Letters
Palliative care Cancer
Volume 196 - Issue 1

Decision making in older patients with advanced cancer: does doctor know best?

Authors:  Lakshmi P Venkateswaran, Phyllis N Butow, Jesse Jansen, Nicholas R C Wilcken, Mark K Wong, Rina Hui, George Szonyi, Val J Gebski, Vasi Naganathan, Lisa G Horvath and Martin H N Tattersall

Med J Aust 2012; 196 (1): 35-36. || doi: 10.5694/mja11.10907
Published online: 16 January 2012
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To the Editor: The median age of Australian patients at first diagnosis of cancer is 67.8 years.1 In advanced, incurable cancer, goals of treatment include symptom control for all patients and prolongation of survival by weeks to months in a subgroup. In older people, treatment decisions can be complicated by comorbidities, polypharmacy, frailty and cognitive impairment. Few studies have investigated older patients’ information needs and preferences for involvement in decisions about their care.2,3 We performed an exploratory study to investigate whether the health status of older cancer patients predicted their information needs, decision preferences and their oncologists’ treatment recommendations. Concordance between patients’ stated preferences and the perceptions of their oncologists was also measured.

Fifty outpatients with advanced lung (n = 30) or bowel (n = 20) cancer, with a mean age of 66.9 years (range, 51–91 years) participated. Fourteen patients (28%) were older than 70 years and 80% were diagnosed with advanced cancer within the previous 4 months. Patients’ health status was measured using the Vulnerable Elders Survey (VES) 13, a validated questionnaire used to identify older persons at risk of health decline (indicated by scores of ≥ 3).4 Role preferences were elicited using the Control Preferences Scale.5

Thirteen patients (26%) had VES 13 scores of ≥ 3. Of these, five (38%) were over 70 years. Twenty-six of 49 patients (53%) wanted a passive role in decision making, and 29 of 50 patients (58%) wanted prognostic information. Age and VES 13 scores did not predict patients’ role preferences or desire for prognostic information. Oncologists were less likely to recommend chemotherapy for patients over 70 years (25% v 75%, P = 0.04) or for those who had VES 13 scores of 3 or above (20% v 80%, P = 0.02). Concordance between patients’ participation preferences and oncologist perceptions was 54%.

Until there is more evidence from larger studies of patient preferences, oncologists should ask patients their preferences about decision making and prognostic information.

Patients with advanced cancer, by characteristic and preference

Characteristic

Prefer non-passive decision control*

Prefer prognostic information

Total patients (n = 50)

23

29

Age 50–60 years

6

7

Age 61–70 years

11

14

Age 71–80 years

5

5

Age > 80 years

1

3

Male

10

18

Female

13

11

Born in Australia

15

14

Born outside Australia

8

15

Bowel cancer

13

19

Lung cancer

10

10

0 comorbidities†

3

5

1 comorbidity†

3

5

2 comorbidities†

4

7

≥ 3 comorbidities†

12

12

0 concomitant medications‡

1

4

1 concomitant medication‡

2

3

2 concomitant medications‡

7

5

≥ 3 concomitant medications‡

13

15

Lives alone

8

9

Lives with someone

15

20

Lives in aged care facility

0

0

ECOG PS = 0–1

20

24

ECOG PS = 2–3

2

4

Married

9

13

Not married

14

16

Primary education§

3

5

Secondary education§

14

14

Tertiary education§

5

10

VES 13 score = 0–2

17

19

VES 13 score = > 3

6

10

ECOG PS = Eastern Cooperative Oncology Group performance status; higher score = poorer status. VES = Vulnerable Elders Survey. * Total in passive and non-passive categories was 49 (one patient gave no preference). † Missing data for one patient. ‡ Missing data for three patients. § Missing data for two patients. VES 13 scores range from 0–10; scores > 3 indicate vulnerability to health decline.

Authors

  • Lakshmi P Venkateswaran1
  • Phyllis N Butow2
  • Jesse Jansen2
  • Nicholas R C Wilcken2
  • Mark K Wong1
  • Rina Hui1
  • George Szonyi3
  • Val J Gebski2
  • Vasi Naganathan2
  • Lisa G Horvath3
  • Martin H N Tattersall2
  • 1. Westmead Hospital, Sydney, NSW.
  • 2. University of Sydney, Sydney, NSW.
  • 3. Royal Prince Alfred Hospital, Sydney, NSW.

Correspondence: Lakshmi.Venkateswaran@swahs.health.nsw.gov.au

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