What is the treatment decision-making process in older adults with cancer?
Dr Martine Puts - University of Toronto, Toronto, Canada
You have been looking at treatment decision making which can be difficult in older patients and you’ve been looking at a number of variables. Can you tell me what you were doing in this study that you’re reporting here?
In this study, based on our previous research where we found out that older adults refused more commonly treatment, and when we looked at the overall literature what do we know about treatment decision making experiences in older adults we found that there’s very, very few studies that are focussed on older adults where we know from the literature as well that there’s more variability in what is offered. So we wanted to know, to explore from the older adults and their family members’ perspective, how they were making treatment decisions, what was important to them and from their perspective what they think could be done better to help future older patients.
And you were looking at comorbidity, for instance, also frailty and functional status. What did you find about these and their influence on decision making?
From the patient perspective it had no influence on the treatment decision making experiences. We asked how they came to make their treatment decisions and they really just accepted what the oncologist recommended. So they trusted the oncologist and they just accepted whatever he recommended. Although most of our study patients had comorbidities it seems to not be important in their treatment decision making process at all and similarly with their functional status, they just go with what the oncologist recommends they should do.
What then is the outcome of your study?
We don’t have a final outcome yet because we’re still analysing the follow-up data. We followed the older adults for 3-6 months so we have a few more interviews to complete. But from their perspective they were very satisfied but the information provided to them could be improved because not all of them understand the written information and they would like it to be more accessible. They would also like their healthcare team to give them more information about reliable websites. Most older adults and their family members went online on the internet to find more information but the healthcare team doesn’t provide them with where they can find reliable information. So that is what they really would like to see, that their healthcare team gives them a list of websites to go to.
Which cancer types were you looking at and how many patients did you include in the study?
This was an exploratory study so we had 26 patients between the age of 70-79 and we had 12 patients over the age of 80. We purposely chose breast, lung, colorectal and prostate because these are the four most common cancers in Canada. We divided our age groups so that we would also have enough older adults over the age of 80 because we anticipated that treatment decision making experiences might be different in the oldest old and in the younger old.
We’re hearing at this very meeting here in Prague that it’s important to consult patients and find out what the patient’s agenda is in order to make some of these decisions. Yet you’re saying that your overall finding was that the patients did whatever the doctor said. How much was the doctor influenced by what the patients said?
The doctor, we also interviewed the cancer specialists and they take into account what the patients want but particularly because we recruited patients who were offered palliative treatment they tried to find the most easy treatment for the older adults with the least amount of hospital visits and the least amount of side effects.
So they’d already been filtered out the more challenging cases then?
So what are the big messages coming out of your study so far? I know there’s more to be done but what kind of clinical messages are coming out of this for doctors?
We have to think about our education because we find over, and in our review we found the same thing, that older adults just go with the doctor’s recommendations. So as healthcare teams we need to make sure that we assess what is important for the older adults because we have so much influence on their treatment decisions. So we have to make sure that we assess their preferences and make sure they understand the information and that we offer a treatment that is relevant and important to them.
Are you satisfied with the level of communication going on between doctors and patients or do you think the patients might be just obedient and not getting perhaps everything they would like in their agenda?
In the literature we tend to see that older adults are very satisfied with the information, that this generation is not so vocal in saying that they are not satisfied. Also our study sample was 38 older adults who chose to come to a comprehensive cancer centre.
So already co-operative.
So they were already referred from their local hospital to the big cancer treatment centres meaning that they were more likely to seek active treatment.
What sort of call for action would you make at this stage coming out of the data you’re reporting here?
We need to have a good look at the written information, what we provide them, if they can understand it, that it’s at a level that meets their information needs. We also interviewed the family physicians and a lot of them didn’t receive timely information about the cancer patients so we also have to look at how we communicate with other healthcare team members about what the older adults are getting in terms of treatment and that they have accurate information because half of the older adults in our study went to see their family physician but the family physicians didn’t often have received the information from the oncologist yet. So we have to find a way to make sure that as a hospital we give the relevant information to the family physician.
So let me get this right, you’re saying there’s a need for more informational glue to keep the multidisciplinary team together and on message for everything?
Yes, because older adults tend to see many doctors and they have many diseases so to make sure that every member of the healthcare team has the right information.