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Originally published as JCO Early Release 10.1200/JCO.2004.09.960 on November 1 2004 © 2004 American Society of Clinical Oncology.
Perspectives, Preferences, Care Practices, and Outcomes in Late-Stage Cancer Patients: Connecting the DotsUCLA Multicampus Program in Geriatric Medicine and Gerontology, Jonsson Comprehensive Cancer Center and Division of Hematology-Oncology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA Although cancer affects children and young adults, it is largely a disease of middle-aged and older persons. In both men and women, the incidence of cancer begins to rise sharply at age 50 years and peaks by 80 years. The reasons for this age distribution are not entirely clear, but may result from the loss of tumor-suppressor mechanisms that delay the development of cancer until after the period of sexual maturity and reproduction.1 As a result, 58% of all cancers are diagnosed in persons aged 65 years or older.2 Decision making in oncology is complicated because there frequently is no single correct treatment pathway or choice,3 especially for older persons who have shorter life expectancies regardless of a cancer diagnosis.4 Individual preferences and value of the benefits, harms, and costs of different treatment options must be considered within the context of alternative treatment pathways.5 Physicians and patients need to weigh a multitude of factors, such as longevity, short- and long-term quality of life, personal risk and risk tolerance, and treatment-response uncertainty in the process of making treatment decisions.6,7 Once treatment decisions have been made, the link between these decisions and the care subsequently provided is a major issue for cancer patients of all ages. In this issue of the Journal of Clinical Oncology, Rose et al used data from the Study to Understand Prognoses and Preferences for Risks of Treatments (SUPPORT) to better examine these links in late-stage cancer patients.8 The authors developed a theoretical model that includes physician and patient estimates of 6-month survival and patients' perceived quality of life (perspectives), patients' treatment goals and desires for cardiopulmonary resuscitation (CPR; patient preferences), discussions about aggressiveness of care and therapeutic interventions that were provided (care practices), and hospital re-admissions and length of survival (outcomes). Although it could be argued that physicians' preferences should be included in the model, the elements of the model selected by the authors are valuable. Most importantly, the study permits examination of the links among these different elements. Based on the authors' model, the general findings for the four individual components are: (1) physicians estimate the rates of 6-month survival at about half that estimated by middle-aged or older patients; (2) older patients are somewhat less likely than younger patients to want to extend life and to want CPR than younger patients; (3) older patients had more discussions about end-of-life care, but there were no differences by age in the interventions provided; and (4) older patients were less likely to be re-admitted to the hospital or to survive for 6 months than were younger patients. Of note, actual 6-month survival rates in both age groups were almost identical to the physicians' estimated 6-month survival rates. These findings are consistent with previous studies indicating that lung cancer patients are more optimistic than their physicians about the possibility of cure and symptomatic improvement,9 and that older patients are more likely to have discussions about treatment limitation than younger or middle-aged patients, but are not more likely to be discharged to hospice or home care.10 When examining the relationships among the four elements of the model, most of the associations were similar in both the middle-aged and the older age groups. Specifically, if doctors or patients believed that a patient would survive at least 6 months, the patient was more likely to want CPR. In addition, if patients believed that they would survive for at least 6 months, then they preferred to extend life. If physicians believed that their patients would survive at least 6 months, then conversations about end of life care (presumably initiated by the physicians) were much less likely to occur, and these patients were much less likely to die. Documented discussions about aggressiveness of care were associated with increased likelihood of death, but also predictive of hospital re-admission. This last finding suggests that discussions of limitations had little impact on the care provided, though the authors did not examine the specific relationships between discussions and therapeutic interventions in either age group. In the older group, but not the middle-aged group, there was a relationship in age-stratified analyses between patient preferences for extending life or wanting CPR, and the number of therapeutic interventions provided. Again, some these findings are consistent with findings in previously published literature.11 To put Rose et al's findings into context, some background about SUPPORT is necessary. SUPPORT was conducted in teaching hospital settings and focused on seriously ill patients, many of whom were in intensive care units. The cancer participants selected were late stage, and admitted because of non–small-cell lung cancer, colon cancer with metastases to the liver, or malignancy associated with multiorgan system failure. In these patients, there was no association between aggressiveness of care and overall survival in either age group. Thus, it is likely that many patients were on a relentless path toward death. If so, the ascertainment of preferences and implementation of therapy may have more symbolic than