Mariken Stegmann

Decision making in  cancer  Illustrative case  Consider the case of Mrs. Johnson, a 79‐year old widow who valued her independency and  loved the outdoor lifestyle, who despite having sold her eld, continued to live at her old  farm. When she presented to her general practitioner (GP) with persistent dyspnoea, this  led to a standard sequence of events. She was sent to the pulmonologist for further  assessment, at which point an x‐ray showed features suggestive of lung cancer. This, in  turn, prompted additional diagnostic tests that conrmed stage IV lung cancer and led to  medical intervention with chemotherapy. Although her initial response was favourable,  fever developed after the second round of chemotherapy. Per the medical care plan, this  prompted contact with an oncologist who admitted her to hospital, and she died two days  later. In this case, all aspects of her care were appropriate and consistent with current  standards of care, and her family was content with the care provided. However, the  question was raised: did this patient truly want to receive chemotherapy?  Healthcare providers in cancer care  Worldwide, an estimated 14.1 million new cancer cases and 8.2 million cancer deaths  occurred in 2012, and the incidence is expected to increase as a result of population aging. 1 The percentage of patients with cancer who are aged 65 years or older is, therefore,  expected to increase to as high as 70% by 2030. 2 The care of patients with cancer is complex and involves many different healthcare  providers. 3  At present, GPs are formally involved before referral to specialist oncology  services and during end‐of‐life care, 4  while in the other phases the role of the GP is not well  dened. 3,5  Nevertheless, it is now increasingly recognised that GP involvement is essential  at all stages of cancer treatment to optimise patient outcomes, not only through their role  in coordinating care but also through their ability to help when making complex treatment  decisions and providing psychological support. 5,6 Treatment decisions in older people  Complex treatment decisions are often necessary for older patients with cancer because  they frequently have multiple comorbidities and shorter life expectancies. These factors  may unfavourably inuence the risk/benet assessment before treatment, and could  explain why older patients are sometimes not treated according to the recommended  standards of care. 7  Multiple studies have shown that reduction of mortality was less  important for older patients with cancer than improvement or maintenance of function. 8,9 Medical doctors play a very important role in treatment decisions made by older patients. 10 The process of shared decision making (SDM) involves the patient and a medical doctor  coming together, recognizing that a decision has to be made, discussing the available  options, discussing the patient’s preferences, and ultimately, making or deferring a  decision. 11  Patients with cancer express a higher preference for active participation in this  process than other patient groups, 12  especially when decisions are related to quality of  life. 13 There is sufcient evidence that SDM improves knowledge of the options and outcomes  among patients, and can lead to more accurate expectations. 14  Besides, SDM may improve  patient condence and empowerment, which can be measured by decision self‐efcacy. 14 This is, the condence or belief in one’s ability to make decisions, including the ability to  2 19 Protocol for the OPTion study