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Decision Making in Cancer Prevention and Control: From Prevention Through End of Life

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... to take medication for chemoprevention of breast cancer? ... Breast Cancer Risk Assessment Tool. http://www.cancer.gov/bcrisktool/ Why Study Decision Making? ... – PowerPoint PPT presentation

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Title: Decision Making in Cancer Prevention and Control: From Prevention Through End of Life


1
Decision Making in Cancer Prevention and Control
From Prevention Through End of Life
Wendy Nelson Basic and Biobehavioral Research
Branch Behavioral Research Program July 22, 2009
2
Medical Decision Making
  • Judgment and decision making
  • Economics
  • Behavioral economics
  • Neuroeconomics
  • Neuroscience
  • Memory and Cognition
  • Pharmacoeconomics
  • Decision analysis
  • Human factors
  • Mathematics
  • Engineering
  • Behavioral science
  • Psychology (clinical, social, experimental)

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7
Decision Aids
  • Tools to inform patients about the probability of
    benefits and harms associated with treatment
    options, and to help patients consider their
    personal values and preferences
  • Designed for preference sensitive decisions
  • May take any number of forms
  • Web-based
  • DVD
  • Audiotape
  • Brochure
  • Workbooks

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10
Decision Making in Cancer Prevention
  • How does one decide to initiate and maintain
    healthy lifestyle changes involving diet,
    exercise, and smoking?
  • What cognitive and affective processes are
    involved in deciding whether to take medication
    for chemoprevention of breast cancer?
  • Should my child receive the HPV vaccine?

11
Decision Making in Cancer Screening
  • What is the effect of a false positive reading on
    a womans decision to undergo future mammography
    screening?
  • What are the effects of framing on the decision
    to undergo cancer screening?
  • What are the effects of testimonials on the
    decision to undergo cancer screening?

12
Decision Making in Cancer Treatment
  • What factors enter into the decision to
    participate in a clinical trial?
  • How do physicians and patients make treatment
    decisions under uncertainty (e.g., early stage
    prostate cancer, early stage breast cancer)?
  • How stable are treatment preferences?

13
Decision Making At End of Life
  • How do patients/family members/physicians decide
    when to discontinue treatment? When to begin
    hospice care?
  • Do advance directives work?

14
Why Study Decision Making?
  • Decision making is fundamental to all aspects of
    cancer care
  • In order to design effective decision support
    tools it is necessary to have a better
    understanding of human decision-making processes

15
Breast Cancer Risk Assessment Tool
http//www.cancer.gov/bcrisktool/
16
Why Study Decision Making?
  • Classical decision theory has limited
    applicability to real world decision making

17
Expected Utility Theory
18
  • Preferences Stable or Constructed?

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Framing Effects
  • Of 100 people having surgery, 10 will die during
    treatment, 32 will have died by one year and 66
    will have died by five years. Of 100 people
    having radiation therapy, none will die during
    treatment, 23 will die by one year and 78 will
    die by five years.
  • McNeil et al. On the elicitation of preferences
    for alternative therapies. NEJM 19823061259-1262

21
Preference Shifts in Situations Involving
Multiple Alternatives
  • A 67-year-old farmer has osteoarthritis of the
    hip. NSAIDs have not been effective. You decide
    to refer the patient for a hip replacement
    surgery consultation. But before the patient
    leaves your office, you realize that there is one
    NSAID the patient has not tried. What do you do?
  • Refer to ortho and start new NSAID
  • Refer to ortho and do not start new
    NSAID
  • Redelmeier Shafir. Medical decision making in
    situations that offer multiple alternatives. JAMA
    1995273302

22
Preference Shifts in Situations Involving
Multiple Alternatives
  • A 67-year-old farmer has osteoarthritis of the
    hip. NSAIDs have not been effective. You decide
    to refer the patient for a hip replacement
    surgery consultation. But before the patient
    leaves your office, you realize that there are
    two NSAIDS the patient has not tried. What do you
    do?
  • Refer to ortho and start new NSAID A
  • Refer to ortho and start new NSAID B
  • Refer to ortho and do not start a new NSAID
  • Redelmeier Shafir. Medical decision making in
    situations that offer multiple alternatives. JAMA
    1995273302

23
Is More Information Always Better?
  • Scenario 1 Imagine you are on the admissions
    committee. You are reviewing the file of an
    applicant who plays varsity soccer, has
    supportive letters of recommendation, and is
    editor of the school newspaper. The applicant has
    a combined SAT score of 1250 and a high school
    average grade of B. Do you accept or reject the
    applicant?
  • Redelmeier et al. The beguiling pursuit of more
    information. Med Decis Making 200121376.
  • Bastardi Shafir. On the pursuit and misuse of
    useless information. J Pers Soc Psychol
    19987519.

24
Is More Information Always Better?
  • Scenario 1 Imagine you are on the admissions
    committee. You are reviewing the file of an
    applicant who plays varsity soccer, has
    supportive letters of recommendation, and is
    editor of the school newspaper. The applicant has
    a combined SAT score of 1250 and a high school
    average grade of B. Do you accept or reject the
    applicant?
  • Accept applicant 57
  • Reject applicant 43
  • Redelmeier et al. The beguiling pursuit of more
    information. Med Decis Making 200121376.
  • Bastardi Shafir. On the pursuit and misuse of
    useless information. J Pers Soc Psychol
    19987519.

