Oncologists' End of Life Treatment Decisions: How Much Does Patient Age Matter? (original) (raw)
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Community Oncologists' Decision-Making for Treatment of Older Patients With Cancer
Journal of the National Comprehensive Cancer Network : JNCCN, 2018
This study's objectives were to describe community oncologists' beliefs about and confidence with geriatric care and to determine whether geriatric-relevant information influences cancer treatment decisions. Community oncologists were recruited to participate in 2 multisite geriatric oncology trials. Participants shared their beliefs about and confidence in caring for older adults. They were also asked to make a first-line chemotherapy recommendation (combination vs single-agent vs no chemotherapy) for a hypothetical vignette of an older patient with advanced pancreatic cancer. Each oncologist received one randomly chosen vignette that varied on 3 variables: age (72/84 years), impaired function (yes/no), and cognitive impairment (yes/no). Other patient characteristics were held constant. Logistic regression models were used to identify associations between oncologist/vignette-patient characteristics and treatment decisions. Oncologist response rate was 61% (n=305/498). Most ...
Patient Age and Cancer Treatment Decisions. Patient and Physician Views
Cancer Practice, 2000
The purpose of this study was to examine patient and physician factors influencing the decision to use adjuvant chemotherapy for stage III colon cancer in elderly persons. A cross-sectional mailed population-based survey of patients 65 years of age and older who had undergone surgical resection of stage III colon cancer in Colorado between August 1995 and December 1997 were identified by the statewide cancer registry (n = 276) and their treating physicians (n = 232). A questionnaire about the determinants of colon cancer treatment decisions was mailed to all patients for whom physician permission was granted (n = 119). A similar questionnaire was sent to treating physicians. Ninety-two physicians (internal medicine 23%; family medicine 12%; surgery 37%; and oncology 24%) and 67 patients (mean age 75.8 years; 55% women) completed surveys. Fifty-four (80.6%) of the patients had received adjuvant chemotherapy. The major determinants of receiving adjuvant chemotherapy were having seen an oncologist (P = .003), being younger (P = .003), and being married (P = .021). After controlling for other potential influences, only having seen an oncologist (odds ratio 8.0; confidence interval 1.5-43.1) remained significantly associated with the receipt of chemotherapy. Physicians were more likely than patients to rank comorbid conditions (39.1% versus 3.0%, respectively; P < .001) and the medical literature (20.7% versus 4.5%, respectively; P = .004) as important factors in making treatment decisions, while patients were more likely than physicians to rank physician opinion (73.1% versus 26.1%, respectively; P = .001), family preference (31.3% versus 9.8%, respectively; P = .001), and family burden (10.4% versus 2.2%, respectively; P = .038). In this elderly population, patient age is not recognized by patients or physicians as affecting the decision to use adjuvant chemotherapy. Other biologic and social factors are important, however, and the perspectives of physicians and patients differ regarding their relative importance.
Journal of Geriatric Oncology, 2020
Patients with cancer have varied preferences for involvement in decision-making. We sought older adults' preferred and perceived roles in decision-making about palliative chemotherapy; priorities; and information received and desired. Methods: Patients ≥65y who had made a decision about palliative chemotherapy with an oncologist completed a written questionnaire. Preferred and perceived decision-making roles were assessed by the Control Preferences Scale. Wilcoxon rank-sum tests evaluated associations with preferred role. Factors important in decision-making were rated and ranked, and receipt of, and desire for information was described. Results: Characteristics of the 179 respondents: median age 74y, male (64%), having chemotherapy (83%), vulnerable (Vulnerable Elders Survey-13 score ≥ 3) (52%). Preferred decision-making roles (n = 173) were active in 39%, collaborative in 27%, and passive in 35%. Perceived decision-making roles (n = 172) were active in 42%, collaborative in 22%, and passive in 36% and matched the preferred role for 63% of patients. Associated with preference for an active role: being single/widowed (p = .004, OR = 1.49), having declined chemotherapy (p = .02, OR = 2.00). Ranked most important (n = 159) were "doing everything possible" (30%), "my doctor's recommendation" (26%), "my quality of life" (20%), and "living longer" (15%). A minority expected chemotherapy to cure their cancer (14%). Most had discussed expectations of cure (70%), side effects (88%) and benefits (82%) of chemotherapy. Fewer had received quantitative prognostic information (49%) than desired this information (67%). Conclusion: Older adults exhibited a range of preferences for involvement in decision-making about palliative chemotherapy. Oncologists should seek patients' decision-making preferences, priorities, and information needs when discussing palliative chemotherapy.
