Shared Decision Making Will Require New Tools, Paradigms in Radiation Oncology
Radiation oncology is moving toward patient-centered care.
Fully achieving the potential of personalized or patient-centered radiation oncology will require not only technological advances but also evolutions in conceptual approaches, workflow, and the use of decision aids that facilitate shared decision making with patients, argue the authors of a new paper on the future of the field.
Implementing patient-centered care will require an expansion of outcome measures to encompass not only objective clinical end points such as tumor control, clinician-reported adverse events, and overall survival, but also patient-reported and patient-centered outcomes, such as the interrelated benchmarks of patient satisfaction, engagement, and treatment-plan adherence, argue the authors of a new paper on the future of radiation oncology.1
“Evaluations that investigate the safety and efficacy of treatments are increasingly soliciting participation from patients within a model of shared decision making [SDM] that improves patients' knowledge, satisfaction, physical and emotional well-being, and trust in providers,” wrote lead author Abigail T. Berman, MD, MSCE, of the Department of Radiation Oncology at the University of Pennsylvania in Philadelphia, and coauthors.
Recording patient-reported outcomes (PROs) is a fundamental component of shared decision making in cancer care and quickly becoming a routine component of patient–clinician communication, they noted. Patient-reported outcomes will likely prove most useful, at least initially, in that setting. In research settings, patient-reported outcomes have long been treated as supplementary or exploratory end points — like afterthoughts, in some cases.
But PROs have real prognostic and clinical value. Quality of life (QoL), for example, “significantly predicts outcomes, including local control and survival,” the authors noted.1
Patient-reported outcomes for QoL, subjective assessments of radiotoxicities and other adverse events, and similar parameters might therefore soon move from being secondary to primary end points in some clinical trials, displacing “the time-honored physician-reported events,” the team predicted.
“[T]hey can not only support high-quality, high-value patient care but also enhance recruitment to clinical oncology trials, both of which are challenging to achieve in today's relatively resource-strapped environment,” they argued.
Radiation oncology is well suited to lead the way in patient-centered care; radiotherapy planning and delivery are inherently “personalized” to each patient to maximize treatment efficacy while minimizing irradiation of healthy, nontarget tissues, thereby minimizing harm. And that has led to the development of important technological advances such as contoured and intensity-modulated radiotherapy.
Personalized radiotherapy “will be greatly enhanced with SDM and PROs in the clinical and research setting; at the same time, the field is also fortunately rife with other aspects of ‘personalized' [radiotherapy]: molecular genomics that may allow [radiotherapy] dose escalation or de-escalation, including current successful ongoing de-escalation efforts in human papillomavirus–positive head and neck cancer,” Dr Berman's team wrote.1
But nontechnical advances “are equally if not perhaps more important to patient satisfaction, engagement, compliance, and ultimately outcomes,” Dr Berman and colleagues wrote. Shared decision making “with or without the use of clinical decision aids (DAs), holds the promise of providing the degree of personalization and patient-centered care for patients in their journey toward discovering the most appropriate radiation treatment plan, including whether radiation is at all appropriate or the modality used.”