Challenges in shared medical      decision making: an oncologist’s perspective    Wendy Y. Chen, MD MPH
Breast cancer statistics - 2012• 226,879 invasive breast cancer cases• 39, 510 breast cancer deaths  – Prostate cancer: 24...
Breast Cancer Decision Aids1. Ductal carcinoma in situ2. Early stage: local treatments3. Early stage: systemic therapy4. B...
Challenges to decision aidsStandardization           Personalization
Standardization• National Comprehensive Cancer Network  (NCCN) guidelines• Quality Oncology Practice Initiative  – Part of...
Breast QOPI module measures• Chemotherapy recommended within 4 mths of  diagnosis for Stage I (T1c) – III ER negative  bre...
Breast cancer treatment trend - Personalization • Old theory   – Stage major determinant of aggressiveness     of treatmen...
OncotypedxAvailable for ER positive tumors and mainly node negative
Chemo benefit as function of OncotypeDX score                                      Paik S,JCO 2006
Heuristics in oncology• Frameworks people use for decision making• Risk aversion  – Preference for smaller certain gain ov...
Shared Decision Making in OncologyPreference sensitivity – early stage breast cancer                                      ...
Shared Decision Making in OncologyPreference sensitivity – early stage breast cancer                                      ...
Shared Decision Making in Oncology• Mastectomy vs lumpectomy + RT  – No difference in overall survival• Radiation after lu...
Challenges to decision aidsStandardization           Personalization
Breast Cancer Decision Aids1. Ductal carcinoma in situ2. Early stage: local treatments3. Early stage: systemic therapy4. B...
Challenges in Shared Medical Decision Making: An Oncologist's Perspective
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Challenges in Shared Medical Decision Making: An Oncologist's Perspective

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2012 Summer Medical Editors Meeting: Wendy Y. Chen, MD, MPH

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Challenges in Shared Medical Decision Making: An Oncologist's Perspective

  1. 1. Challenges in shared medical decision making: an oncologist’s perspective Wendy Y. Chen, MD MPH
  2. 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. 3. Breast Cancer Decision Aids1. Ductal carcinoma in situ2. Early stage: local treatments3. Early stage: systemic therapy4. Breast reconstruction5. Metastatic breast cancer
  4. 4. Challenges to decision aidsStandardization Personalization
  5. 5. Standardization• National Comprehensive Cancer Network (NCCN) guidelines• Quality Oncology Practice Initiative – Part of ABIM recertfication process for Oncology
  6. 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. 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. 8. OncotypedxAvailable for ER positive tumors and mainly node negative
  9. 9. Chemo benefit as function of OncotypeDX score Paik S,JCO 2006
  10. 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. 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. 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. 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. 14. Challenges to decision aidsStandardization Personalization
  15. 15. Breast Cancer Decision Aids1. Ductal carcinoma in situ2. Early stage: local treatments3. Early stage: systemic therapy4. Breast reconstruction5. Metastatic breast cancer
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