Journal of Clinical Oncology, 2004
Although cancer affects children and young adults, it is largely a disease of middle-aged and older persons. In both men and women, the incidence of cancer begins to rise sharply at age 50 years and peaks by 80 years. The reasons for this age distribution are not entirely clear, but may result from the loss of tumor-suppressor mechanisms that delay the development of cancer until after the period of sexual maturity and reproduction. 1 As a result, 58% of all cancers are diagnosed in persons aged 65 years or older. Decision making in oncology is complicated because there frequently is no single correct treatment pathway or choice, 3 especially for older persons who have shorter life expectancies regardless of a cancer diagnosis. 4 Individual preferences and value of the benefits, harms, and costs of different treatment options must be considered within the context of alternative treatment pathways. 5 Physicians and patients need to weigh a multitude of factors, such as longevity, short-and long-term quality of life, personal risk and risk tolerance, and treatment-response uncertainty in the process of making treatment decisions. Once treatment decisions have been made, the link between these decisions and the care subsequently provided is a major issue for cancer patients of all ages. In this issue of the Journal of Clinical Oncology, Rose et al used data from the Study to Understand Prognoses and Preferences for Risks of Treatments (SUPPORT) to better examine these links in late-stage cancer patients. The authors developed a theoretical model that includes physician and patient estimates of 6-month survival and patients' perceived quality of life (perspectives), patients' treatment goals and desires for cardiopulmonary resuscitation (CPR; patient preferences), discussions about aggressiveness of care and therapeutic interventions that were provided (care practices), and hospital re-admissions and length of survival (outcomes). Although it could be argued that physicians' preferences should be included in the model, the elements of the model selected by the authors are valuable. Most importantly, the study permits examination of the links among these different elements.
Supportive Care in Cancer, 2016
Purpose Although comorbidities, frailty, and functional impairment are common in older adults (OA) with cancer, little is known about how these factors are considered during the treatment decision-making process by OAs, their families, and health care providers. Our aim was to better understand the treatment decision process from all these perspectives. Methods A mixed methods multi-perspective longitudinal study using semi-structured interviews and surveys with 29 OAs aged ≥70 years with advanced prostate, breast, Electronic supplementary material The online version of this article
Leukemia & Lymphoma, 2020
Little is known about the characteristics of patients, physicians, and organizations that influence treatment decisions in older patients with AML. We conducted qualitative interviews with community oncologists and older patients with AML to elicit factors that influence their treatment decision-making. Recruitment was done via purposive sampling and continued until theoretical saturation was reached, resulting in the inclusion of 15 patients and 15 oncologists. Participants' responses were analyzed using directed content analysis. Oncologists and patients considered comorbidities, functional status, emotional health, cognition, and social factors when deciding treatment; most oncologists evaluated these using clinical gestalt. Sixty-seven percent of patients perceived that treatment was their only option and that they had not been offered a choice. In conclusion, treatment decision-making is complex and influenced by patient-related factors. These factors can be assessed as part of a geriatric assessment which can help oncologists better determine fitness and guide treatment decision-making.
Medical decision making for older patients during multidisciplinary oncology team meetings
Journal of Geriatric Oncology
Multidisciplinary team meetings aim to facilitate efficient and accurate communication surrounding the complex process of treatment decision making for older patients with cancer. This process is even more complicated for older (≥ 70 years) patients as the lack of empirical evidence on treatment regimens in patients with age-related problems such as comorbidity and polypharmacy, necessitates a patient-centered approach. This study investigates the decision-making process for older patients with cancer during multidisciplinary team meetings and the extent to which geriatric evaluation and geriatric expertise contribute to this process. Non-participant observations of 171 cases (≥ 70 years) were conducted during 30 multidisciplinary team meetings in five hospitals and systematically analyzed using a medical decision making framework. First, not all steps from the medical decision making framework (e.g., alternative treatment options and arguments were often skipped) were followed. Second, we found limited use of patient-centered information such as (age-related) patient characteristics and patient preferences during the decision-making process. Third, a geriatric perspective was largely missing in multidisciplinary team meetings. This study uncovers gaps in the treatment decision-making process for older patients with cancer during multidisciplinary team meetings. In particular, individual vulnerabilities and patient wishes are often neglected. CHAPTER 5 83 Medical decision making for older patients during multidisciplinary oncology team meetings
The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 2008
Background. Among advanced-stage cancer patients, age is an important determinant of decision making about medical care. We examined age-related differences in patient well-being, care perspectives, and preferences, and the relationship between these patient characteristics and subsequent care practices including care communication, pain management, and acute care utilization during the early treatment phase of late-stage cancer. Methods. Patient demographics, well-being, and care perspectives were assessed during patient and physician baseline interviews. Care practices were measured using outpatient and inpatient records for the 30-day period after baseline assessment. Multivariate regression models were used to examine the patterns of association of age and other patient characteristics with care practices. Results. A total of 174 middle-aged and 149 older patients with recently diagnosed late-stage cancer were included. Older patients had more comorbidities but lower levels of depression, anxiety, and symptom distress. Older patients preferred pain relief/comfort as a treatment goal, but received fewer prescriptions for opioids. Whereas provider-initiated communication with patients/families was positively associated with severity of illness, patient/family-initiated communication was associated with patient psychosocial attributes and care perspectives. Satisfaction with care was inversely associated with reports of pain. Symptom distress was positively associated with subsequent opioid prescriptions and hospitalizations. Conclusions. Our results help to explain the role of patients' psychosocial attributes, care perspectives, and preferences in subsequent care practices during the early treatment phase for late-stage cancer. Age-related differences in patient wellbeing and care perspectives suggest a role for age-sensitive interventions in the treatment of advanced cancer patients.
Managing older patients with cancer
Journal of the American Academy of Physician Assistants, 2020
With the growing population of adults over age 70 years, clinicians must know how to care appropriately for the increasing number of older patients with cancer. Although older adults have higher rates of surgical complications and chemotherapy-related toxicity, they should not be excluded from treatment opportunities based on age alone. Rather, patients should be assessed for fi tness, or functional age, for a more accurate estimation of how they will tolerate treatment. This article discusses considerations clinicians should take into account when developing effective treatment plans that do not compromise quality of life for older patients with cancer.