Oncology Program, Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Boston, MA, USA
| | - Rebecca A Ferrer
- Division of Cancer Control and Population Sciences, Basic Biobehavioral and Psychological Sciences Branch, Behavioral Research Program, National Cancer Institute, Bethesda, MD, USA
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Lau-Min KS, Guerra CE, Nathanson KL, Bekelman JE. From Race-Based to Precision Oncology: Leveraging Behavioral Economics and the Electronic Health Record to Advance Health Equity in Cancer Care. JCO Precis Oncol 2021; 5:PO.20.00418. [PMID: 34250405 DOI: 10.1200/po.20.00418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/03/2021] [Accepted: 01/20/2021] [Indexed: 12/23/2022] Open
Affiliation(s)
- Kelsey S Lau-Min
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Carmen E Guerra
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA.,Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Katherine L Nathanson
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA.,Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Justin E Bekelman
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA.,Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Gillespie EF, Tringale KR, Bach PB, Bekelman JE. Evaluation of Use of Shorter Radiation Regimens for Breast and Prostate Cancer in the US, 2015-2017. JAMA Netw Open 2020; 3:e2010519. [PMID: 32672827 PMCID: PMC7366185 DOI: 10.1001/jamanetworkopen.2020.10519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This cross-sectional study examines the usage rates and trends of shorter vs longer radiation regimens for breast cancer and prostate cancer treatments in the US.
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Affiliation(s)
- Erin F. Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kathryn R. Tringale
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter B. Bach
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Justin E. Bekelman
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia
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6
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Ozdemir S, Finkelstein EA. Cognitive Bias: The Downside of Shared Decision Making. JCO Clin Cancer Inform 2019; 2:1-10. [PMID: 30652609 DOI: 10.1200/cci.18.00011] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
This narrative review presents theoretical and empirical evidence of common cognitive biases that are likely to influence treatment choices of patients with cancer and other illnesses. We present an overview of common cognitive biases that result from how and when information is presented to patients. We supplement these descriptions with cancer-specific examples or those from other health fields if no cancer-specific examples are available. The results provide compelling evidence that patient treatment choices are subconsciously influenced by both known and unknown biases. Shared decision making is ideal in theory, but in reality, it is fraught with risks resulting from cognitive biases and undue influence of even the best-intentioned physicians and family members. Efforts should be made to minimize these concerns and to help patients to make decisions that their future selves are least likely to regret.
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Affiliation(s)
- Semra Ozdemir
- All authors: Duke-NUS Medical School Singapore, Singapore
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7
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Kogan LG, Davis SL, Brooks GA. Treatment delays during FOLFOX chemotherapy in patients with colorectal cancer: a multicenter retrospective analysis. J Gastrointest Oncol 2019; 10:841-846. [PMID: 31602321 DOI: 10.21037/jgo.2019.07.03] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background FOLFOX (folinic acid, 5-fluorouracil and oxaliplatin) is the most commonly used chemotherapy regimen for the treatment of colorectal cancer. FOLFOX is administered in 14-day cycles, though toxicities frequently lead to unplanned delays. We report the incidence of unplanned delays among patients receiving FOLFOX and describe the reasons for delays. Methods We conducted a retrospective analysis of patients receiving FOLFOX chemotherapy for colorectal cancer. Patients were treated at one of two tertiary cancer centers between January 2012 and April 2016. Cycles 2-6 were assessed for delays, and treatments were considered delayed when the interval from prior treatment was >18 days. Reasons for unplanned delays were categorized based on review of clinical records. Results We identified 214 patients receiving FOLFOX as standard-of-care therapy. The median age was 59 years, and 55% were female. Of 961 evaluable treatment cycles, 124 (13%) had unplanned delays, and 92 of 214 patients (43%) had one or more unplanned delays in cycles 2-6. Cytopenias (neutropenia and/or thrombocytopenia) were the most common cause of unplanned delays, affecting 34% of patients and accounting for 74 of 124 unplanned delays (60%). Conclusions Delays are common during FOLFOX chemotherapy, with 43% of patients having at least one unplanned delay prior to completing cycle 6. Neutropenia and thrombocytopenia were the leading causes of unplanned delays. Our findings justify the development of systematic approaches for preventing unplanned delays, such as standardized laboratory treatment criteria and/or proactive dose adjustment strategies.
