Imagine this common clinical scenario: A 64-year-old woman presents with a new abnormality on a mammogram. A core needle biopsy and subsequent partial mastectomy reveal a 1.8-cm invasive ductal carcinoma. Sentinel lymph nodes are negative for cancer. The tumor is moderately differentiated and is estrogen receptor–positive, progesterone receptor–positive, and HER2-negative. Oncotype DX testing reveals a recurrence score of 12 (low risk). The patient completes postlumpectomy radiation and now presents to your clinic to discuss adjuvant antiestrogen strategies. What are the treatment options? How do you present them clearly to your patient? And how do you ensure that she is a partner in decision-making?
ASCO Decision Aids (asco.org/clinicaltools) can facilitate these discussions. These tools are based on the science in ASCO’s evidence-based clinical practice guidelines and incorporate the best practices of decision aid development (see Additional Readings). They allow the clinician to display and explain information on risk and benefits, and help the patient think about his or her own values and preferences. Research suggests that the use of decision aids increases patient knowledge without increasing anxiety, and can increase patient satisfaction.
Streamlining the Decision-making Process
Decision aids can streamline the decision-making process and their use frequently leads to a finalized decision about care. “When I have used the ASCO Adjuvant Endocrine Therapy Decision Aid with women in my practice, it has cut down on the number of times I’ve received follow-up phone calls,” said Michael A. Danso, MD, of Virginia Oncology Associates and ASCO Practice Guidelines Implementation Network (PGIN) Co-Chair.
In the scenario above, the patient has more than one treatment option (outlined in the ASCO Guideline Update on Adjuvant Endocrine Therapy for Women with Hormone Receptor–Positive Breast Cancer). The options carry benefits and risks and none is clearly superior—a frequent experience in oncology. Patients in this situation may experience feelings of uncertainty, difficulty identifying the best option, and concern they will regret their choice (“decisional conflict”). Although clinical practice guidelines and clinical trials may guide the clinician, guidelines and study results are typically not written with a patient audience in mind, and circumstances may constrain the clinician in explaining them. Decision aids help to bridge this gap and lead to shared decision-making.
For example, the ASCO Decision Aid for this scenario includes data showing potential benefits and risks or harms of tamoxifen, aromatase inhibitors, or a sequential combination. It appeals to a variety of learning styles, including visual and auditory. Graphics are formatted to quickly and comprehensibly communicate data in text and pictographs. After the visit, the patient can use the Decision Aid’s worksheet (based on the Ottawa Personal Decision Guide), to reflect on the discussion, plan next steps (such as seeking support from others), and make the best choice for him or herself.
ASCO Decision Aids are available for adjuvant endocrine therapy and risk reduction in breast cancer, and adjuvant treatment and treatment of advanced disease in non–small cell lung cancer.
“This information allows me to give my patients a more complete picture of the treatment regimen, potential benefits and risks, including an excellent summary table on potential chemotherapy toxicities,” said James N. Frame, MD, of Charleston Area Medical Center and PGIN Co-Chair, who uses the ASCO Decision Aid on the treatment of advanced non-small cell lung cancer in his practice.■
Originally printed in ASCO Connection. © 2013 American Society of Clinical Oncology. (“ASCO Decision Aids Intersect Evidence-Based Guidelines, Productive Patient Communication.” ASCO Connection, November 2012: 36-37) All rights reserved.
Additional Readings
1. O’Brien MA, Whelan TJ, Villasis-Keever M, et al. Are cancer-related decision aids effective? A systematic review and meta-analysis. J Clin Oncol 6:974-985, 2009.
2. O’Connor A, Jacobsen MJ, Stacey D. An evidence-based approach to managing women’s decisional conflict. J Obstet Gynecol Neonatal Nurs 31;570-581, 2002.
3. Barry MJ, Edgman-Levitan S. Shared decision making—pinnacle of patient-centered care. N Engl J Med 366:780-781, 2012.
4. Fagerlin A, Zikmund-Fisher BJ, Ubel PA. Helping patients decide: Ten steps to better risk communication. J Natl Cancer Inst 103:1436-1443, 2011.
5. Stacey D, Bennett CL, Barry MJ, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 10:CD001431, 2011.
