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Cancer patients' choices clearer with decision aid.

CHICAGO -- A decision aid designed to explain choices about chemotherapy and palliative care can help patients with metastatic cancer understand that the goal of therapy is not a cure, without increasing their anxiety, Dr. Natasha B. Leighl reported at the annual meeting of the American Society of Clinical Oncology.

A randomized, controlled trial conducted in Australia and Canada focused on communication of information to adult patients considering first-line therapy for metastatic colorectal cancer. The decision aid was used during a physician consultation, and patients received a booklet to read at home, said Dr. Leighl of Princess Margaret Hospital, Toronto.

Compared with 100 patients who had only a standard consultation, a larger proportion of 107 patients given the decision aid claimed English as their first language (78% vs. 64%). All patients had a median age in their early 60s, about half were men, and only about a third had prior chemotherapy.

Although the decision aid clarified the patients' poor prognosis, the investigators saw no difference between the groups in satisfaction with the treatment decision, conflict over the treatment decision, or anxiety levels immediately or in the weeks after the consultations.

Initially, both sets of patients understood the definition of metastatic cancer (89%), the general effects of chemotherapy (76%), and chemotherapy side effects (75%). Most overestimated the likelihood of experiencing chemotherapy side effects, and only 17% knew the correct percentage of patients who suffer severe chemotherapy toxicity. Other difficult concepts were survival with supportive care (17%), 1-year survival with chemotherapy (23%), and palliative intent of chemotherapy (57%).

Compared with the control group, patients given the decision aid had a significantly better grasp of information 2 weeks after the initial consult. Both groups knew a median of 8 out of 16 important facts about their disease before the decision aid was introduced. Two weeks later, patients given the decision aid knew a median of 11 facts correctly vs. 9 for the control group (P = .0008).

Similarly, less than 60% understood that the goal of therapy was not a cure after the initial consult. Two weeks later, more than 90% of the decision aid group but barely 70% of the control group understood this important but disheartening concept. Although the decision aid led to improved comprehension of the goal of therapy, it did not have much impact on treatment decisions. That's because two-thirds of decisions were made at the initial consultations, before the patients could read the material.

"Delayed decision making needs to be evaluated as an optimal strategy," Dr. Leighl said. More than 70% of both groups opted for chemotherapy.

In discussing the study and another investigation that found parents of pediatric cancer patients felt more hopeful when given more information--even if a child's prognosis was poor--Dr. Paul R. Helft of Indiana University, Indianapolis, observed that curable and incurable cancer patients see hope differently. "Patients treated with curable intent have a kind of built-in hope.... Patients treated with noncurable intent have a different problem with hope," he said. "What should they hope for? Is it longer life? Is it cure? Is it a good death? I've heard that said many times."

Dr. Leighl's study shows that a decision aid can benefit patients in the latter group when making difficult "gray area" decisions, according to Dr. Helft.

Nonetheless, Dr. Helft called for a moratorium on trials of new and existing decision aids. The problem is that they are not used, he said, calling for greater efforts at bringing them into practice, possibly through the use of "information prescriptions" and lobbying for reimbursement for their use.


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Title Annotation:Gastroenterology
Author:MacNeil, Jane Salodof
Publication:Internal Medicine News
Geographic Code:1USA
Date:Dec 1, 2007
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