SDM in LACC treatment: balancing evidence with patient values despite barriers
04 Nov 2024
byDr. Mel M. Beluan
A recent review by Manila-based researchers Bacorro et al attempted to shed light on the status of local SDM in locally advanced cervical cancer (LACC), and the challenges it faces. Their systematic search of literature revealed only seven local studies on SDM in oncology. Among these, they reported a global, multicenter, cross-sectional clinical trial, in which the University of Santo Tomas Hospital (USTH) arm of the study showed greater acceptability of SDM among patients with advanced cancer (n=100): “Shared or active decision control preferences were more common (48.5 and 29.3 percent, respectively) than passive decisional control (22.2 percent)”. [Glob Oncol 2024 May:10:e2300486. doi: 10.1200/GO.23.00486]
The USTH arm also revealed that “high educational attainment was a significant negative predictor (odds ratio [OR], 0.64 [95% CI, 0.49 to 0.83]) for passive decision control preference.” This result has consequences in local practice, as, Bacorro et al noted, cervical cancer is more common among the socioeconomically disadvantaged, who, in turn, have likely lower educational attainment.
Bacorro et al also reported one plan to survey the country’s oncologists and allied professionals regarding SDM; two articles on a cross-sectional study on outpatient perspectives on SDM in the Philippine General Hospital; and three articles on a prospective study in USTH on testing a PtDA specific to LACC patients. Bacorro et al said that at the time of their writing, this PtDA was being tested in a multicenter clinical trial for effectiveness in “reducing decisional conflict [and preparing] for decision making.”
PtDAs are said to be tools to facilitate patients’ participation in SDM, by helping them understand their disease, the main intervention considered, other treatment options, the pros and cons of such, and their impacts on mental and physical health. Results of subanalyses abroad favoring cancer-related PtDAs bear out important lessons to apply in the local cervical cancer clinics. These lessons pertain to “patient decisional preferences, the role of PtDAs and the standards for their development and evaluation, their effectiveness, and barriers and facilitators to their use in cancer-related decision making”.
The global evidence-based approach to LACC is reportedly concurrent chemoradiation prior to brachytherapy. While treatment should be evidence-based as much as possible, PtDAs are necessary to factor in patient and caregiver circumstances, such as sociocultural-economic background, role, and values (eg, housewife-mother of reproductive age in a poor household), to prevent poor compliance and outcomes, according to Bacorro et al. This is reportedly important in situations where a CPG recommendation is backed by weak evidence. Bacorro et al noted how important SDM is in patients with LACC where chemotherapy is contraindicated, as its “… benefit decreases with more advanced stages and the toxicity risks increases”.
SDM will be without problems. In the local setting, these would include “clinician factors … unfavorable financial situations, urgency of clinical decisions, low patient or caregiver educational attainment, and poor integration of multidisciplinary and SDM in organizational workflows.”
The USTH arm also revealed that “high educational attainment was a significant negative predictor (odds ratio [OR], 0.64 [95% CI, 0.49 to 0.83]) for passive decision control preference.” This result has consequences in local practice, as, Bacorro et al noted, cervical cancer is more common among the socioeconomically disadvantaged, who, in turn, have likely lower educational attainment.
Bacorro et al also reported one plan to survey the country’s oncologists and allied professionals regarding SDM; two articles on a cross-sectional study on outpatient perspectives on SDM in the Philippine General Hospital; and three articles on a prospective study in USTH on testing a PtDA specific to LACC patients. Bacorro et al said that at the time of their writing, this PtDA was being tested in a multicenter clinical trial for effectiveness in “reducing decisional conflict [and preparing] for decision making.”
PtDAs are said to be tools to facilitate patients’ participation in SDM, by helping them understand their disease, the main intervention considered, other treatment options, the pros and cons of such, and their impacts on mental and physical health. Results of subanalyses abroad favoring cancer-related PtDAs bear out important lessons to apply in the local cervical cancer clinics. These lessons pertain to “patient decisional preferences, the role of PtDAs and the standards for their development and evaluation, their effectiveness, and barriers and facilitators to their use in cancer-related decision making”.
The global evidence-based approach to LACC is reportedly concurrent chemoradiation prior to brachytherapy. While treatment should be evidence-based as much as possible, PtDAs are necessary to factor in patient and caregiver circumstances, such as sociocultural-economic background, role, and values (eg, housewife-mother of reproductive age in a poor household), to prevent poor compliance and outcomes, according to Bacorro et al. This is reportedly important in situations where a CPG recommendation is backed by weak evidence. Bacorro et al noted how important SDM is in patients with LACC where chemotherapy is contraindicated, as its “… benefit decreases with more advanced stages and the toxicity risks increases”.
SDM will be without problems. In the local setting, these would include “clinician factors … unfavorable financial situations, urgency of clinical decisions, low patient or caregiver educational attainment, and poor integration of multidisciplinary and SDM in organizational workflows.”