clinical meaning. Moreover, little can be said about the links among perspectives, preferences, and care practices for patients earlier in their cancer course, when aggressiveness of care might have affected clinical outcomes. The setting of academic health centers must also be taken into consideration. Although teaching hospitals are known for having outstanding physicians and access to the latest diagnostic and therapeutic technologies, the complexity of care by multiple providers (including primary care physicians, oncologists, intensivists, and trainees) may obscure the lines of responsibility for linking preferences to care practices. Other limitations of the study should be noted. The study sample size was too large for many of the questions being asked. While this gives us confidence that the study was adequately powered to prevent type II errors, it also means that some differences that are statistically significant probably do not have much clinical meaning. For example, physicians' and patients' prognostic estimates of 6-month survival differed significantly between middle-aged patients and older patients (40% v 34% and 81% v 79%, respectively) but it would be difficult to say that these are really different from a clinical care perspective. Rose et al also interpret apparent differences in ß-coefficients in age-stratified models as evidence for differential relations between preferences and therapeutic interventions in middle-aged and older patients. However, the authors do not provide 95% CIs around the raw or standardized coefficients, so the reader is unable to determine whether these coefficients truly differ by age. Moreover, the large sample size and the questions asked of the model might have been better suited for a different method of analysis, such as structural equation modeling. What are the implications of this study? First, despite being seriously ill, both middle-aged and older groups of cancer patients are more optimistic and less accurate about their prognosis than their physicians. In this study, the patients' estimates of prognosis, in turn, had strong influences on preferences for CPR and extending life methods. Accordingly, it is important that physicians communicate effectively about prognosis. Physicians have used diverse strategies to convey prognosis and discuss end-of-life issues,12 but often fail to communicate key information about prognosis and alternative treatments to patients.13 Developing and testing interventions that improve communication about prognosis should be high on the agenda for future research. Second, the causes of discord between patient preferences and care provided need to be better identified and then eliminated. It is hard to argue that late-stage cancer patients should ever receive care that is not in keeping with their preferences. Third, the study raises the question of why discussions about aggressive care are associated with increased re-admission rates. Perhaps these discussions occurred more frequently with patients and families who were reluctant to limit care and physicians had made multiple attempts to discuss this topic. Finally, the study's focus on late-stage cancer raises the question of whether these insights also apply to cancer patients earlier in the course of their disease, when there is less clarity about their prognosis. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest. REFERENCES 1. Campisi J: Cancer and ageing: Rival demons? Nat Rev Cancer 3:339-349, 2003[CrossRef][Medline]
2. Gloekler Ries LA, Reichman ME, Lewis DR, et al: Cancer survival and incidence from the Surveillance, Epidemiology, and End Results (SEER) program. Oncologist 8:541-552, 2003
3. O'Connor AM, Legare F, Stacey D: Risk communication in practice: The contribution of decision aids. BMJ 327:736-740, 2003 4. Fried VM, Pager K, MacKay AP, et al: Chartbook on Trends in the Health of Americans. Health, United States, 2003. Hyattsville, MD: National Center for Health Statistics. US Life Tables, 2000 National Vital Statistics Reports, Vol. 51, No. 3, December 19, 2002, p 29 5. Lewis M, Pearson V, Corcoran-Perry S, et al: Decision making by elderly patients with cancer and their caregivers. Cancer Nurs 20:389-397, 1997[Medline] 6. Davison BJ, Parker PA, Goldenberg SL: Patients' preferences for communicating a prostate cancer diagnosis and participating in medical decision-making. BJU Int 93:47-51, 2004 7. Solomon MJ, Pager CK, Keshava A, et al: What do patients want? Patient preferences and surrogate decision making in the treatment of colorectal cancer. Dis Colon Rectum 46:1351-1357, 2003[CrossRef][Medline]
8. Rose JH,O'Toole EE, Dawson NV et al: Perspective, preferences, care practices, and outcomes among older and middle-aged patients with late-stage cancer. J Clin Oncol 22:4907-4917, 2004 9. Quirt CF, Mackillop WJ: Ginsburg AD, et al: Do doctors know when their patients don't? A survey of doctor-patient communication in lung cancer. Lung Cancer 18:1-20, 1997[CrossRef][Medline] 10. Rose JH, O'Toole EE, Dawson NV, et al: Age differences in care practices and outcomes for hospitalized patients with cancer. J Am Geriatr Soc 48:S25-S32, 2000 (suppl 5)[Medline]
11. Weeks JC, Cook EF, O'Day SJ, et al: Relationship between cancer patients' predictions of prognosis and their treatment preferences. JAMA 279:1709-1714, 1998 12. Friedrichsen MJ, Strang PM: Doctors' strategies when breaking bad news to terminally ill patients. J Palliat Med 6:565-574, 2003[Medline]
13. Gattellari M, Voigt KJ, Butow PN, et al: When the treatment goal is not cure: Are cancer patients equipped to make informed decisions? J Clin Oncol 20:503-513, 2002 Related Article
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Copyright © 2004 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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