Mariken Stegmann

Introduction  Treatment decisions are often complex for older patients with cancer. The expected positive  effects of treatment are unclear in this group because most studies of therapeutic efficacy  are performed in younger patients. 1,2  Older patients also tend to be more frail or to have  comorbidities that increase the negative effects of treatment. 3  It is therefore advised that  health care providers discuss the benefits and harms of available treatment options  comprehensively, making efforts to involve patients in treatment decisions and to respect  their preferences whenever possible. 4  This is important because treatment guidelines are  generally based on optimal survival, whereas not all older patients will value extending life  as the main treatment goal. 5  Indeed, other goals are more important for about half of these  patients, such as maintaining independence. 5  The importance of explicitly discussing  patients’ treatment goals is exemplified by research showing that health care professionals  often make incorrect assumptions about these goals. 6  Furthermore, goals may be dynamic  and change as illness progresses, particularly for incurable disease where treatment  priorities often change gradually from extending life to optimising comfort. 7  In a study of  patients with non‐curable cancer, most patients said they would like to talk to their health  care provider about end‐of‐life care when their health deteriorated. 8  Although this suggests  that health deterioration may trigger a change in treatment preference, we are aware of no  literature on this topic. In the present study, we therefore aimed to investigate the  treatment goals of older patients with non‐curable cancer, to determine if those goals  changed over time, and if they did change, what triggered that change.  Methods  This was a descriptive qualitative study of patients included in the intervention group of the  OPTion study (NTR5419), which was conducted between November 2015 and January 2019.  The protocol and outcomes of the original randomised controlled trial (RCT) have been  published elsewhere. 9,10  The Institutional Review Board of the University Medical Center  Groningen assessed the protocol and we obtained informed consent from all participants.  The OPTion RCT  The original OPTion RCT was designed to assess how patient self‐efficacy was affected by a  structured conversation about goals with a general practitioner prior to making a decision  about treatment. Older patients (age ≥60 years) with non‐curable cancer were included in  the period between their diagnosis and treatment decision, and they were excluded if they  had haematological cancers, a life expectancy of <3 months, or could not complete the  questionnaires. After the treatment decision (baseline), patients completed questionnaires  about demographic characteristics and decision self‐efficacy (primary outcome), as well as  symptoms of fatigue, depression, and anxiety. 10 The Outcome Prioritisation Tool (OPT; Figure 1) was used during the conversation with a GP.  This instrument can be used to discuss and prioritise four generic treatment goals: extending  life, maintaining independence, reducing pain, and reducing other symptoms. 5,11  Each goal is  valued from 0 to 100, resulting in four OPT scores. In the OPTion RCT, patients received  either an OPT‐facilitated conversation (n=53) or care as usual (n=61). Prioritisation  discussions in the intervention arm could be facilitated using moveable sliders (0–100). They  were provided on a card or were available online  (www.optool.nl ).  5 55 Treatment goals and their changes over time