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 toxic one.
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," she said.
"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."