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Affiliation(s)
- Lawrence G Kogan
- Department of Medicine, Rhode Island Hospital, Providence, RI, USA
| | | | - Gabriel A Brooks
- Department of Medicine, Rhode Island Hospital, Providence, RI, USA.,Norris Cotton Cancer Center, Lebanon, NH, USA
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Sharma S, Guttmann D, Small DS, Rareshide CAL, Jones J, Patel MS, Bekelman JE. Effect of Introducing a Default Order in the Electronic Medical Record on Unnecessary Daily Imaging During Palliative Radiotherapy for Adults With Cancer: A Stepped-Wedge Cluster Randomized Clinical Trial. JAMA Oncol 2019; 5:1220-1222. [PMID: 31246224 DOI: 10.1001/jamaoncol.2019.1432] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Sonam Sharma
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York.,Penn Center for Cancer Care Innovation at the Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - David Guttmann
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Dylan S Small
- Penn Center for Cancer Care Innovation at the Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Penn Medicine Nudge Unit, Penn Medicine Center for Innovation, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Statistics, The Wharton School, University of Pennsylvania, Philadelphia
| | - Charles A L Rareshide
- Penn Medicine Nudge Unit, Penn Medicine Center for Innovation, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Joshua Jones
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Mitesh S Patel
- Penn Center for Cancer Care Innovation at the Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Penn Medicine Nudge Unit, Penn Medicine Center for Innovation, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia
| | - Justin E Bekelman
- Penn Center for Cancer Care Innovation at the Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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9
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O’Keeffe M, Traeger AC, Hoffmann T, Ferreira GE, Soon J, Maher C. Can nudge-interventions address health service overuse and underuse? Protocol for a systematic review. BMJ Open 2019; 9:e029540. [PMID: 31239308 PMCID: PMC6597741 DOI: 10.1136/bmjopen-2019-029540] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/15/2019] [Accepted: 05/24/2019] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Nudge-interventions aimed at health professionals are proposed to reduce the overuse and underuse of health services. However, little is known about their effectiveness at changing health professionals' behaviours in relation to overuse or underuse of tests or treatments. OBJECTIVE The aim of this study is to systematically identify and synthesise the studies that have assessed the effect of nudge-interventions aimed at health professionals on the overuse or underuse of health services. METHODS AND ANALYSIS We will perform a systematic review. All study designs that include a control comparison will be included. Any qualified health professional, across any specialty or setting, will be included. Only nudge-interventions aimed at altering the behaviour of health professionals will be included. We will examine the effect of choice architecture nudges (default options, active choice, framing effects, order effects) and social nudges (accountable justification and pre-commitment or publicly declared pledge/contract). Studies with outcomes relevant to overuse or underuse of health services will be included. Relevant studies will be identified by a computer-aided search of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, CINAHL, Embase and PsycINFO databases. Two independent reviewers will screen studies for eligibility, extract data and perform the risk of bias assessment using the criteria recommended by the Cochrane Effective Practice and Organisation of Care (EPOC) group. We will report our results in a structured synthesis format, as recommended by the Cochrane EPOC group. ETHICS AND DISSEMINATION No ethical approval is required for this study. Results will be presented at relevant scientific conferences and in peer-reviewed literature.
