Challenges in Shared Medical Decision Making: An Oncologist's Perspective
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Transcript of Challenges in Shared Medical Decision Making: An Oncologist's Perspective
Challenges in shared medical decision making:
an oncologist’s perspective
Wendy Y. Chen, MD MPH
Breast cancer statistics - 2012
• 226,879 invasive breast cancer cases • 39, 510 breast cancer deaths
– Prostate cancer: 241,740 cases + 28,170 deaths
=>2,971,610 breast cancer survivors
Siegel, CA Cancer J Clin 2012
Breast Cancer Decision Aids
1. Ductal carcinoma in situ
2. Early stage: local treatments
3. Early stage: systemic therapy
4. Breast reconstruction
5. Metastatic breast cancer
Standardization Personalization
Challenges to decision aids
Standardization
• National Comprehensive Cancer Network (NCCN) guidelines
• Quality Oncology Practice Initiative– Part of ABIM recertfication process for Oncology
Breast QOPI module measures
• Chemotherapy recommended within 4 mths of diagnosis for Stage I (T1c) – III ER negative breast cancer
• Trastuzumab recommended for Stage I (T1c) - III Her2+ breast cancer
• Hormonal Rx recommended within 1 yr of diagnosis for patient with ER+ breast cancer
Breast cancer treatment trend - Personalization
• Old theory– Stage major determinant of aggressiveness
of treatment• More advanced stage => more chemotherapy
• New theory– Stage still important, but underlying biology
of tumor may be equally important• Makes standardization difficult
Oncotypedx
Available for ER positive tumors and mainly node negative
Chemo benefit as function of OncotypeDX score
Paik S,JCO 2006
Heuristics in oncology
• Frameworks people use for decision making• Risk aversion
– Preference for smaller certain gain over larger but more uncertain one
=> Patients focus on recurrence
• Anticipated regret– Prospect of regret over omitting therapy if
recurrence were to occurÞ If remains cancer free, benefit ascribed to treatment Þ If cancer recurs, blame ascribed to omitting therapy
Katz & Morrow, JAMA 2012
Shared Decision Making in Oncology
Preference sensitivity – early stage breast cancer
Yes No Maybe
Mastectomy vs lumpectomy + radiation
Radiation after lumpectomy
Hormonal therapy for ER positive tumors
Adjuvant chemotherapy for early stage breast cancer
Shared Decision Making in Oncology
Preference sensitivity – early stage breast cancer
Yes No Maybe
Mastectomy vs lumpectomy + radiation
Radiation after lumpectomy
Hormonal therapy for ER positive tumors
Adjuvant chemotherapy for early stage breast cancer
Shared Decision Making in Oncology
• Mastectomy vs lumpectomy + RT– No difference in overall survival
• Radiation after lumpectomy– Often cited for quality of care/benchmarking => No survival benefit for older pts with early ER+ cancer
• Hormonal therapy for ER+ breast cancer– Often cited for quality of care/benchmarking=> Unclear survival benefit for older pts with early stage ER+
cancer and comorbidities• Adjuvant chemotherapy for early stage breast cancer
– Relative benefit fixed, but absolute benefits vary
Standardization Personalization
Challenges to decision aids
Breast Cancer Decision Aids
1. Ductal carcinoma in situ
2. Early stage: local treatments
3. Early stage: systemic therapy
4. Breast reconstruction
5. Metastatic breast cancer