Challenges in Shared Medical Decision Making: An Oncologist's Perspective
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  • 1. Challenges in shared medical decision making: an oncologist’s perspective Wendy Y. Chen, MD MPH
  • 2. Breast cancer statistics - 2012• 226,879 invasive breast cancer cases• 39, 510 breast cancer deaths – Prostate cancer: 241,740 cases + 28,170 deaths=>2,971,610 breast cancer survivors Siegel, CA Cancer J Clin 2012
  • 3. Breast Cancer Decision Aids1. Ductal carcinoma in situ2. Early stage: local treatments3. Early stage: systemic therapy4. Breast reconstruction5. Metastatic breast cancer
  • 4. Challenges to decision aidsStandardization Personalization
  • 5. Standardization• National Comprehensive Cancer Network (NCCN) guidelines• Quality Oncology Practice Initiative – Part of ABIM recertfication process for Oncology
  • 6. Breast QOPI module measures• Chemotherapy recommended within 4 mths of diagnosis for Stage I (T1c) – III ER negative breast cancer• Trastuzumab recommended for Stage I (T1c) - III Her2+ breast cancer• Hormonal Rx recommended within 1 yr of diagnosis for patient with ER+ breast cancer
  • 7. Breast cancer treatment trend - Personalization • Old theory – Stage major determinant of aggressiveness of treatment • More advanced stage => more chemotherapy • New theory – Stage still important, but underlying biology of tumor may be equally important • Makes standardization difficult
  • 8. OncotypedxAvailable for ER positive tumors and mainly node negative
  • 9. Chemo benefit as function of OncotypeDX score Paik S,JCO 2006
  • 10. Heuristics in oncology• Frameworks people use for decision making• Risk aversion – Preference for smaller certain gain over larger but more uncertain one => Patients focus on recurrence• Anticipated regret – Prospect of regret over omitting therapy if recurrence were to occur If remains cancer free, benefit ascribed to treatment If cancer recurs, blame ascribed to omitting therapy Katz & Morrow, JAMA 2012
  • 11. Shared Decision Making in OncologyPreference sensitivity – early stage breast cancer Yes No MaybeMastectomy vs lumpectomy + radiationRadiation after lumpectomyHormonal therapy for ER positive tumorsAdjuvant chemotherapy for early stagebreast cancer
  • 12. Shared Decision Making in OncologyPreference sensitivity – early stage breast cancer Yes No MaybeMastectomy vs lumpectomy + radiationRadiation after lumpectomyHormonal therapy for ER positive tumorsAdjuvant chemotherapy for early stagebreast cancer
  • 13. Shared Decision Making in Oncology• Mastectomy vs lumpectomy + RT – No difference in overall survival• Radiation after lumpectomy – Often cited for quality of care/benchmarking => No survival benefit for older pts with early ER+ cancer• Hormonal therapy for ER+ breast cancer – Often cited for quality of care/benchmarking => Unclear survival benefit for older pts with early stage ER+ cancer and comorbidities• Adjuvant chemotherapy for early stage breast cancer – Relative benefit fixed, but absolute benefits vary
  • 14. Challenges to decision aidsStandardization Personalization
  • 15. Breast Cancer Decision Aids1. Ductal carcinoma in situ2. Early stage: local treatments3. Early stage: systemic therapy4. Breast reconstruction5. Metastatic breast cancer