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Affiliation(s)
- Mary O’Keeffe
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Adrian C Traeger
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Giovanni Esteves Ferreira
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jason Soon
- Royal Australasian College of Physicians, Sydney, New South Wales, Australia
| | - Christopher Maher
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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10
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Ojerholm E, Freedman GM, Bekelman JE. The Dollars and Sense of Hypofractionated Breast Radiation. J Natl Cancer Inst 2019; 109:3852223. [PMID: 29059429 DOI: 10.1093/jnci/djx090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 04/11/2017] [Indexed: 11/15/2022] Open
Affiliation(s)
- Eric Ojerholm
- Department of Radiation Oncology, Department of Medical Ethics and Health Policy, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Department of Radiation Oncology, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA
| | - Gary M Freedman
- Department of Radiation Oncology, Department of Medical Ethics and Health Policy, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Department of Radiation Oncology, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA
| | - Justin E Bekelman
- Department of Radiation Oncology, Department of Medical Ethics and Health Policy, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Department of Radiation Oncology, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA
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11
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Hamilton JG, Shuk E, Garzon MG, Rodríguez VM, Westerman J, Hay JL, Offit K, Robson ME. Decision-Making Preferences About Secondary Germline Findings That Arise From Tumor Genomic Profiling Among Patients With Advanced Cancers. JCO Precis Oncol 2017; 1. [PMID: 31938761 DOI: 10.1200/po.17.00182] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Purpose In patients with advanced cancers, tumor genomic profiling (TGP) can reveal secondary germline findings (SGFs) regarding inherited disease risks. This study examines the process by which patients with advanced cancers would make the decision about whether or not to learn these SGFs, and their preferences regarding specific challenging decision scenarios including whether patients should be required to receive SGFs and whether SGFs should be returned to family after a patient's death. Patients and Methods We conducted qualitative semi-structured interviews with 40 patients with advanced breast, bladder, colorectal, or lung cancer who had TGP. Data were collected regarding participants' perspectives about the hypothetical decision to learn their SGFs including their anticipated approach to the decision-making process, as well as their preferences about challenging decision scenarios. Data were evaluated using thematic content analysis. Results We identified themes regarding participants' preferred degree of decisional autonomy, perceived vital role of doctors, information needs, and anticipated process of deliberation. Although participants reported that this decision was ultimately their own, many wanted input from family and trusted others. Oncologists were expected to provide decision guidance and key clarifying information. Most participants stated that patients should be able to make a choice about receiving actionable SGFs, and a majority stated that SGFs should be available to family after a patient's death. Conclusion These results provide insight into SGFs decision-making processes of patients with advanced cancers, which can allow clinicians to provide patients optimal decision support in this context. Patients with advanced cancers have specific information needs and decision-making preferences that educational and communication interventions should address to ensure that patients make informed choices about learning SGFs.
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Affiliation(s)
- Jada G Hamilton
- Behavioral Sciences Service, Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY.,Department of Psychiatry, Weill Cornell Medical College, Cornell University, New York, NY.,Clinical Genetics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Elyse Shuk
- Behavioral Sciences Service, Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Margaux Genoff Garzon
- Behavioral Sciences Service, Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Vivian M Rodríguez
- Behavioral Sciences Service, Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Joy Westerman
- Behavioral Sciences Service, Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jennifer L Hay
- Behavioral Sciences Service, Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY.,Department of Psychiatry, Weill Cornell Medical College, Cornell University, New York, NY
| | - Kenneth Offit
- Clinical Genetics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.,Department of Medicine, Weill Cornell Medical College, Cornell University, New York, NY
| | - Mark E Robson
- Clinical Genetics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.,Department of Medicine, Weill Cornell Medical College, Cornell University, New York, NY
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12
