Doctor Decisions and Quality of Life
A more interesting title for this entry would be: "Does your doctor care about your quality of life?" The absolute answer for all the medical oncologists whom I know is a resounding "yes", but this study suggests that may not always be true. We know that decisions around treatment are very tough, and that patients never have all the information that the doctors do. For early cancer in general, and breast cancer in particular, this issue is usually not a hot one. The choices are between a few standard treatments that carry similar side effects. If there are particular reasons that a woman would be better served by one or another, or if she has other medical problems that would complicate some medications, that is clear. It becomes trickier in cases of advanced disease when the question is always about quality vs quantity of life.
Patients tend to over-estimate the possible benefit of treatments in advanced cancer. Doctors may quote response statistics, but defining "response" may or may not happen. Are we talking about a number of statistical significance (that may be quite small) or are we talking about a period of time that clearly has value? Immediately we are in a mire of values and subjective choices. While one person might tolerate any side effects in order to prolong life another few weeks or months, someone else might choose otherwise. It seems to me that the defining question must be being certain that the patient fully understands the possibilities (e.g. are we talking about living another week or another six months if treatment X is helpful?) and that respecting the patient's decision. This becomes a long and difficult conversation between doctor and patient, but it is one that must happen. We need to be sure that it is our values, not our doctors', that are driving the choices.
Here is the abstract and a link to this really interesting study:
How Long and How Well: Oncologists’ AttitudesToward the Relative Value of Life-Prolonging v.
Quality of Life-Enhancing Treatments
Michael A. Kozminski, BA, Peter J. Neumann, PhD, Eric S. Nadler, Aleksandra Jankovic, MSc, Peter A. Ubel, MD
Objective. To determine how oncologists value qualityenhancing v. life-prolonging outcomes attributable to chemotherapy.
Methods. The authors surveyed a random
. The authors surveyed a random
sample of 1379 US medical oncologists (members of the
American Society of Clinical Oncology), presenting them
with 2 scenarios involving a hypothetical new chemotherapy
drug. Given their responses, the authors derived the
implicit cost-effectiveness ratios each physician attributed
to quality-enhancing and life-prolonging chemotherapies.
Results. The authors received responses from 58% of the
. The authors received responses from 58% of the
oncologists surveyed. On average, the responses implied
that oncologists were willing to prescribe treatments that
cost $245,972 per quality-adjusted life-year (QALY; SD
$243,663 per QALY) in life-prolonging situations v. only
$119,082 per QALY (SD $197,048 per QALY) for treatments
that improve quality of life but do not prolong survival (P <
0.001). This difference did not depend on age, gender, percentage
of time in clinical work, or self-reported preparedness
to use and interpret cost-effectiveness information (P
> 0.05 for all specifications). Differences across these situations
persisted even among those who considered themselves
to be “well-prepared” to make cost-effectiveness
Conclusion. Cost-effectiveness thresholds for
oncologists vary widely for life-prolonging chemotherapy
compared to treatments that only enhance quality of life.
This difference suggests that oncologists value length of
survival more highly than quality of life when making chemotherapy
decisions.. (Med Decis Making 2011;31:380–385)
. To determine how oncologists value qualityenhancing v. life-prolonging outcomes attributable to chemotherapy.. The authors surveyed a random. The authors received responses from 58% of the