Are Oncology Patients -- But Not Docs -- Using Decision Aids?

Nick Mulcahy

September 01, 2010

September 1, 2010 —The use of decision aids by physicians caring for cancer patients is "low", say the authors of a Canadian study.

Only 24% of general surgeons, medical oncologists, and radiation oncologists in Ontario report using the aids, which are information guides that help patients make choices about cancer treatment.

The study, based on a survey of clinicians, was published in the May issue of the Journal of Clinical Oncology (2010;28:2286-2292).

However, in a letter published online August 30 in the journal, a German researcher raises an interesting possibility: that patients might be using decision aids at higher rates.

In other words, patients might be adapting this clinical tool more widely than the doctors who care for them.

Dirk Vordermark, MD, from the Martin Luther University Halle-Wittenberg in Germany, reports that a 2008 survey of German patients undergoing radiotherapy for cancer found that 41% of the patients had obtained information about their disease or its treatment on the Internet (Radiat Oncol. 2009;4:40).

Although the German survey did not indicate if the patients used decision aids specifically, Dr. Vordermark suggests that such use is a strong possibility.

"One could speculate that the actual use of decision aids by patients with cancer may be much higher" than that of physicians in the study from Canada, he writes.

However, do not expect patients to tell you, the clinician, what they are up to, says Dr. Vordermark.

The 2008 German survey indicated that only about one third of patients (39%) informed their clinician about their Internet explorations.

Both Dr. Vordermark and the Canadian authors, who are led by Chantalle Brace, MD, from the University Health Network–Toronto General Hospital in Ontario, are champions of decision aids.

However, the Canadian study found that most clinicians are largely uninformed about these tools — 70% of the survey respondents indicated that lack of awareness was the main barrier to the use of decision aids.

This might change; the influential American Cancer Society (ACS) recently gave what amounted to a high-profile endorsement of the aids, although the context was not treatment-related.

As reported by Medscape Medical News, the most dramatic change in the ACS's recently revised prostate cancer screening guideline revolved around mandated "informed decision-making" with men considering undergoing the screening. The society specifically recommended decision aids to help clinicians sufficiently inform patients.

"The American Cancer Society guideline strongly advocates the use of decision aids," said the lead author of the guideline.

More Extensively Evaluated

Decision aids are especially important in oncology because of the need to have patients understand the balance between the benefits and harms of treatment, suggest the Canadian authors.

"In many cases, there is an inherent trade-off between oncologic outcome (i.e., survival, local recurrence) and quality of life and functional outcomes," they write. "Under these circumstances, communication between the patient and physician is essential to guide treatment decision making to select the treatment that is most consistent with the patient's values and lifestyle."

There are many strategies, including patient videos and patient coaching, that can be used in the pursuit of enhanced doctor–patient communication, but decision aids are the "most extensively developed and evaluated," write the study authors.

Decision aids for cancer treatment have been shown to affect clinical practice. In various studies, they have significantly reduced "the rate of mastectomy (relative to lumpectomy), the use of adjuvant chemotherapy for breast cancer, and the use of radical prostatectomy (relative to hormonal treatment) for prostate cancer, and did not show any significant differences in anxiety or depression," the authors write.

Medical Oncologists More Likely Users

To evaluate the understanding and use of decision aids in cancer practice, the Canadian survey was mailed to 878 physicians. The overall response rate to the survey was 64.5%, which the authors called "relatively high for surveys of physicians." Of the responses, 477 surveys were complete and used in the analysis.

Overall, 69% of the respondents were aware of decision aids, and 46% said that they were aware of decision aids relevant to their practice. However, only 24% were currently using decision aids.

The main reasons for not using them were reported as lack of awareness, lack of resources, and lack of time.

"Strategies to improve physician awareness about how to find, use, and evaluate [decision aids] in their clinical practice are important and will likely require physician advocates and opinion leaders to endorse their use for cancer treatment," the authors say, offering a prescription for change.

Notably, a multivariate analysis showed specialty to be the only physician characteristic influencing the use of decision aids.

Medical oncologists were twice as likely to use decision aids as general surgeons with practices where less than 50% of patients have cancer (< .001). Medical oncologists were also more likely to use decision aids than radiation oncologists, but this difference was not statistically significant.

The authors have disclosed no relevant financial relationships.

J Clin Oncol. Published online August 30, 2010.


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