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Arnold DR. Countervailing incentives in value-based payment. Healthcare (Basel) 2017; 5:125-128. [DOI: 10.1016/j.hjdsi.2016.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 04/27/2016] [Accepted: 04/28/2016] [Indexed: 10/21/2022] Open
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Initiative to reduce bone scans for low-risk prostate cancer patients: A quasi-experimental before-and-after study in a Veterans Affairs hospital. Adv Radiat Oncol 2017; 2:416-419. [PMID: 29114610 PMCID: PMC5605298 DOI: 10.1016/j.adro.2017.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 07/07/2017] [Indexed: 11/26/2022] Open
Abstract
Purpose Bone scans (BS) are a low-value test for asymptomatic men with low-risk prostate cancer. We performed a quality improvement intervention aimed at reducing BS for these patients. Methods and materials The intervention was a presentation that leveraged the behavioral science concepts of social comparison and normative appeals. Participants were multidisciplinary stakeholders from the Radiation Oncology and Urology services at a Veterans Affairs hospital. We determined the baseline rate of BS by retrospectively analyzing cases of asymptomatic men with newly diagnosed low-risk prostate cancer. For social comparison, we presented contemporary peer BS rates in the United States—including Veterans Affairs hospitals. For normative appeals, we reviewed guidelines from various professional groups. To analyze the effect of this intervention, we performed a quasi-experimental, uncontrolled, before-and-after study. Results During the 1-year period before the intervention, 32 of 37 patients with low-risk prostate cancer (86.5%) received a BS. The contemporary peer rate was approximately 30%. All reviewed guidelines recommended against BS. During the 1-year period after the intervention, the rate of BS was reduced to 65.5% (19 of 29 patients; P = .043 by one-sided Fisher's exact test). Conclusions We observed a modest reduction in guideline-discordant BS after the quality improvement intervention. BS rates might be influenced by initiatives that combine social comparisons with appeals to professional norms.
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Waldeck AR, Botteman MF, White RE, van Hout BA. The Importance of Economic Perspective and Quantitative Approaches in Oncology Value Frameworks of Drug Selection and Shared Decision Making. J Manag Care Spec Pharm 2017; 23:S6-S12. [PMID: 28535105 PMCID: PMC10408393 DOI: 10.18553/jmcp.2017.23.6-a.s6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED The debate around value in oncology drug selection has been prominent in recent years, and several professional bodies have furthered this debate by advocating for so-called value frameworks. Herein, we provide a viewpoint on these value frameworks, emphasizing the need to consider 4 key aspects: (1) the economic underpinnings of value; (2) the importance of the perspective adopted in the valuation; (3) the importance of the difference between absolute and relative measures of risk and measuring patient preferences; and (4) the recognition of multiple quality-of-life (QoL) domains, and the aggregation and valuation of those domains, through utilities within a multicriteria decision analysis, may allow prioritization of QoL above the tallying of safety events, particularly in a value framework focusing on the individual patient. While several frameworks exist, they incorporate different attributes and-importantly-assess value from alternative perspectives, including those of patients, regulators, payers, and society. The various perspectives necessarily lead to potentially different, if not sometimes divergent, conclusions about the valuation. We show that the perspective of the valuation affects the framing of the risk/benefit question and the methodology to measure the individual patient choice, or preference, as opposed to the collective, or population, choice. We focus specifically on the American Society of Clinical Oncology (ASCO) Value Framework. We argue that its laudable intent to assist in shared clinician-patient decision making can be augmented by more formally adopting methodology underpinned by micro- and health economic concepts, as well as application of formal quantitative approaches. Our recommendations for value frameworks focusing on the individual patient, such as the ASCO Value Framework, are 3-fold: (1) ensure that stakeholders understand the importance of the adopted (economic) perspective; (2) consider using exclusively absolute measures of risk and formal patient-preference methodology; and (3) consider foregoing safety parameters for higher-order utility considerations. DISCLOSURES No funding was received for conceptualizing, writing, and/or editing this manuscript. Waldeck and White are employees of, and received stock option grants from, Celldex Therapeutics. Van Hout and Botteman are employees and shareholders of Pharmerit International. Pharmerit International is a research contractor for Celldex. All authors have retained editorial control of the content of the manuscript. Conceptualization of this viewpoint article was contributed primarily by Waldeck, along with Botteman, White, and van Hout. Data analysis and revision of the manuscript was contributed equally by all the authors. The manuscript was written by Waldeck, Botteman, van Hout, and White.
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