Women’s Perceptions About Treatment Decision-Making for Ovarian Cancer
Abstract & Commentary
Synopsis: Women with advanced epithelial ovarian cancer did not describe the treatment decision-making process as shared; rather, they described an interaction that was directed by their physician.
Source: Elit L, et al. Gynecol Oncol. 2003;88:89-95.
Elit and colleagues conducted in-depth semistructured interviews with 21 patients who underwent initial surgery for stage III or IV ovarian cancer and who had received less than 2 cycles of chemotherapy. Their analysis highlighted 5 themes:
1. Knowledge of treatment benefits and risks.
Women understood that the treatment had both survival and quality-of-life benefits. Women could clearly articulate the risks of chemotherapy.
2. Readiness to make a decision.
When making treatment decisions, women described being overwhelmed by the effects of concurrent drugs like analgesics, the severity of the illness, unexpected diagnosis of cancer and grief, and feeling pressured into a decision.
3. Perception of a treatment choice.
Most women felt that they made their treatment decision; however, most women did not perceive that they had a treatment choice. Thus, treatment decision-making is really a process of coming to terms with the disease and the recommended treatment.
4. Physician-patient relationship.
All women suggest that their doctor knew the right treatment for them and they felt confident in their cancer physician.
5. Social supports.
Women described supports through decision-making processes that included individuals who advocated for them, faith, and past experience with the cancer system. Hindrances to decision-making included people who were negative, the cancer label, and employers. Elit et al concluded that women with advanced epithelial ovarian cancer did not describe the treatment decision-making process as shared; rather, they described an interaction that was directed largely by the physician. These women attribute this form of decision-making to their advanced age, severity of illness, immediate ramification of treatment choices, and lack of advocacy for a different model of interaction. They further concluded that the onus is on the physician to ensure that there is an environment for shared decision-making in the event that the patient is interested in such an interaction.
Comment by David M. Gershenson, MD
This study underscores the importance of the doctor-patient relationship surrounding the initial diagnosis of advanced epithelial ovarian cancer. Over the past 2 decades or so, this interaction has transitioned from a paternalistic attitude on the part of the physician toward the patient to an environment in which there is a shared decision-making process. Obviously, from the reading of this article, there is still much room for improvement. A new diagnosis of advanced ovarian cancer is generally very devastating, and there is an expected feeling of "loss of control" for the patient and her family. Because the standard management for a woman with suspected advanced ovarian cancer is primary cytoreductive surgery followed by combination chemotherapy, patients may feel that their options are very limited. One strategy for broadening treatment options for patients is to be able to offer innovative clinical trials, and much more work is needed to extend clinical trials into more community based practice settings. Elit et al use the comparison of this scenario to that of women with early-stage breast cancer, who are more easily able to assume a more autonomous role in decision-making regarding their treatment. There are several reasons for this disparity, including differences in average age, general condition, and the influence of prognosis on psychological well-being. Much more study is needed in this area, but we are continuously moving closer to the ideal in which patient preferences emerge as key components during this most sensitive time.
Dr. Gershenson is Professor and Chairman, Department of Gynecology, M.D. Anderson Cancer Center, Houston.