Melina Gattellari

Sharing decisions in cancer care.

Previous studies have demonstrated that the majority of cancer patients fail to achieve their desired level of participation during treatment decision making. However, it is unclear whether this failure affects patient well-being and satisfaction. Furthermore, whilst shared decision making is currently espoused as the preferred model for doctor patient relations, little empirical evidence exists showing it has beneficial effects for patients. We aimed to evaluate the impact of shared decision making and the achievement of preferred role on patient anxiety, recall of information, and satisfaction. Patients with cancer indicated their preferred level of participation in decision making and preferences for information and emotional support prior to their initial consultation with an oncologist. Anxiety was assessed prior to and immediately after the consultation and recall seven days after the consultation. Anxiety was reassessed at two-weeks post-consultation at which time patients also reported their satisfaction with the consultation and perceived role of participation in treatment decision making. Satisfaction with the information and emotional support received was also evaluated. Of the 233 patients available for analysis, a match between preferred and perceived roles was found for over one-third of patients (34%), with 29% more active and 37% less involved in decision making than preferred. Multivariate analyses demonstrated that role mismatch significantly predicted changes in anxiety levels from pre to immediate postconsultation (p = 0.03). However, irrespective of preferred role in decision making, perceived role, but not role mismatch, significantly and independently predicted satisfaction with both the consultation (p = 0.0005) and the amount of information and emotional support received from the doctor (p = 0.004). Patients who reported a shared role in decision making were most satisfied with the consultation and with the information about treatment and emotional support received. Those who reported that either themselves or the doctor exclusively made the decision were least satisfied. These findings underscore the pre-eminence of the shared decision making model and suggest that encouraging participation may be the safest standard approach. Doctor - as well as patient - based interventions are required to promote patient participation.

The use of unproven methods of treatment by cancer patients. Frequency, expectations and cost.

The use of unproven therapies is of concern for a number of reasons, including the lack of scientific evidence to support them, their potential financial costs and the possibility of interference with conventional treatment. This study xplored the prevalence, predictors and experiences of unproven therapy use by cancer patients attending an oncology clinic at an Australian teaching hospital. A questionnaire was administered to patients whilst they were waiting for a consultation with their oncologist. A total of 173 patients were invited to participate, and 156 consented to complete the survey (90%). Over half the patients (81, 52%) had used at least one unproven therapy since their diagnosis, and 28% had used three or more. Patients most commonly practised meditation/relaxation, changed their diet and used multi- vitamins. Most expected that the therapies would aid their conventional treatments and make them feel more in control of their situation. Benefits reported were largely psychological, such as an increased sense of control or a reduction in anxiety. Younger patients, those with early stage or advanced metastatic disease and those who had used unproven therapies prior to developing cancer were more likely to use unproven therapies. Health professionals involved in the care of cancer patients should be prepared to discuss the use of unproven therapies and try to identify and deal with unmet needs to help patients to cope with their illness.

Discussing Adjuvant Cancer Therapy

PURPOSE To document the adequacy of patient information in oncology consultations concerning adjuvant therapy and explore predictors of physician communication patterns, treatment decisions, patient information recall, and satisfaction. PATIENTS AND METHODS Retrospective analysis of audiotapes and verbatim transcripts of 101 initial adjuvant therapy consultations with medical and radiation oncologists was undertaken. Content analysis, data on communication patterns, treatment decisions, patient anxiety, satisfaction, and information recall were collected. Predictors of physician communication, treatment decisions, recall, and satisfaction with the consultation were identified. RESULTS The majority of patients were well informed of their prognosis, benefits and risks of therapy, and alternative management options. Only half were asked about preferences for information or decision-making involvement. Predictors of information detail given include patient sex, age, occupation, and education. Radiation and medical oncologists express prognosis and treatment benefit using similar phrases. When offered the chance to delay decision-making, most patients do so (P <.01). Final treatment decisions appear to be influenced by the presentation of choice in treatment options by the oncologist and whether the treatment decision was made during the initial consultation (P <.01). Information recall was not influenced by communication factors. Patients receiving less detailed information had slightly higher satisfaction with the consultation (P =.03). More anxious patients tended to be less satisfied (P =.07). CONCLUSION The optimal way to discuss adjuvant therapy is undefined. More emphasis can be placed on soliciting patient preferences for information and decision-making involvement and tailoring both to the needs of the individual patient. Providing choice in treatment and delaying decision-making may affect the patients treatment decision.

