Abstract
Background: The systemic treatment of epithelial ovarian cancer (OC) is one of the cornerstones in the multimodal management of advanced OC in both primary and recurrent stages of this disease. In most situations various treatment options are available but only few data exists about the treatment decision-making process. Therefore, we conducted a review of the current literature regarding the decision-making process concerning the systemic therapy in patients with advanced ovarian cancer. Materials and Methods: The electronic database MEDLINE (PubMed) was systematically reviewed for studies that evaluate the treatment decision-making processes in patients with advanced OC. Results: The PubMed database was searched in detail for all titles and abstracts of potentially relevant studies published between 1995 and 2011. An initial search identified 15 potentially relevant studies, but only seven met all inclusion criteria. Factors that influence treatment decisions in patients with OC include not only rational arguments and medical reasons, but also individual attitudes, fears, existential questions, various projections resulting from the physician patient relationship and the social environment. The physician's personal experience with OC treatment seems to be an important factor, followed by previous personal experience with medical issues, and the fear of side-effects and future metastases. Family and self-support organisations also seem to play a significant role in the treatment decision-making process. Conclusion: This review underlines the need for more research activities to explore the treatment decision-making process to enable the best individual support for patients in treatment decision-making. It is a challenge for clinicians to determine the individual information needs of women with OC and to involve them during the decision-making process to the extent they wish.
Ovarian cancer is the fifth the most common type of cancer among women. The worldwide annual incidence rate varies considerably, ranging in 2008 from 9 per 100,000 in industrialized countries to 5 per 100,000 in developing countries. With a mortality rate of 3.8 per 100,000 women, the survival expectation of patients with ovarian cancer compared with other types of cancer of the female reproductive system is very low (1).
In most patients, primary cytoreduction followed by postoperative adjuvant chemotherapy with a platinum- and taxane-based regimen given for six cycles are the cornerstone in the clinical management of advanced ovarian cancer. In cases of advanced stage IIIb, IIIc and IV stage diseases recent randomized trials indicated a significantly better progression survival upon addition of maintenance therapy with bevacizumab for a period of 15 months. Despite improvements in radical surgery and systemic therapy, recurrences are frequent and most patients will die due to tumor progression. Based on the platinum-free interval, there are different treatment options for systemic chemotherapy for patients with recurrent ovarian cancer (2). The patient's preference should be considered in cases of relapsed ovarian cancer and is demanded by various guidelines, but surprisingly, only few data exists about the decision-making process in patients with cancer.
The increasingly advocated shared decision-making model can strengthen the physician-patient relationship and make the patient a part of the decision-making process. This process of treatment decision-making involves three stages (3): The first stage involves an information exchange regarding relevant disease and treatment options. The information exchange should also take into account the patient's attitudes and values, as well as their needs, emotions and preferences. The second stage is the deliberation- a process of identifying values which are important for the patient/physician interaction and details about treatment preferences. The last stage is the actual decision-making stage, where the treatment is determined by a consensus. This last stage is mainly influenced by the patients perception of the disease, as well as the balance between treatment advantages and toxicity and the goal of therapy. Study by Stewart et al., 105 women with ovarian cancer were asked who should ideally make the final treatment decision. Almost 20% of the patients expected their physician to make the decision about the treatment, 15% of the women wanted to make the final decision themselves, and 60% wished to have a shared decision-making process with their treating physician. However, all women required detailed and broad information about their disease and the various treatment options (4).
The paths followed, by both physicians and patients that lead them to their final decision regarding treatment are difficult and complex, as is the identification of the actual criteria and factors that influence this decision. Potential influential factors on the patients side are fear of reccurence or metastasis and toxicity, while the advice of family and medial staff also play a relevant role (5). Physicians are supposed to support their patients throughout the entire process, even though it is very complex to find a consistent method that supports the patient in decision-making. There are very few data about this relevant topic regarding patients with ovarian cancer. Therefore, we conducted this review to analyze the current literature to identify the potential factors influencing treatment decision-making in patients with ovarian cancer.
Materials and Methods
Inclusion and exclusion criteria. Medical literature was systematically reviewed for studies evaluating processes regarding decision-making in ovarian cancer. PubMed was searched by using the following key words “ovarian cancer, gynecological cancer and treatment decision-making”. The evaluated period covered 16 years, namely 1995 to 2011.
All full papers of the individual studies dealing with treatment decision-making in patients with ovarian cancer were retrieved. All studies with ovarian cancer patients, regardless of study type, size of study population, geographic region and cancer progress during treatment decision (first-line therapy, recurrence) were included. Studies dealing with the decision-making process in patients with gynecological cancer where ovarian cancer was included were also considered. Studies were excluded if their abstract did not contain the sought key words. They were also excluded if their contents did not cover the researched topics although their title contained the relevant key words.
