Cancer care 'rated more highly' if patients can share decisions

Last updated: 14 February 2015 at 12am PST

Decision-making controlled by doctors leads to poorer ratings from cancer patients on the quality of their care and physician communication, a survey reveals. It shows that reaching decisions in a shared way with patients is important even for those patients who prefer their doctors to take the control.

Doctors do not always know best, the study suggests, and - especially for cancer - need to involve patients in decisions.

Dr. Nancy Keating, from Harvard Medical School in Boston, MA, worked with her co-authors on survey results from patients diagnosed with lung or colorectal cancer. The study analyzed responses from 5,315 patients about the decision-making roles behind 10,817 treatment decisions.
All the patients' answers were drawn from a large study known as CanCORS, and Dr. Keating's analysis was designed to assess the relationship between how patients play a role in decisions and how they report the quality of their care and rate their physician's communication.
Most patients, 58%, expressed a preference for a shared approach between themselves and their doctor when it came to decisions about treatments. The patients reported, however, that less than half, 44%, of decisions were shared, and that 17% were controlled by physicians.
The quality of care was rated as "excellent" by:

• Just under 70% of the patients who said they shared the decision-making
• Less than 60% of the patients who said they had treatment decisions made for them.

In contrast to responses varying by styles of decision-making actually received, the proportion giving the highest rating did not vary by the style that patients preferred.
The excellent rating hovered around the 67-68% mark regardless of whether patients preferred to lead decisions, share them, or have them controlled by their doctors.
So even if patients preferred their doctors to control decisions, they reported less satisfaction with the quality of care if decisions were in fact controlled in this way.
A similar relationship was seen for ratings of communication given for physicians by patients. The highest rating was given by just under 60% of patients overall, but patients were less likely to give it if they experienced physician-controlled rather than shared decisions:

• 58% described physician communication as excellent when decisions were shared
• 44% said it was excellent when physicians controlled the decision-making.

The study authors conclude that even patients' expressed preferences should not lead to decision-making processes being controlled by physicians, and that a shared approach is important for patients' experiences of quality care. The paper's conclusion reads:

"Given the increasing emphasis on patient experiences and ratings in health care, these results highlight the benefits of promoting shared decision-making among all patients with cancer, even those who express preferences for less active roles."

'Not all cancer care' fits one style of decision-making

The data for this analysis led by Dr. Keating came from the CanCORS (Cancer Care Outcomes Research and Surveillance Consortium) study, a large population-based survey of lung or colorectal cancer patients between 2003 and 2005. The results on the effect of decision-making have been published online by JAMA Oncology.
The survey responses about cancer care decision-making regarded surgery (42%), chemotherapy (36%) and radiation therapy (22%).
A commentary article about the study in the same journal issue says it adds "critical evidence" toward "individualizing the approach to decision-making in an evidence-based fashion." But the commentary does not accept the value of shared decision-making, or SDM, outright.
Written by bioethicist Sarah Hawley, PhD, and radiation oncologist Dr. Reshma Jagsi - both experts in cancer patient preferences and decision-making - the commentary says "shared decision-making is a key element of high-quality care, but this does not mean that 'one size fits all.'"
Drs. Hawley and Jagsi conclude:

"While the important study [...] confirms that most patients want a voice in their care, we believe that there remains much need to improve our understanding so that physicians may tailor treatment discussions to the different types of patients they encounter."

Shared decision-making has been identified, particularly within the field of oncology, as a "key element in patient-centered care," says the commentary, adding that SDM has been associated with better patient knowledge about treatment options and improved satisfaction with care.
Questions remain though, it says, about how this approach impacts on patients who vary by:

• Type of cancer diagnosis
• Socio-demographic characteristics, and
• Preferences for involvement in decision-making.

Using evidence such as revealed in the survey will improve doctors' ability to "individualize" decision-making approaches and "allow us to maximize the respect we accord to the patients in our care."
Written by Markus MacGill