Physicians need to find more effective ways to determine their
patients' preferences about cancer treatment, according to an
editorial in the November 7, 1994 issue of the Journal of the
National Cancer Institute.
"Patient preferences about treatment vary widely, regardless
of age, and we need to learn how to better elicit them,"
said Jane C. Weeks, MD, MSC, of the Division of Cancer Epidemiology
and Control at Dana-Farber Cancer Institute, author of the editorial.
Dr. Weeks has devoted considerable time to studying patterns of
care and the process of decision-making in oncology. Recent studies
of national data bases have found some unsettling differences
in care on the basis of nonmedical issues, such as geography,
insurance status, and age. For instance, older patients tend to
receive less aggressive care than younger ones, but it has been
unclear whether this reflects their own preferences or age discrimination.
Dr. Weeks' editorial accompanies a paper by Suzanne B. Yellen,
PHD, of Rush Cancer Institute, entitled "Age and Clinical
Decision-Making in Oncology Patients." The Yellen study sought
to determine how age influenced treatment choices and tradeoffs.
Investigators asked 248 cancer patients of all ages to make hypothetical
decisions about treatment after reading two sets of vignettes.
The first set was designed to determine whether age influences
patients' acceptance of cancer therapy. The second gauged patients'
willingness to trade quality of life for increased survival. The
researchers found that elderly patients were as willing to choose
chemotherapy as younger patients, but they required a greater
survival advantage before choosing a toxic regimen over a less
The study showed something else. According to Dr. Weeks, "Perhaps
the most striking feature of the data presented by Yellen et al
is not the differences in preferences across age groups, but the
wide variability in preferences within age groups." This
variation springs from highly personalized views on what is valuable
in life, and what sacrifices someone is willing to make in exchange
for achieving a goal. It cannot be intuitively determined from
someone's age alone.
The challenge for oncologists is to present medical information
while eliciting treatment and tradeoff preferences from a patient--no
easy task, especially in an era of managed care, when physicians
are under pressure to see more patients in less time. "We
need to find new tools to help us solicit patient values,"
stated Dr. Weeks. For instance, a patient preference survey could
help guide physicians and patients through a decision-making process.
"Given time pressure nowadays, we can't necessarily rely
on the old approaches to physician/patient communication any more,"
"This whole area needs more research," Dr. Weeks writes.
In the meantime, she advises physicians to ask about patient values.
"This study shows that if you don't ask, you won't know."