Supportive Care in Cancer

, Volume 17, Issue 2, pp 117–127 | Cite as

Decision making and quality of life in the treatment of cancer: a review

  • S. Yousuf ZafarEmail author
  • Stewart C. Alexander
  • Kevin P. Weinfurt
  • Kevin A. Schulman
  • Amy P. Abernethy
Review Article



Complexity in decision making for cancer treatment arises from many factors. When considering how to treat patients, physicians prioritize factors such as stage of disease, patient age, and comorbid illnesses. However, physicians must balance these priorities with the patient’s preferences, quality of life, social responsibilities, and fear of uncertainty. Although these factors are important, physicians are often unable to effectively judge their patients’ preferences. Patients are often unable to fully understand their prognoses and the treatment intent.


These differences influence how patients and physicians make treatment-related decisions. Partially due to these differences, patients are initially more likely than their physicians to accept greater risk for lesser benefit from treatment. As time progresses and as they experience treatment, a patient’s preference changes, yet little is known about this process since few studies have examined it in a prospective longitudinal manner. We present an overview of the literature related to patient and physician decision making and quality of life in patients with advanced cancer, and we propose approaches to future decision-making models in cancer treatment.


Decision making Quality of life Patient-reported outcomes 



The authors wish to acknowledge Neal J. Meropol, MD, for his input and assistance in reviewing this manuscript.


