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

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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
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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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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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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?

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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?

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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?

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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?

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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

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Breast Cancer Risk Assessment Tool
http//www.cancer.gov/bcrisktool/
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Why Study Decision Making?

• Classical decision theory has limited
  applicability to real world decision making

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Expected Utility Theory
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• 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

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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

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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

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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.

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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.

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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.

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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.

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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

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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.

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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

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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)

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Reducing Cognitive Biases of Decision Aids

• Affective reactions to health outcomes

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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.

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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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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