Systemic Therapy Decision Making in Advanced Cancer: A Qualitative Analysis of Patient-Oncologist Encounters

Abstract

PURPOSE: We sought to characterize patient-oncologist communication and decision making about continuing or limiting systemic therapy in encounters after an initial consultation, with a particular focus on whether and how oncologists foster shared decision making (SDM). METHODS: We performed content analysis of outpatient oncology encounters at two US National Cancer Institute–designated cancer centers audio recorded between November 2010 and September 2014. A multidisciplinary team used a hybrid approach of inductive and deductive coding and theme development. We used a combination of random and purposive sampling. We restricted quantitative frequency counts to the coded random sample but included all sampled encounters in qualitative thematic analysis. RESULTS: Among 31 randomly sampled dyads with three encounters each, systemic therapy decision making was discussed in 90% (84 of 93) encounters. Thirty-four (37%) broached limiting therapy, which 27 (79%) framed as temporary, nine (26%) as completion of a standard regimen, and five (15%) as permanent discontinuation. Thematic analysis of these 93 encounters, plus five encounters purposively sampled for permanent discontinuation, found that (1) patients and oncologists framed continuing therapy as the default, (2) deficiencies in the SDM process (facilitating choice awareness, discussing options, and incorporating patient preferences) contributed to this default, and (3) oncologists use persuasion rather than deliberation when broaching discontinuation. CONCLUSION: In this study of outpatient encounters between patients with advanced cancer and their oncologists, when discussing systemic therapy, there exists a default to continue systemic therapy, and deficiencies in SDM contribute to this default.

Patients' experiences of cancer immunotherapy with immune checkpoint inhibitors: A systematic review and thematic synthesis

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“…In the foregoing example, the correlation between alcohol consumption and increased risk of breast cancer may arise from confounding factors such as an indigent lifestyle, family history of breast cancer, or germline BRCA mutation, all of which have been shown to increase the likelihood of developing breast cancer [18]. Second, understanding the causal relationships between ICM features and pCR after NST may lead to opportunities for targeted therapies and help oncologists make informed decisions about continuing or limiting systemic therapy after initial consultation [19].…”

Anticancer Drugs Compared to No Anticancer Drugs in Patients with Advanced Hepatobiliary Cancer: A Mapping Review and Evidence Gap Map

“…[3][4][5][6] Nevertheless, they are associated with important toxicity and impact on quality of life (QoL), which may be in conflict with patient values and preferences and, therefore, may be considered an indicator of poor-quality and aggressive care. [6][7][8][9][10] Recommendations for ADCs are usually based on their impact on survival outcomes, with less consideration of other critically important outcomes, such as QoL or quality of end of life (EoL) care. 3,4,11 Additionally, some guidelines recognize evidence gaps for particular clinical scenarios, such as second-line treatments for advanced biliary tract tumors.…”