  1. 1.
    Au H, Karapetis C, Jonker D, O’Callaghan C, Kennecke H, Shapiro J (2007) Quality of life in patients with advanced colorectal cancer treated with cetuximab: results of the NCIC CTG and AGITG CO.17 trial. J Clin Oncol 25:4002 2007 ASCO Annual Meeting ProcGoogle Scholar
  2. 2.
    Ayanian JZ, Zaslavsky AM, Fuchs CS, Guadagnoli E, Creech CM, Cress RD et al (2003) Use of adjuvant chemotherapy and radiation therapy for colorectal cancer in a population-based cohort. J Clin Oncol 21:1293–1300 doi: 10.1200/JCO.2003.06.178 PubMedCrossRefGoogle Scholar
  3. 3.
    Baldwin LM, Dobie SA, Billingsley K, Cai Y, Wright GE, Dominitz JA et al (2005) Explaining black–white differences in receipt of recommended colon cancer treatment. J Natl Cancer Inst 97:1211–1220PubMedCrossRefGoogle Scholar
  4. 4.
    Beaver K, Jones D, Susnerwala S, Craven O, Tomlinson M, Witham G et al (2005) Exploring the decision-making preferences of people with colorectal cancer. Health Expect 8:103–113 doi: 10.1111/j.1369-7625.2005.00320.x PubMedCrossRefGoogle Scholar
  5. 5.
    Bruera E, Sweeney C, Calder K, Palmer L, Benisch-Tolley S (2001) Patient preferences versus physician perceptions of treatment decisions in cancer care. J Clin Oncol 19:2883–2885PubMedGoogle Scholar
  6. 6.
    Bui L, Rempel E, Reeson D, Simunovic M (2006) Lymph node counts, rates of positive lymph nodes, and patient survival for colon cancer surgery in Ontario, Canada: a population-based study. J Surg Oncol 93:439–445 doi: 10.1002/jso.20499 PubMedCrossRefGoogle Scholar
  7. 7.
    Cassileth BR, Zupkis RV, Sutton-Smith K, March V (1980) Information and participation preferences among cancer patients. Ann Intern Med 92:832–836PubMedGoogle Scholar
  8. 8.
    Cheng JD, Hitt J, Koczwara B, Schulman KA, Burnett CB, Gaskin DJ et al (2000) Impact of quality of life on patient expectations regarding phase I clinical trials. J Clin Oncol 18:421–428PubMedGoogle Scholar
  9. 9.
    Colorectal Cancer Collaborative Group (2000) Surgery for colorectal cancer in elderly patients: a systematic review. Lancet 356:968–974CrossRefGoogle Scholar
  10. 10.
    Curran D, Giralt J, Harari PM, Ang KK, Cohen RB, Kies MS et al (2007) Quality of life in head and neck cancer patients after treatment with high-dose radiotherapy alone or in combination with cetuximab. J Clin Oncol 25:2191–2197 doi: 10.1200/JCO.2006.08.8005 PubMedCrossRefGoogle Scholar
  11. 11.
    Daugherty CK, Banik DM, Janish L, Ratain MJ (2000) Quantitative analysis of ethical issues in phase I trials: a survey interview of 144 advanced cancer patients. IRB 22:6–14 doi: 10.2307/3564113 PubMedCrossRefGoogle Scholar
  12. 12.
    Degner LF, Kristjanson LJ, Bowman D, Sloan JA, Carriere KC, O’Neil J et al (1997) Information needs and decisional preferences in women with breast cancer. JAMA 277:1485–1492 doi: 10.1001/jama.277.18.1485 PubMedCrossRefGoogle Scholar
  13. 13.
    Demissie K, Oluwole OO, Balasubramanian BA, Osinubi OO, August D, Rhoads GG (2004) Racial differences in the treatment of colorectal cancer: a comparison of surgical and radiation therapy between Whites and Blacks. Ann Epidemiol 14:215–221PubMedCrossRefGoogle Scholar
  14. 14.
    Du XL, Fang S, Vernon SW, El-Serag H, Shih YT, Davila J et al (2007) Racial disparities and socioeconomic status in association with survival in a large population-based cohort of elderly patients with colon cancer. Cancer 110:660–669 doi: 10.1002/cncr.22826 PubMedCrossRefGoogle Scholar
  15. 15.
    Elkin EB, Kim SH, Casper ES, Kissane DW, Schrag D (2007) Desire for information and involvement in treatment decisions: elderly cancer patients’ preferences and their physicians’ perceptions. J Clin Oncol 25:5275–5280 doi: 10.1200/JCO.2007.11.1922 PubMedCrossRefGoogle Scholar
  16. 16.
    Eng C, Maurel J, Scheithauer W, Wong L, Lutz M, Middleton G (2007) Impact on quality of life of adding cetuximab to irinotecan in patients who have failed prior oxaliplatin-based therapy: The EPIC trial. J Clin Oncol 25:4003 2007 ASCO Annual Meeting ProcGoogle Scholar
