Mariken Stegmann

Discussion  Summary  A structured OPT‐facilitated conversation about generic treatment goals with the GP had no  statistically significant effect on empowering older patients with non‐ curable cancer  compared with care as usual. However, there were more patients with low empowerment  scores in the control group. This study also found that patients in the intervention group had  statistically significantly lower mean anxiety scores and less mild fatigue. Furthermore, half  of the participating patients in the intervention group reported that it helped them make a  decision and that it had improved their relationship with the GP. One‐third of the GPs  reported they had gained new insights from the OPT conversations.  Strengths and limitations  Though the OPT has been used in other settings, 12  the authors believe this was the first  application by GPs for patients with cancer and it was well received. Despite the small  differences in empowerment between groups, the OPT conversation was considered to  support treatment decisions by about half of the patients, suggesting that the OPT may have  an added value to usual care.  Despite the small sample size, the authors argue that the results of the present analyses  have clinical relevance. Furthermore, the study sample mainly included older patients with  less education and with lung cancer. The authors believe it is very important to gain data  from this vulnerable group as this group can be difficult to include in studies, making these  data informative and useful in an otherwise scarce research landscape.  The main limitation of the present study was the failure to meet the pre‐specified sample  size requirements; including older patients with non‐curable cancer appeared to be difficult  for various reasons. Oncologists did not ask all eligible patients whether they could be  contacted by the researchers because they forgot or because they thought it too difficult to  combine delivering ‘bad news’ with a request to participate in a study. The interval between  diagnosis and treatment decision was often surprisingly short (1–2 days). Sometimes the  decision had already been made when the researchers contacted the patient or the interval  was too short a time for the intervention to take place. The short interval appears to be a  frequently encountered phenomenon, which is exemplified by the current discussion in the  Netherlands that patients should be given multiple treatment options and a ‘time‐out’  interval to allow non‐rushed decision making. 36  Further, dropout rates were higher than  expected. Despite requiring that patients should have a life expectancy of >3 months, many  patients died or became too ill before they could complete questionnaires. Various methods  were employed, such as weekly personal contact between researchers and oncologists, to  improve accrual and the changing of the original inclusion criterion from age >70 years to  ≥60 years.  Finally, it is important to realise that the effects of an OPT‐facilitated conversation can be  partly determined by other topics of a conversation with the GP, such as attention to  symptoms, and words of reassurance and support. Though the authors have no information  about the conversations in the usual care group, earlier research showed that many patients  have contact with their doctor immediately after a cancer diagnosis. 13 48 Chapter 4