Assumptions About Patient Desires Can Be Unjustified

The notion that “survival is survival” was challenged by a recent study by Dr Doctor and colleagues, published in the Journal of Clinical Epidemiology.1 Sometimes patients prefer treatments that confer shorter survival times, on average, because of other considerations, the researchers found.

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“Most Americans value hopeful outcomes and are willing to take risks to achieve them when their survival prospects are bleak,” Dr Doctor explained. “Americans tend to want to avoid risky treatments when their overall survival prospects are good. Because context matters so much in valuing survival, it is important we take these factors into consideration.”

“Certainly, patients want to live longer and feel better,” he said. “But if there are reasons for living that they want to fulfill, they may be more likely to choose treatments that offer the greatest chance of achieving the PFS landmarks closest to their personal objectives.”

Some types and stages of cancer involve more “preference sensitive” decision-making than others, of course. Men with clinically-localized prostate cancer face a different set of questions than people diagnosed with advanced or metastatic cancers, for example.

“I think the increasingly global recognition of understanding the importance of a patient’s goals for care, and what the risks they’re willing to take on, for what types of benefits, is really important,” said Matthew E. Nielsen, MD, MS, FACS, director of urologic oncology at the University of North Carolina at Chapel Hill Lineberger Comprehensive Cancer Center. “Particularly in geriatric settings, there have been really interesting findings suggesting that for many older patients, preserving their independence and quality of life may be more important than longevity measures commonly used in clinical trial endpoints, like OS or PFS, measured in months.”

Patient-reported Outcomes

Whereas regulatory considerations led to an emphasis on survival endpoints “which are unquestionably important,” there is now an emerging emphasis on quality of life and patient-reported outcomes (PROs), as well, Dr Nielsen said, which are endpoints that can better inform shared decision-making about treatment.

For older patients with relatively low-risk disease, weighing side-effect profiles against quality of life goals will sometimes lead to the conclusion that foregoing curative treatment “might be fine, if progression risk is sufficiently low,” Dr Nielsen told Cancer Therapy Advisor. “A careful discussion of patients’ preferences and goals for care sometimes reveals that a treatment considered effective by 1 criterion may not align with what’s most important to patients.”

Toxicity concerns can be even more important in advanced-disease settings, he added. Oncologists and patients often make even more fundamental assumptions about cancer and treatment goals, such as whether a treatment option is potentially curative.

As shared decision-making begins to replace “historical, paternalistic” models of treatment planning, clinicians need to be explicit in articulating the goals of a given treatment, and asking how those goals square with patients’ priorities, Dr Nielsen said. Only then can patients’ treatment preferences be ascertained and accommodated in treatment planning.

“There is often an incorrect perception among patients that a particular treatment might provide an opportunity for cure, when in reality, for many patients, particularly those with advanced adult solid tumors, cure may not really be possible,” Dr Nielsen explained.