  17. 17.
    Fried TR, Bradley EH (2003) What matters to seriously ill older persons making end-of-life treatment decisions?: a qualitative study. J Palliat Med 6:237–244 doi: 10.1089/109662103764978489 PubMedCrossRefGoogle Scholar
  18. 18.
    Gaskin DJ, Kong J, Meropol NJ, Yabroff KR, Weaver C, Schulman KA (1998) Treatment choices by seriously ill patients: the Health Stock Risk Adjustment model. Med Decis Mak 18:84–94 doi: 10.1177/0272989X9801800116 CrossRefGoogle Scholar
  19. 19.
    Gaskin DJ, Weinfurt KP, Castel LD, DePuy V, Li Y, Balshem A et al (2004) An exploration of relative health stock in advanced cancer patients. Med Decis Mak 24:614–624 doi: 10.1177/0272989X04271041 CrossRefGoogle Scholar
  20. 20.
    Gattellari M, Butow PN, Tattersall MH (2001) Sharing decisions in cancer care. Soc Sci Med 52:1865–1878 doi: 10.1016/S0277-9536(00)00303-8 PubMedCrossRefGoogle Scholar
  21. 21.
    Goldberg RM, Tabah-Fisch I, Bleiberg H, de Gramont A, Tournigand C, Andre T et al (2006) Pooled analysis of safety and efficacy of oxaliplatin plus fluorouracil/leucovorin administered bimonthly in elderly patients with colorectal cancer. J Clin Oncol 24:4085–4091 doi: 10.1200/JCO.2006.06.9039 PubMedCrossRefGoogle Scholar
  22. 22.
    Gross CP, Guo Z, McAvay GJ, Allore HG, Young M, Tinetti ME (2006) Multimorbidity and survival in older persons with colorectal cancer. J Am Geriatr Soc 54:1898–1904 doi: 10.1111/j.1532-5415.2006.00973.x PubMedCrossRefGoogle Scholar
  23. 23.
    Gross CP, McAvay GJ, Guo Z, Tinetti ME (2007) The impact of chronic illnesses on the use and effectiveness of adjuvant chemotherapy for colon cancer. Cancer 109:2410–2419 doi: 10.1002/cncr.22726 PubMedCrossRefGoogle Scholar
  24. 24.
    Grossman M (1972) On the concept of health capital and the demand for health. J Pol Econ 80:168–199Google Scholar
  25. 25.
    Halyard MY, Frost MH, Dueck A (2006) Integrating QOL assessments for clinical and research purposes. Curr Probl Cancer 30:319–330 doi: 10.1016/j.currproblcancer.2006.08.009 PubMedCrossRefGoogle Scholar
  26. 26.
    Harrison LE, Guillem JG, Paty P, Cohen AM (1997) Preoperative carcinoembryonic antigen predicts outcomes in node-negative colon cancer patients: a multivariate analysis of 572 patients. J Am Coll Surg 185:55–59PubMedGoogle Scholar
  27. 27.
    Jansen SJ, Otten W, Stiggelbout AM (2004) Review of determinants of patients’ preferences for adjuvant therapy in cancer. J Clin Oncol 22:3181–3190 doi: 10.1200/JCO.2004.06.109 PubMedCrossRefGoogle Scholar
  28. 28.
    Jansen SJ, Stiggelbout AM, Wakker PP, Nooij MA, Noordijk EM, Kievit J (2000) Unstable preferences: a shift in valuation or an effect of the elicitation procedure? Med Decis Mak 20:62–71 doi: 10.1177/0272989X0002000108 CrossRefGoogle Scholar
  29. 29.
    Kiebert GM, Stiggelbout AM, Kievit J, Leer JW, van de Velde CJ, de Haes HJ (1994) Choices in oncology: factors that influence patients’ treatment preference. Qual Life Res 3:175–182 doi: 10.1007/BF00435382 PubMedCrossRefGoogle Scholar
  30. 30.
    Kilbridge KL, Weeks JC, Sober AJ, Haluska FG, Slingluff CL, Atkins MB et al (2001) Patient preferences for adjuvant interferon alfa-2b treatment. J Clin Oncol 19:812–823PubMedGoogle Scholar
  31. 31.
    Lavori PW, Dawson R (2004) Dynamic treatment regimes: practical design considerations. Clin Trials 1:9–20 doi: 10.1191/1740774S04cn002oa PubMedCrossRefGoogle Scholar
  32. 32.
    Lavori PW, Dawson R, Rush AJ (2000) Flexible treatment strategies in chronic disease: clinical and research implications. Biol Psychiatry 48:605–614 doi: 10.1016/S0006-3223(00)00946-X PubMedCrossRefGoogle Scholar
  33. 33.
    Law CH, Wright FC, Rapanos T, Alzahrani M, Hanna SS, Khalifa M et al (2003) Impact of lymph node retrieval and pathological ultra-staging on the prognosis of stage II colon cancer. J Surg Oncol 84:120–126 doi: 10.1002/jso.10309 PubMedCrossRefGoogle Scholar
  34. 34.
