Physician-Controlled Decisions in Cancer Care Linked to Lower Quality Rating

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Nancy L. Keating, MD, MPH

Patients who described physician-controlled decisions about their cancer care vs shared decision-making were less likely to report receiving excellent quality of care, according to a study published by JAMA Oncology.1

The Institute of Medicine has called for shared decision-making and accommodation of patient preferences to improve the overall quality of health care. Although metrics of quality are controversial, patients’ reports about the quality of their care are increasingly important health -care performance measures.

Nancy L. Keating, MD, MPH, of Harvard Medical School, and colleagues surveyed patients in the Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) study who were diagnosed with lung and/or colorectal cancer. The authors analyzed responses from 5,315 patients who reported decision roles for 10,817 treatment decisions. They then assessed the association between patients’ roles in their decisions and their reported quality of care and physician communication.

A total of 58% of patients preferred shared roles in decision-making about their cancer, 36% preferred patient-controlled decisions, and 6% preferred physician-controlled decisions. Of the treatment decisions made by patients, 42% were regarding surgery, 36% regarding chemotherapy, and 22% regarding radiation therapy. The patients in the study reported their actual decision-making process was patient-controlled in 39% of decisions, shared in 44% of decisions, and controlled by physicians in 17% of decisions.

Patients reported their care by the physician performing the treatment as excellent in 67.8% of cases. While a patient’s preferred role in decision-making was not associated with quality ratings, patient reports that treatment decisions were controlled by physicians (vs shared) were associated with lower odds of excellent patient-reported quality.

Overall, 55.8% of patients gave their physicians the highest possible rating of communication. However, patients who preferred physician-controlled to shared decisions were less likely to give top ratings to their physicians, as were patients who reported actually experiencing physician-controlled vs shared decisions, the results show.

“Given the increasing emphasis on patient experiences and ratings in health care, these results highlight the benefits of promoting shared decision making among all patients with cancer, even those who express preferences for less active roles,” the study concludes.

Shared Decision-Making

In a related commentary,2 Sarah T. Hawley, PhD, MPH, and Reshma Jagsi, MD, DPhil, both of the University of Michigan, wrote, “We find it unsurprising that even patients who preferred a physician-controlled decision rated the physician communication outcomes highest when the actual decision-making process was more shared, as the individual items that constitute the communication measure described elements most likely to be absent when the actual decision is not shared.”

They continued, “More compelling is the association found between shared decision-making and patient appraisal of excellent quality of care. It is intriguing that this association remained, even when controlling for preferred role. Dr. Kehl and colleagues conclude from this finding that it is important to promote shared decision-making, even among patients who may seek less active roles. Yet these results are in some contrast to prior work that has suggested that it is the match between patients’ preferred and actual involvement that contributes to greater satisfaction with care. These conflicting results underscore the need for further work to better quantify and link measures of shared decision making to patient appraisal of care,” they concluded. ■

Disclaimer: This work of the CanCORS Consortium was supported by grants from the National Cancer Institute and the Department of Veterans Affairs.


1. Kehl KL, Landrum MB, Arora NK, et al: JAMA Oncol. February 12, 2015 (early release online).

2. Hawley ST, Jagsi R: JAMA Oncol. February 12, 2015 (early release online).