Palliative chemotherapy or best supportive care? A prospective study explaining patients' treatment preference and choice

Abstract

In palliative cancer treatment, the choice between palliative chemotherapy and best supportive care may be difficult. In the decisionmaking process, giving information as well as patients' values and preferences become important issues. Patients, however, may have a treatment preference before they even meet their medical oncologist. An insight into the patient's decision-making process can support clinicians having to inform their patients. Patients (n ¼ 207) with metastatic cancer, aged 18 years or older, able to speak Dutch, for whom palliative chemotherapy was a treatment option, were eligible for the study. We assessed the following before they consulted their medical oncologist: (1) socio-demographic characteristics, (2) disease-related variables, (3) quality-of-life indices, (4) attitudes and (5) preferences for treatment, information and participation in decision-making. The actual treatment decision, assessed after it had been made, was the main study outcome. Of 207 eligible patients, 140 patients (68%) participated in the study. At baseline, 68% preferred to undergo chemotherapy rather than wait watchfully. Eventually, 78% chose chemotherapy. Treatment preference (odds ratio (OR) ¼ 10.3, confidence interval (CI) 2.8 -38.0) and a deferring style of decision-making (OR ¼ 4.9, CI 1.4 -17.2) best predicted the actual treatment choice. Treatment preference (total explained variance ¼ 38.2%) was predicted, in turn, by patients' striving for length of life (29.5%), less striving for quality of life (6.1%) and experienced control over the cause of disease (2.6%). Patients' actual treatment choice was most strongly predicted by their preconsultation treatment preference. Since treatment preference is positively explained by striving for length of life, and negatively by striving for quality of life, it is questionable whether the purpose of palliative treatment is made clear. This, paradoxically, emphasises the need for further attention to the process of information giving and shared decision-making.

The relationship between smoking and quality of life in advanced lung cancer patients: a prospective longitudinal study

“…Our data indicate a significant preference for quality over length of life up to six months post-diagnosis in advanced lung cancer patients, which is a new finding supported by previous related literature [6,7,25]. Preference for quality was independent of smoking status.…”

“…A high score on the Q scale indicates a high value for quality of life over length and a high score on L indicates a preference for length of life over quality. The QQQ has demonstrated validity for use with cancer patients: internal reliability scores range from 0.68-0.75 for Quality and 0.67-0.79 for Length [6,7,25].…”

Decisions for lung cancer chemotherapy: the influence of physician and patient factors

“…In essence, there are differences in opinion in the valuing of toxicity and survival between doctors and patients, along with wide variation in beliefs within both These factors underscore the importance of considering the impact of these factors in treatment choices as they may ultimately impact on the survival and quality of life of the patients. Clinicians must be attentive to the decision-making style of the patient [8], their desired level of involvement in treatment decisions [28] and cognitive and affective determinants of patient choice [22] as these seem to influence patient decisions regarding chemotherapy for lung cancer, although their impact is not well understood. The complexities of these decisions underscores the importance of a multidisciplinary approach and the need to obtain the perspectives of all clinicians involved in care [30].…”

“…A review of determinants of cancer patient preferences concluded that patients are more positive toward adjuvant treatment in the context of larger benefits, less toxicity, personal experience of the particular treatment and having dependents, especially children living at home [22]. One study found patients' preference to undergo chemotherapy treatment was positively explained by striving for length of life and negatively by striving for quality of life [8]. Other factors suggested as influencing patients' attitudes to treatment and treatment decisions include parenthood status, personal experience of illness, health literacy, functional status and quality of life indicators [23][24][25][26].…”

“…Current evidence and clinical guidelines recommend chemotherapy for all stages of lung cancer, however in practice, the prescription of chemotherapy for lung cancer patients remains inconsistent and varies significantly both nationally and internationally [5][6][7]. Weighing the risks and benefits of therapy in lung cancer is an important consideration in developing the goals of care [2,8]. Understanding the views of physicians involved in the diagnosis and management of lung cancer and how these perspectives manifest in clinical decision making is important in addressing barriers to lung cancer treatment and the mismatch between current evidence and clinical practice in chemotherapy uptake.…”