    Lee L, Jannapureddy M, Albo D, Awad SS, Farrow B, Bellows CC et al (2007) Outcomes of Veterans Affairs patients older than age 80 after surgical procedures for colon malignancies. Am J Surg 194:646–651 doi: 10.1016/j.amjsurg.2007.08.003 PubMedCrossRefGoogle Scholar
  35. 35.
    Love N, Bylund C, Meropol NJ, Marshall JL, Curley SA, Ellis LM (2007) How well do we communicate with patients concerning adjuvant systemic therapy? A survey of 150 colorectal cancer survivors. J Clin Oncol 25:4020 2007 ASCO Annual Meeting Proc Part IGoogle Scholar
  36. 36.
    Mackillop WJ, Stewart WE, Ginsburg AD, Stewart SS (1988) Cancer patients’ perceptions of their disease and its treatment. Br J Cancer 58:355–358PubMedGoogle Scholar
  37. 37.
    Mahoney T, Kuo YH, Topilow A, Davis JM (2000) Stage III colon cancers: why adjuvant chemotherapy is not offered to elderly patients. Arch Surg 135:182–185 doi: 10.1001/archsurg.135.2.182 PubMedCrossRefGoogle Scholar
  38. 38.
    Maly RC, Umezawa Y, Ratliff CT, Leake B (2006) Racial/ethnic group differences in treatment decision-making and treatment received among older breast carcinoma patients. Cancer 106:957–965 doi: 10.1002/cncr.21680 PubMedCrossRefGoogle Scholar
  39. 39.
    Meropol NJ, Weinfurt KP, Burnett CB, Balshem A, Benson AB 3rd, Castel L et al (2003) Perceptions of patients and physicians regarding phase I cancer clinical trials: implications for physician–patient communication. J Clin Oncol 21:2589–2596 doi: 10.1200/JCO.2003.10.072 PubMedCrossRefGoogle Scholar
  40. 40.
    Meyerhardt JA, Catalano PJ, Haller DG, Mayer RJ, Macdonald JS, Benson AB 3rd et al (2003) Impact of diabetes mellitus on outcomes in patients with colon cancer. J Clin Oncol 21:433–440 doi: 10.1200/JCO.2003.07.125 PubMedCrossRefGoogle Scholar
  41. 41.
    Moertel CG, Fleming TR, Macdonald JS, Haller DG, Laurie JA, Tangen CM et al (1995) Fluorouracil plus levamisole as effective adjuvant therapy after resection of stage III colon carcinoma: a final report. Ann Intern Med 122:321–326PubMedGoogle Scholar
  42. 42.
    Murphy DJ, Cluff LE (1990) The SUPPORT study. Introduction. J Clin Epidemiol 43(Suppl):V–XPubMedCrossRefGoogle Scholar
  43. 43.
    Murphy SA, Lynch KG, Oslin D, McKay JR, TenHave T (2007) Developing adaptive treatment strategies in substance abuse research. Drug Alcohol Depend 88(Suppl 2):S24–S30 doi: 10.1016/j.drugalcdep.2006.09.008 PubMedCrossRefGoogle Scholar
  44. 44.
    National Cancer Institute Surveillance Epidemiology and End Results (SEER) Program (2004) Median age of cancer patients at diagnosis, 2000–2004 by primary cancer site, race and sex. National Cancer InstituteGoogle Scholar
  45. 45.
    O’Connor AM, Boyd NF, Warde P, Stolbach L, Till JE (1987) Eliciting preferences for alternative drug therapies in oncology: influence of treatment outcome description, elicitation technique and treatment experience on preferences. J Chronic Dis 40:811–818 doi: 10.1016/0021-9681(87)90133-0 PubMedCrossRefGoogle Scholar
  46. 46.
    Ohman U (1982) Prognosis in patients with obstructing colorectal carcinoma. Am J Surg 143:742–747 doi: 10.1016/0002-9610(82)90050-2 PubMedCrossRefGoogle Scholar
  47. 47.
    Popescu RA, Norman A, Ross PJ, Parikh B, Cunningham D (1999) Adjuvant or palliative chemotherapy for colorectal cancer in patients 70 years or older. J Clin Oncol 17:2412–2418PubMedGoogle Scholar
  48. 48.
    Potosky AL, Harlan LC, Kaplan RS, Johnson KA, Lynch CF (2002) Age, sex, and racial differences in the use of standard adjuvant therapy for colorectal cancer. J Clin Oncol 20:1192–1202 doi: 10.1200/JCO.20.5.1192 PubMedCrossRefGoogle Scholar
  49. 49.
    Prehn AW, Topol B, Stewart S, Glaser SL, O’Connor L, West DW (2002) Differences in treatment patterns for localized breast carcinoma among Asian/Pacific islander women. Cancer 95:2268–2275 doi: 10.1002/cncr.10965 PubMedCrossRefGoogle Scholar
  50. 50.
    Reuben DB, Naeim A (2004) Perspectives, preferences, care practices, and outcomes in late-stage cancer patients: connecting the dots. J Clin Oncol 22:4869–4871 doi: 10.1200/JCO.2004.09.960 PubMedCrossRefGoogle Scholar
  51. 51.
