Stalmeier Peep F M, van Tol-Geerdink Julia J, van Lin Emile N J Th, Schimmel Erik, Huizenga Henk, van Daal Willem A J, Leer Jan-Willem
Department of Radiation Oncology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands.
J Clin Oncol. 2007 Jul 20;25(21):3096-100. doi: 10.1200/JCO.2006.07.4955.
Physicians hold opinions about unvoiced patient preferences, so-called substitute preferences. We studied whether doctors can predict preferences of patients supported with a decision aid.
A total of 150 patients with prostate cancer facing radiotherapy were included. After the initial consultation, without discussing any treatment choice, physicians gave substitute judgments for patients' decision-making and radiation dose preferences. Physicians knew that several weeks later, patients would be empowered by a decision aid supporting a choice between two radiation doses involving a trade-off between disease-free survival and adverse effects. Subsequently, patient preferences for decision making (whether or not they wanted to choose a radiation dose) and for treatment (low or high dose) were obtained. The chosen radiation dose actually was administered.
Of the patients studied, 79% chose a treatment; physicians believed that 66% of the patients wanted to choose. Agreement was poor (64%; = 0.13; P = .11), and was better as patients became more hopeful (odds ratio [OR] = 4.4 per unit; P = .001) and as physicians' experience increased (OR = 1.09 per year; P = .02). Twenty percent of physicians' preferences, 51% of physicians' substitute preferences, and 71% of patients' preferences favored the lower dose; agreement was again poor (70%; = 0.2; P = .03).
Physicians had problems predicting the preferences of patients empowered with a decision aid. They slightly underestimated patients' decision-making preferences, and underestimated patients' preferences for the less toxic treatment. Counseling might be improved by first informing patients-possibly using a decision aid--before discussing patient preferences.
医生对未表达出来的患者偏好（即所谓的替代偏好）持有看法。我们研究了医生是否能够预测在决策辅助工具帮助下患者的偏好。
共纳入150例面临放疗的前列腺癌患者。在初次咨询后，未讨论任何治疗选择，医生对患者的决策和放射剂量偏好做出替代判断。医生知道几周后，患者将通过决策辅助工具来辅助做出关于两种放射剂量选择的决策，这两种剂量在无病生存期和不良反应之间存在权衡。随后，获取患者对决策（是否想要选择放射剂量）和治疗（低剂量或高剂量）的偏好。实际给予所选择的放射剂量。
在研究的患者中，79%选择了一种治疗方式；医生认为66%的患者想要做出选择。一致性较差（64%；κ = 0.13；P = 0.11），并且随着患者变得更有希望（优势比[OR] = 每单位4.4；P = 0.001）以及医生经验的增加（OR = 每年1.09；P = 0.02），一致性有所改善。20%的医生偏好、51%的医生替代偏好以及71%的患者偏好倾向于较低剂量；一致性再次较差（70%；κ = 0.2；P = 0.03）。
医生在预测使用决策辅助工具的患者偏好方面存在问题。他们略微低估了患者的决策偏好，并且低估了患者对毒性较小治疗的偏好。在讨论患者偏好之前，或许可以通过首先告知患者（可能使用决策辅助工具）来改善咨询效果。
