Mariken Stegmann

addition to having cancer, therapies can also cause or increase symptoms of depression  and/or anxiety. Furthermore, cancer treatment has a social impact through reducing  independence, e.g. by being hospitalised or being temporarily bedridden. These problems  can be of great importance, in particular for older patients.  As it is impossible to predict which patients will benefit from cancer treatment, international  guidelines suggest discussing adjuvant systemic treatment with patients if that particular  treatment yields at least 3‐5% absolute benefit in terms of overall mortality. However, this  also implies 95‐97% overtreatment. 7  When the potential risks of a treatment are severe or  highly unwanted, this can influence the risk/benefit assessment for treatment. This may  explain why older patients are sometimes not treated according to the recommended  regimes. 8 Shared decision making  Because cancer treatment has both positive and negative effects, decisions about cancer  treatment often strongly depend on patients’ preferences, and are therefore preference  sensitive. Preference sensitive decisions are decisions for which there is no obvious ‘best’  treatment. Treatment choice then depends on a necessarily subjective trade‐off between  the benefits and side‐effects of treatment alternatives. 7,9 For older patients, treatment decisions are more preference sensitive because the positive  effects of treatment can be smaller and the negative effects may be greater than in younger  patients. For older patients the effects of a specific cancer treatment on survival are often  not known, because older patients are generally excluded from clinical trials of new  treatments. Even if the effect on survival would be the same as in younger patients, this can  be of less consequence because older patients have a shorter life‐expectancy. Negative  treatment effects, on the other hand, can be more serious due to pre‐existing frailty caused  by aging itself and/or comorbidity. 10  A systematic review showed that treatment  complications are more common in frail patients, including intolerance to cancer treatment  because of side effects and postoperative complications. 10  Older patients might therefore  value the importance of positive and negative effects differently than younger patients.  However, there is no literature about this topic, nor on how these considerations may  change as the illness progresses. Research in older non‐cancer patients has  shown that for  many older patients maintaining independence is more important than extending life. 11,12 Decisions and empowerment  For all preference sensitive decisions, it is advised that both healthcare provider and patient  decide on the most appropriate treatment option. This process is called shared decision  making (SDM).  Emanuel & Emanuel already stated that there are four models of patient‐ healthcare provider interaction (paternalistic, informative, interpretive and deliberative). 13 Each model has a different concept of the patient’s autonomy and the role of the healthcare  provider. They concluded that although different models may be suitable in different  settings, the deliberative model is generally the ideal model. The aim of the interaction  between healthcare provider and patient in this model is to help the patient determine and  choose the best health‐related values that can be realised in the clinical situation. The  patient should be empowered to consider, through dialogue, all health‐related values, their  worthiness and their implications for treatment. 13 In line with this, recent research has shown that most patients prefer to be involved in  treatment decisions. 14,15  Patients with cancer express a higher preference for active  1 9 General introduction