Results
Search results. The MEDLINE (PubMed) search identified 15 relevant studies regarding the decision-making process in gynecological cancer (4-18). Seven studies focused on decision-making process in patients with ovarial cancer (4-10).
Only one study was identified that evaluated the decision-making process of patients with gynecological cancer in general, but patients with ovarian cancer were analyzed separately as a subgroup (5).
Eight studies out of the 15 identified were excluded because their contents did not cover the researched topics although their title contained the relevant key words (11-18). Two of these excluded studies deal with the decision-making process regarding risk reduction for patients with hereditary breast or ovarian cancer; another study analyzed the impact of [18F]-fluorodeoxyglucose positron emission tomography and computed tomography (FDG-PET/CT) in the decision-making of a suspected ovarian cancer recurrence (11-13).
Study overview. The main methodological characteristics and influencing factors of the relevant articles are summarized in Table I.
Discussion
The present analysis is an attempt to give an overview of the factors influencing the decision-making process in patients with primary or relapsed ovarian cancer who are scheduled to undergo a systemic treatment. The overall knowledge and sensitive regarding this important issue is very scarce and only a few studies exist that have systematically evaluated treatment decision-making in patients with ovarian cancer. A better insight into the involved processes will not only contribute to a better understanding of the interaction between patients and physicians, but will also improve patient's compliance.
In the two studies of Elit and colleagues from the 2003 (patients with primary OC) and 2010 (patients with ROC) the expectations and behavior of patients on their way to treatment decision did not follow the shared decision-making model (1) like that described by Charles et al. (3). Elit et al. showed that patients with ovarian cancer usually follow the physician's recommendation without restrictions, are not expecting to know exact details about treatment toxicity or the names of the applied substances. Furthermore, the authors showed that most patients wished to be treated by the same physician who treated them at the initial manifestation of the disease, so that there would be no need to elucidate their beliefs and perspectives in the treatment decision-making again. This continuity facilitates the communication process.
Both studies of Elit et al. share the same background in terms of the patients' attitudes. The difference between these two studies is that patients with recurrent ovarian cancer had different goals compared with patients with primary diagnosis. The primary objective in the primary situation is cure, whereas symptom control and quality of life aspects are generally the aims for recurrent disease.
As expected, the data show that the patients with recurrent disease from the year 2010 appear to be more involved in the treatment decision process than at the time of first diagnosis. However, in both studies, the authors showed that patients feel overwhelmed by the entire decision-making process regardless of their disease stage or status of disease (i.e. primary vs. relapse). The most important influential factors in both studies were the family and friends, as well as other patients with ovarian cancer (6, 9). In almost all studies the physician's treatment recommendation played a decisive role in the patient's treatment decision-making. Moreovers the personal experience of the patient herself seems to play a crucial role in the attitude which is developed towards the disease.
In contrast to the 2003 study, 2010 study of Elit et al. examine the perceptions of patients in the treatment decision process very closely. However, the study does not verify exactly how the patient's perception influences the physician's behavior and communication style (9).
Other studies, like that from Stewart et al. showed that most patients demand shared decision-making processes at every stage of their illness, especially if the disease is progressive.
In another study by Kitamura, the pair-wise comparisons by the analytic hierarchy process (AHP) offers a possibility to understand the patient's choice and it also demonstrates the need to question the importance of various criteria, e.g. social demographic and psychological factors, because they have an effect on the investigation. Such a model supports the treatment decision process of patients in order to quantitatively represent the patient's situations and help the patient to ask specific questions regarding treatment options (5). Recently, the North-Eastern German Society of Gynecological Oncology (NOGGO) finished enrolment of a study in elderly patients with relapsed ovarian cancer (preference trial). Patients had a free choice of the alkylating agent treosulfan given intravenously (i.v.) or as tablets. Interestingly, most patients preferred the i.v. application because most had already been taking many other tablets for their co-morbidities (19).
An international survey on patients' preferences and attitudes regarding physician-patient relationship and cancer management is ongoing (20). A recent interim analysis showed that most patients demand more explanations about side-effects to be able to make a choice of a specific cancer treatment (21). The final analyses of this study, with more than 1500 participants, will be awaited in 2013 and will also try to identify cultural-based differences in the patients' expectations.
Conclusion
The currently available literature does not provide enough evidence to identify the relevant and reproducible factors of a treatment decision-making for patients with relapsed ovarian cancer. The patient physician interaction seems to be mainly based on random events without any systematic basis, while efforts towards an improvement of this process are not sufficient, with a global lack of overall attention to this highly important issue. As novel treatments and therapeutic options are continuously emerging, patients are now more than ever called to make critical decisions without any systematic or professional psychosocial support. Therefore, there is an urgent need to understand better the factors that underpin the treatment decision-making process. This would undoubtedly lead to an increase in patients' compliance and satisfaction.
- Received May 26, 2012.
- Revision received July 26, 2012.
- Accepted July 30, 2012.
- Copyright© 2012 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved