June 09, 2017

Radiation Oncology Embraces Shared Decision Making

The message was clear from American College of Radiology Radiation Oncology Commission Chair Seth A. Rosenthal, MD, FACR, at a session on Patient- and Family-Centered Care in Shared Decision-Making at ACR 2017: Shared decision-making has always been a core concept in radiation oncology, and it will become more important in the future.

“We have always been a patient-facing specialty,” he said. “We are focused on specific treatment goals and making difficult decisions on the choice of therapies.”

The past success of radiation oncology in such areas does not preclude the need for future improvement. “We need to move our specialty forward into the patient- and family-centered universe,” Rosenthal said.

This change means transitioning from physician control to physician collaboration, from an expert model to a partnership model, from restricted information to information-sharing, and a dependent view of the patient to an empowered view of the patient, he said.

Patient- and family-centered care is becoming more important to the individual radiation oncologist as medical practices shift from fee-for-service reimbursement to value-based criteria for rewarding superior clinical performance. Radiation oncologists should make note of changes in family and community structures and how they influence optimal choices for cancer therapy and affect patient outcomes, Rosenthal explained.

Radiation oncologists also need to be sensitive to the differences between their patients’ priorities and their own. Convenience and ease of access to radiation therapy planning and actual treatment are important to patients but often are an afterthought for their physicians. Younger patients and their families are concerned about disruptions to their daily routine and if they can work while they are under treatment. Radiation oncologists often are unaware of health care costs when such expenses are major issues for their patients and families, Rosenthal stated.

Radiation therapy shared decision-making aids can help prepare patients and their families to engage in collaborations with their radiation oncologists, noted Laurie E. Gaspar, MD, FACR, professor of radiation oncology at the University of Colorado School of Medicine. For decision-making aid development, she recommends an Ottawa Hospital Patient Decision Aid website where a five-step implementation toolkit for creating shared decision-making aids can be found.

“Patient decision aids should be used for clinical options that have no clear right answer,” she said.

Abigail T. Berman, MD, assistant professor of radiation oncology at the University of Pennsylvania, considered how added value can be drawn from patient-reported outcomes and shared decision-making mechanisms integrated into radiation oncology clinical trials.

Surveys measuring patient satisfaction with the clinical decision-making process and their ability to collaborate with their radiation oncologist to assess treatment and quality of life options are beginning to appear in clinical trials, she said. Other survey instruments measure patient confidence in clinical decisions or decisional regret, health efficacy, mental health, and physical and emotional well-being.

Clinical trials are being designed to measure longer-term patient outcomes of radiation therapy, such as treatment adherence and end of life issues, Berman stated. In palliative care, shared decision-making has been shown to decrease the probability of chemotherapy in the final 14 days of life. The effect of shared decision-makings on remission can also be assessed.

But these are still early days for shared decision-making in cancer research, Berman noted.

A recent example includes a study of 312 early stage breast cancer patients using decisional conflict as a primary endpoint in shared decisions to use radiotherapy or hormonal therapy after breast conservation surgery. In another study, a video decision aid and written educational material were used help prostate cancer patients understand and participate in selecting their treatment options.

At the University of Pennsylvania, Berman is collaborating with resident Kristina Woodhouse, MD, on a trial using a decision aid to compare the effectiveness of stereotactic radiation versus surgery in non-small cell lung cancer with a primary endpoint of decisional conflict.

“Our aims were essential to assess patient quality of life, to develop an actual decision aid and to study the decision-making process by randomizing patients to either use a decision aid or to receive the usual care with the outcome of decisional conflict,” Berman said.

The crux of the question in Berman and Woodhouse’s trial is also a central question that patient- and family-centered care in general attempts to address. That is – what does the patient want to do and how can their involvement in the clinical decision-making process have a positive effect on the outcomes of their care? The session showcased the ways in which ACR and the radiation oncology community are working to make patient-centered care a focus of the way radiation oncologists practice medicine. These are consistent with the aims of the ACR’s patient- and family-centered care initiative.