Palda V A, Llewellyn-Thomas H A, Mackenzie R G, Pritchard K I, Naylor C D
St Michael's Hospital, University of Toronto, Canada.
J Clin Oncol. 1997 Oct;15(10):3192-200. doi: 10.1200/JCO.1997.15.10.3192.
Along with evidence, clinical policies must take patients' values into account. Particularly where evidence is limited and where assumptions of utility-maximizing behavior may not be valid, new methods such as trade-off techniques (TOTs), which allow elicitation of patients' treatment alternatives, might be useful in policy formulation. We used TOTs to assess breast cancer patients' attitudes toward two clinical policies designed to ration adjuvant postlumpectomy breast radiation therapy.
Cross-sectional interviews were performed in a tertiary cancer center. A total of 102 patients were presented with information about the side effects and benefits associated with two hypothetical decisions: (1) willingness to receive treatment elsewhere to shorten the wait for radiation therapy, and (2) foregoing radiation therapy in the face of small marginal benefits. For each scenario, a TOT was used to identify the maximal acceptable wait time (MAWT) for therapy and the benefit threshold at which the patient would forego therapy. Associations of clinical and demographic factors with these decisions were determined by regression analysis.
Patients would be willing to wait, on average, 7 weeks before wanting to leave their city for radiation therapy, less than the 13-week delay our patients actually faced. Older patients were less willing to wait (P = .013); 46% of patients would not give up radiation therapy, even in the face of no stated benefit. Willingness to give up radiation therapy was predicted by willingness to accept delay (odds ratio [OR], 1.84; 95% confidence interval [CI], 1.05 to 3.37) and being employed (OR, 2.61; 95% CI, 1.08 to 6.54). Patients with larger tumors were less willing to give up radiation therapy (OR, 0.57; 95% CI, 0.31 to 0.97).
Even in difficult decisions such as rationing postlumpectomy breast cancer radiation therapy, TOTs can inform policy formulation by indicating the distributions of patients' preferences.
临床政策必须结合证据并考虑患者的价值观。特别是在证据有限且效用最大化行为的假设可能无效的情况下，诸如权衡技术（TOTs）等新方法可能有助于政策制定，该技术可用于引出患者对治疗方案的选择。我们使用TOTs来评估乳腺癌患者对旨在合理分配保乳术后辅助性乳房放射治疗的两项临床政策的态度。
在一家三级癌症中心进行横断面访谈。向总共102名患者提供了与两个假设决策相关的副作用和益处信息：（1）愿意在其他地方接受治疗以缩短等待放射治疗的时间，以及（2）在边际益处较小的情况下放弃放射治疗。对于每种情况，使用TOTs来确定治疗的最大可接受等待时间（MAWT）以及患者会放弃治疗的益处阈值。通过回归分析确定临床和人口统计学因素与这些决策之间的关联。
患者平均愿意等待7周后才想离开所在城市去接受放射治疗，这比我们的患者实际面临的13周延迟要短。年龄较大的患者不太愿意等待（P = 0.013）；46%的患者即使在没有明确益处的情况下也不会放弃放射治疗。放弃放射治疗的意愿可通过接受延迟的意愿（优势比[OR]，1.84；95%置信区间[CI]，1.05至3.37）和就业情况（OR，2.61；95%CI，1.08至6.54）来预测。肿瘤较大的患者不太愿意放弃放射治疗（OR，0.57；95%CI，0.31至0.97）。
即使在诸如合理分配保乳术后乳腺癌放射治疗这样的困难决策中，TOTs也可以通过表明患者偏好的分布来为政策制定提供信息。
