Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA.
J Clin Oncol. 2010 Oct 1;28(28):4364-70. doi: 10.1200/JCO.2009.26.8870. Epub 2010 Aug 16.
Patients with more active roles in decisions are more satisfied and may have better health outcomes. Younger and better educated patients have more active roles in decisions, but whether patients' roles in decisions differ by characteristics of the decision itself is unknown.
We surveyed a large, population-based cohort of patients with recently diagnosed lung or colorectal cancer about their roles in decisions regarding surgery, radiation therapy, and/or chemotherapy. We used multinomial logistic regression to assess whether characteristics of the decision, including evidence about the treatment's benefit, whether the decision was likely preference-sensitive (palliative therapy for metastatic cancer), and treatment modality, influenced patients' roles in that decision.
Of 10,939 decisions made by 5,383 patients, 38.9% were patient controlled, 43.6% were shared, and 17.5% were physician controlled. When there was good evidence to support a treatment, shared control was greatest; when evidence was uncertain, patient control was greatest; and when there was no evidence for or evidence against a treatment, physician control was greatest (overall P < .001). Decisions about treatments for metastatic cancers tended to be more physician controlled than other decisions (P < .001).
Patients making decisions about treatments for which no evidence supports benefit and decisions about noncurative treatments reported more physician control, which suggests that patients may not want the responsibility of deciding on treatments that will not cure them. Better strategies for shared decision making may be needed when there is no evidence to support benefit of a treatment or when patients have terminal illnesses that cannot be cured.
在决策中扮演更积极角色的患者会更加满意，并且可能会有更好的健康结果。年轻和受教育程度更高的患者在决策中扮演更积极的角色，但患者在决策中的角色是否因决策本身的特征而异尚不清楚。
我们调查了一个大型的基于人群的肺癌或结直肠癌患者队列，了解他们在手术、放疗和/或化疗决策中的角色。我们使用多项逻辑回归来评估决策的特征，包括治疗效果的证据、决策是否可能是偏好敏感的（转移性癌症的姑息治疗）以及治疗方式，是否会影响患者在该决策中的角色。
在 5383 名患者做出的 10939 个决策中，38.9%由患者控制，43.6%由患者和医生共同控制，17.5%由医生控制。当有很好的证据支持治疗时，共同控制最大；当证据不确定时，患者控制最大；当没有或没有证据支持或反对治疗时，医生控制最大（总体 P <.001）。治疗转移性癌症的决策往往比其他决策更受医生控制（P <.001）。
对于没有证据支持获益的治疗和非治愈性治疗的决策，患者更倾向于医生控制，这表明患者可能不希望承担不会治愈他们的治疗决策的责任。当没有证据支持治疗获益或患者患有无法治愈的终末期疾病时，可能需要更好的共享决策策略。
