challenges in shared medical decision making: an oncologist's perspective

Challenges in shared medical decision making:

an oncologist’s perspective

Wendy Y. Chen, MD MPH

Breast cancer statistics - 2012

• 226,879 invasive breast cancer cases • 39, 510 breast cancer deaths

– Prostate cancer: 241,740 cases + 28,170 deaths

=>2,971,610 breast cancer survivors

Siegel, CA Cancer J Clin 2012

Breast Cancer Decision Aids

1. Ductal carcinoma in situ

2. Early stage: local treatments

3. Early stage: systemic therapy

4. Breast reconstruction

5. Metastatic breast cancer

Standardization Personalization

Challenges to decision aids

Standardization

• National Comprehensive Cancer Network (NCCN) guidelines

• Quality Oncology Practice Initiative– Part of ABIM recertfication process for Oncology

Breast QOPI module measures

• Chemotherapy recommended within 4 mths of diagnosis for Stage I (T1c) – III ER negative breast cancer

• Trastuzumab recommended for Stage I (T1c) - III Her2+ breast cancer

• Hormonal Rx recommended within 1 yr of diagnosis for patient with ER+ breast cancer

Breast cancer treatment trend - Personalization

• Old theory– Stage major determinant of aggressiveness

of treatment• More advanced stage => more chemotherapy

• New theory– Stage still important, but underlying biology

of tumor may be equally important• Makes standardization difficult

Oncotypedx

Available for ER positive tumors and mainly node negative

Chemo benefit as function of OncotypeDX score

Paik S,JCO 2006

Heuristics in oncology

• Frameworks people use for decision making• Risk aversion

– Preference for smaller certain gain over larger but more uncertain one

=> Patients focus on recurrence

• Anticipated regret– Prospect of regret over omitting therapy if

recurrence were to occurÞ If remains cancer free, benefit ascribed to treatment Þ If cancer recurs, blame ascribed to omitting therapy

Katz & Morrow, JAMA 2012

Shared Decision Making in Oncology

Preference sensitivity – early stage breast cancer

Yes No Maybe

Mastectomy vs lumpectomy + radiation

Radiation after lumpectomy

Hormonal therapy for ER positive tumors

Adjuvant chemotherapy for early stage breast cancer

Shared Decision Making in Oncology

Preference sensitivity – early stage breast cancer

Yes No Maybe

Mastectomy vs lumpectomy + radiation

Radiation after lumpectomy

Hormonal therapy for ER positive tumors

Adjuvant chemotherapy for early stage breast cancer

Shared Decision Making in Oncology

• Mastectomy vs lumpectomy + RT– No difference in overall survival

• Radiation after lumpectomy– Often cited for quality of care/benchmarking => No survival benefit for older pts with early ER+ cancer

• Hormonal therapy for ER+ breast cancer– Often cited for quality of care/benchmarking=> Unclear survival benefit for older pts with early stage ER+

cancer and comorbidities• Adjuvant chemotherapy for early stage breast cancer

– Relative benefit fixed, but absolute benefits vary

Standardization Personalization

Challenges to decision aids

Breast Cancer Decision Aids

1. Ductal carcinoma in situ

2. Early stage: local treatments

3. Early stage: systemic therapy

4. Breast reconstruction

5. Metastatic breast cancer