Wanting more

USA Today reports on a survey presented at the 2007 Gastrointestinal Cancers Symposium in Orlando, indicating that colorectal cancer patients are more willing to undergo repeat chemo than their doctors think. (Study: Doctors out of sync with cancer patients’ wishes)
Thirty-five percent of patients who’d had surgery and drugs already said they would have chemo again –with all its side effects and dangers– for a 1 percent reduction in the chance of relapse.  Less than 20 percent of physicians thought patients would agree to that deal. Drugmaker Sanofi-Aventis sponsored the survey, which is pretty a clear attempt to boost the use of drugs in hopeless situations, but it doesn’t mean the conclusions are wrong.

What could be the reason for the disconnect? Here are some possibilities:

  • The physicians interpreted the question literally while patients treated the 1 percent as “a low chance”
  • Patients who in healthier times would have been enthusiastic about “death with dignity” and foregoing excessive end-of-life care feel differently when doing nothing means inviting death. Meanwhile, oncologists, unfortunately, become used to seeing patients die and mentally write off patients who reach a certain stage
  • Oncologists are making judgments about what should happen rather than what patients want. This is based partly on a concern about expending huge resources when the outcomes are likely to be poor

A co-author notes another possibility: by definition the respondents already lived through chemo, so may be more positive about it than they otherwise would. I don’t really buy that explanation as the physicians should have adjusted their answers to reflect that fact.

January 23, 2007

4 thoughts on “Wanting more”

  1. The study results are puzzling. I think your posting speculating as to possible explanations is a very productive angle to explore.

    There’s a whole body of research that looks at patient preferences vs. doctor preferences, most typically in the context of exploring what happens when patients become informed of risks of procedures.

    Based on my knowledge of the field — which isn’t exhaustive — a more typical finding is that “informed patients” choose more conservative treatment paths than physicians recommend. For example, there are studies that show men often choose to forego prostate surgery after being informed about risks of surgery vs. typical long-term development cycle for the disease (10+ years).

    I’m not aware of ANY other studies suggesting that well informed patients choose MORE aggressive treatment options than doctors. Anybody else know of any?

  2. It has been my experience (overall) that oncologists are not hesitant to offer chemotherapeutic options. In fact, many patient are offered therapies that have very little chance of success with an unfavorable side effect profile.

    A more subtle issue that this article raises relates to how treatment “options” are presented to patients and how the presentation is invariably biased by the physician’s own perceptions. This applies to all fields of medicine. Physician’s tend to “filter” the available “evidence” upon which we supposedly base our medical decisions. This is not entirely bad, just hope you have a physician with good judgment!

    Speaking of biases, drug company sponsored trials may be valid, but must be scrutinized. Bias can be introduced at many levels of a study. For example, did the researchers ask if the patient would try additional chemotherapy with a “99% chance of failure” or “1% chance of success”? Although both phrases are accurate, they are likely to lead to different responses.

  3. Internist describes a good way to reconcile Vince’s observation with the survey results. As a kid I remember my father telling me, “Surgeons like to cut.” So if you ask a surgeon for his opinion on what to do, don’t be surprised when they advise a surgical procedure. It’s not necessarily because they are seeking the income, just that surgery is the way they know to fix problems.

    The observation that informed patients choose conservative treatments is an interesting one. At least some of these patients are informed by their insurance companies, which stand to gain from foregone treatment. I wrote about the use of scary videos to inform patients/discourage treatment a while back.http://www.healthbusinessblog.com/?p=457

  4. I’m with a company called AmeriSciences; we deal in OTC Pharmacutical Grade Supplements designed for men, women, and children, we are associated with NASA and the Johnson Space Center developing suplements for deep space travel—we have over 4000 doctors on board now—are goal is to change the health of this nation–please look at the website–thank you!

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