Retraction Note: When the treatment goal is not cure: are patients informed adequately?

We determined the extent to which Australian patients with incurable cancer are informed of their prognosis and treatment options by their oncologists and are encouraged to participate in treatment decisions. To this end, 118 patients with incurable cancer presenting for an initial consultation with one of nine oncologists in two Sydney teaching hospitals were enrolled in the study. Consultations were audio-taped. We developed a coding system to assess the disclosure of information considered necessary to equip patients to make informed decisions and to evaluate doctor encouragement of patient participation in treatment decision-making. Patient recall, satisfaction, and anxiety and their perceptions of the decision-making process were assessed. Most patients were informed about the aim of cancer treatment (84.7%), that their disease was incurable (74.6%) and about life expectancy (57.6%); 44.1% were presented with an alternative to cancer treatments, such as supportive care, 36.3% were informed how anticancer treatment would affect quality of life, and 29.7% were offered a management choice. Patient understanding was checked in only 10% of consultations. While greater information disclosure did not appear to elevate anxiety levels, greater patient participation in the decision making process was associated with increased anxiety levels (P=0.0005), which persisted over a 2-week time span. Most patients were well informed, but important gaps remain, especially concerning information about prognosis and alternatives to cancer treatment.

Will donations to their learned college increase surgeons' participation in surveys? A randomized trial

Effective strategies to maximize response rates to self-administered surveys of clinicians are crucial to minimize response bias. Offers of charitable donations have been assessed for their potential to promote participation of community samples but not in the context of medical specialist samples. We randomized all Australian colorectal surgeons (n = 219) to whom we mailed a survey about clinical practice guidelines to receive either a standard covering letter or one promising a donation to their peak professional organization upon our receipt of their completed survey. Contrary to expectations, surgeons advised that their participation would secure a donation to their college were significantly less likely to return their questionnaire (84.3%, 95% CI 76.0-90.5%) than those receiving a standard letter (93.7%, 95% CI 87.4-97.4%). They also were more tardy in their response (Hazard Ratio = 0.75, 95% CI 0.57-1.00) (P = 0.047). In this context, offering donations to surgeons was counterproductive in enhancing response rates.

Implementing guidelines about colorectal cancer: a national survey of target groups.

Background: An Australia‐wide postal survey was undertaken to determine surgeons’ attitudes towards guidelines and their preferred strategies for dissemination and implementation of guidelines for the management of colorectal cancer, developed by the Australian Cancer Network (ACN) and the Clinical Oncological Society of Australia (COSA). This survey was conducted as a baseline before the release of the definitive guidelines.

Incidence of metastatic breast cancer in an Australian population-based cohort of women with non-metastatic breast cancer at diagnosis.

Objectives: To estimate the incidence of metastatic breast cancer (MBC) in Australian women with an initial diagnosis of non‐metastatic breast cancer.

Does type of surgeon matter in rectal cancer surgery? Evidence, guideline consensus and surgeons’ views

One of the most obvious but controversial trends in contemporary surgical practice is that of subspecialization. There is a lack of definitive evidence that subspecialization improves cancer outcomes largely because previous research is compromised by confounding variables of referral practice, lack of standardized definitions of surgical skills and selection bias. Randomized controlled trials of generalized versus subspecialist surgical care are unlikely ever to be performed. The present study of surgeons’ views about the role of subspecialization in the care of colorectal cancer patients demonstrates partisan reactions among surgeons themselves (89% response rate). Results of national audits will contribute to wider debate about surgical subspecialization in colorectal cancer.

Erratum to: When the treatment goal is not cure: are patients informed adequately?

The designation of the paper as original article has been retracted due to redundant publication. The original work presented in this report was submitted to the Journal of Clinical Oncology several months before the Plenary session of the MASCC meeting in Copenhagen in June 2001, and it was subsequently published with the authors Gattellari M, Voigt KJ, Butow PN, Tattersall MHN When the treatment goal is not cure: Are cancer patients equipped to make informed decisions? in the Journal of Clinical Oncology 20: 503–13, 2002. The SCC paper was intended as a plenary paper only, and should be referenced as such. The authors regret any confusion as a result of the SCC publication of their plenary paper.