25
Is More Information Always Better?
  • Scenario 2 The applicant has a combined SAT
    score of 1250 but 2 different reports about high
    school average grade. The guidance counselors
    report indicates a B, whereas the school office
    report indicates an A. The school has notified
    you that the records are being checked and you
    will be informed within a few days which grade is
    correct. Do you accept the applicant? Reject the
    applicant? Wait for further clarification from
    the applicants school?
  • Redelmeier et al. The beguiling pursuit of more
    information. Med Decis Making 200121376.
  • Bastardi Shafir. On the pursuit and misuse of
    useless information. J Pers Soc Psychol
    19987519.

26
Is More Information Always Better?
  • Scenario 2 The applicant has a combined SAT
    score of 1250 but 2 different reports about high
    school average grade. The guidance counselors
    report indicates a B, whereas the school office
    report indicates an A. The school has notified
    you that the records are being checked and you
    will be informed within a few days which grade is
    correct. Do you accept the applicant? Reject the
    applicant? Wait for further clarification from
    the applicants school?
  • Accept applicant 21
  • Reject applicant 5
  • Wait for clarification 74
  • Redelmeier et al. The beguiling pursuit of more
    information. Med Decis Making 200121376.
  • Bastardi Shafir. On the pursuit and misuse of
    useless information. J Pers Soc Psychol
    19987519.

27
Is More Information Always Better?
  • The school informs you that the applicants
    average
  • grade is a B. Now what do you do?
  • Accept applicant 25
  • Reject applicant 49

28
Is More Information Always Better?
  • The pursuit of information increases its salience
    and causes people to attach greater significance
    to it than if the information was immediately
    available
  • People have an imperfect ability to distinguish
    relevant from redundant information
  • People often tend to pursue non-instrumental
    information and attach undue importance to it
  • Relevant information impinges on a decision
  • Instrumental information alters the decision
  • it is hard to tell when clarification ends and
    distortion begins
  • Redelmeier et al. The beguiling pursuit of more
    information. Med Decis Making 200121376.
  • Bastardi Shafir. On the pursuit and misuse of
    useless information. J Pers Soc Psychol
    19987519.

29
Reducing Cognitive Biases of Decision Aids
  • Framing effects
  • Survival and mortality curves
  • Influence of patient testimonials
  • Vividness
  • Numeracy
  • Self-identification
  • Ratio of positive to negative testimonials
  • Added information
  • Preference reversal after addition of a 3rd
    treatment option
  • Conflict
  • Dominance
  • Aversion to extremes
  • Ubel. R01CA87595. University of Michigan

30
Reducing Cognitive Biases of Decision Aids
  • Conflict Two similar options drive people to
    prefer a 3rd option
  • Dominance Option C is clearly inferior to
    Option B, and its inclusion
  • increases the
    attractiveness of Option B
  • A radiation B chemo C chemo
  • If A vs. B, a few people might prefer B
  • If A vs. B vs. C, more people prefer B
    because C makes B
  • look better by contrast
  • Aversion to extremes
  • Treatment A least unpleasant, least
    effective
  • Treatment B intermediate
  • Treatment C most
    unpleasant, most effective
  • When Treatments A and B presented together, few
    prefer B
  • When Treatment C is added, B becomes more
    attractive (happy medium)

31
Reducing Cognitive Biases of Decision Aids
  • Affective reactions to health outcomes

32
Affective Reactions to Health Outcomes
  • Treatment Summary
  • Possible Outcome Surgery 1 Surgery 2
  • Cure without complication 80 80
  • Cure with colostomy 1
  • Cure with chronic diarrhea 1
  • Cure with intermittent bowel obstruction 1
  • Cure with wound infection 1
  • Death 16 20
  • Amsterlaw et al. Can avoidance of complications
    lead to biased healthcare decisions? Judgment and
  • Decision making 2006164.

33
Affective Reactions to Health Outcomes
  • Treatment Summary
  • Possible Outcome Surgery 1 Surgery 2
  • Cure without complication 800 800
  • Cured with one of the following complications
    40 0
  • colostomy, chronic diarrhea, intermittent bowel
  • obstruction, or wound infection
  • No cure, death from scar tissue inflammation
    0 40
  • No cure, death from colon cancer 160 160
  • Amsterlaw et al. Can avoidance of complications
    lead to biased healthcare decisions? Judgment and
  • decision making 2006164.

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35
Decision Making Funding Opportunities
  • Decision making in cancer Single-event decisions
  • (PA-08-063 PA-08-064)
  • http//grants.nih.gov/grants/guide/pa-files/PA-08
    -063.html
  • Research on clinical decision making in people
    with or at risk for life-threatening illness
  • (PA-09-121 PA-09-122)
  • http//grants.nih.gov/grants/guide/pa-files/PA-09
    -122.html
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