Abstract
BackgroundThere is increasing recognition of the delicate balance between the modest benefits of palliative chemotherapy and the burden of treatment. Decision aids (DAs) can potentially help patients with advanced cancer with these difficult treatment decisions, but providing detailed information could have an adverse impact on patients' well-being. The objective of this randomised phase II study was to evaluate the safety and efficacy of DAs for patients with advanced cancer considering second-line chemotherapy.MethodsPatients with advanced breast or colorectal cancer considering second-line treatment were randomly assigned to usual care (control group) or usual care plus a DA (intervention group) in a 1:2 ratio. A nurse offered a DA with information on adverse events, tumour response and survival. Outcome measures included patient-reported well-being (primary outcome: anxiety) and quality of the decision-making process and the resulting choice.ResultsOf 128 patients randomised, 45 were assigned to the control group and 83 to the intervention group. Median age was 62 years (range 32-81), 63% were female, and 73% had colorectal cancer. The large majority of patients preferred treatment with chemotherapy (87%) and subsequently commenced treatment with chemotherapy (86%). No adverse impact on patients' well-being was found and nurses reported that consultations in which the DAs were offered went well. Being offered the DA was associated with stronger treatment preferences (3.0 vs. 2.5; p=0.030) and increased subjective knowledge (6.7 vs. 6.3; p=0.022). Objective knowledge, risk perception and perceived involvement were comparable between the groups.ConclusionsDAs containing detailed risk information on second-line palliative treatment could be delivered to patients with advanced cancer without having an adverse impact on patient well-being. Surprisingly, the DAs only marginally improved the quality of the decision-making process. The effectiveness of DAs for palliative treatment decisions needs further exploration.Trial registrationNetherlands Trial Registry (NTR): NTR1113 (registered on 2 November 2007)
Highlights
There is increasing recognition of the delicate balance between the modest benefits of palliative chemotherapy and the burden of treatment
Starting first-line and further-line palliative chemotherapy in addition to best supportive care should be carefully considered and any treatment implemented should be in harmony with the patient's preferences [5, 11, 12]
The aim of this study is to evaluate the feasibility of offering Decision aid (DA) containing detailed information about estimated life expectancy to patients with advanced breast or colorectal cancer considering second-line palliative chemotherapy, using a randomised multicentre design
Summary
There is increasing recognition of the delicate balance between the modest benefits of palliative chemotherapy and the burden of treatment. Decision aids (DAs) can potentially help patients with advanced cancer with these difficult treatment decisions, but providing detailed information could have an adverse impact on patients' well-being. While patients with advanced cancer beyond cure are commonly offered palliative chemotherapy, there is increasing recognition of the delicate balance between the modest benefits of palliative chemotherapy and the burden of treatment [1,2,3,4,5,6]. In recent studies from the US, 52% and 6981% of patients receiving palliative chemotherapy seemed to be under the false impression that this treatment may well cure their cancer [13, 14] This inaccurate understanding may be related to incomplete communication by the oncologists, as well as patients' inability to accept the incurable nature of their disease [14]. There are indications that clinicians and patients purposefully use a strategy of 'collusion' to communicate about the future, including avoiding or delaying the discussion of estimated life expectancy, in an effort to preserve patients' hope [15,16,17,18,19]
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