    Salkeld G, Solomon M, Short L, Butow PN (2004) A matter of trust—patient’s views on decision-making in colorectal cancer. Health Expect 7:104–114 doi: 10.1111/j.1369-7625.2004.00257.x PubMedCrossRefGoogle Scholar
  52. 52.
    Schrag D, Cramer LD, Bach PB, Begg CB (2001) Age and adjuvant chemotherapy use after surgery for stage III colon cancer. J Natl Cancer Inst 93:850–857 doi: 10.1093/jnci/93.11.850 PubMedCrossRefGoogle Scholar
  53. 53.
    Schrag D, Gelfand SE, Bach PB, Guillem J, Minsky BD, Begg CB (2001) Who gets adjuvant treatment for stage II and III rectal cancer? Insight from Surveillance, Epidemiology, and End Results–Medicare. J Clin Oncol 19:3712–3718PubMedGoogle Scholar
  54. 54.
    Schwartz CE, Sprangers MA (2002) An introduction to quality of life assessment in oncology: the value of measuring patient-reported outcomes. Am J Manag Care 8:S550–S559PubMedGoogle Scholar
  55. 55.
    Simes RJ, Coates AS (2001) Patient preferences for adjuvant chemotherapy of early breast cancer: how much benefit is needed? J Natl Cancer Inst Monogr 30:146–152PubMedGoogle Scholar
  56. 56.
    Solomon MJ, Pager CK, Keshava A, Findlay M, Butow P, Salkeld GP et al (2003) What do patients want? Patient preferences and surrogate decision making in the treatment of colorectal cancer. Dis Colon Rectum 46:1351–1357 doi: 10.1007/s10350-004-6749-0 PubMedCrossRefGoogle Scholar
  57. 57.
    Stiggelbout AM, Jansen SJ, Otten W, Baas-Thijssen MC, van Slooten H, van de Velde CJ (2007) How important is the opinion of significant others to cancer patients’ adjuvant chemotherapy decision-making? Support Care Cancer 15:319–325 doi: 10.1007/s00520-006-0149-z PubMedCrossRefGoogle Scholar
  58. 58.
    Townsley C, Pond GR, Peloza B, Kok J, Naidoo K, Dale D et al (2005) Analysis of treatment practices for elderly cancer patients in Ontario, Canada. J Clin Oncol 23:3802–3810 doi: 10.1200/JCO.2005.06.742 PubMedCrossRefGoogle Scholar
  59. 59.
    True G, Phipps EJ, Braitman LE, Harralson T, Harris D, Tester W (2005) Treatment preferences and advance care planning at end of life: the role of ethnicity and spiritual coping in cancer patients. Ann Behav Med 30:174–179 doi: 10.1207/s15324796abm3002_10 PubMedCrossRefGoogle Scholar
  60. 60.
    Watanabe Y, Takahashi M, Kai I (2008) Japanese cancer patient participation in and satisfaction with treatment-related decision-making: a qualitative study. BMC Public Health 8:77 doi: 10.1186/1471-2458-8-77 PubMedCrossRefGoogle Scholar
  61. 61.
    Weeks JC, Cook EF, O’Day SJ, Peterson LM, Wenger N, Reding D et al (1998) Relationship between cancer patients’ predictions of prognosis and their treatment preferences. JAMA 279:1709–1714 doi: 10.1001/jama.279.21.1709 PubMedCrossRefGoogle Scholar
  62. 62.
    Weinfurt KP, Castel LD, Li Y, Sulmasy DP, Balshem AM, Benson AB 3rd et al (2003) The correlation between patient characteristics and expectations of benefit from phase I clinical trials. Cancer 98:166–175 doi: 10.1002/cncr.11483 PubMedCrossRefGoogle Scholar
  63. 63.
    Wong JH, Bowles BJ, Bueno R, Shimizu D (2002) Impact of the number of negative nodes on disease-free survival in colorectal cancer patients. Dis Colon Rectum 45:1341–1348 doi: 10.1007/s10350-004-6423-6s PubMedCrossRefGoogle Scholar
  64. 64.
    Yellen SB, Cella DF (1995) Someone to live for: social well-being, parenthood status, and decision-making in oncology. J Clin Oncol 13:1255–1264PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2008

Authors and Affiliations

  • S. Yousuf Zafar
    • 1
    Email author
  • Stewart C. Alexander
    • 2
  • Kevin P. Weinfurt
    • 3
  • Kevin A. Schulman
    • 3
  • Amy P. Abernethy
    • 4
  1. 1.Division of Medical Oncology, Department of MedicineDuke University Medical CenterDurhamUSA
  2. 2.Center for Palliative CareDuke University Medical CenterDurhamUSA
  3. 3.Center for Clinical and Genetic Economics, Duke Clinical Research InstituteDuke University Medical CenterDurhamUSA
  4. 4.Division of Medical Oncology, Department of MedicineDuke University Medical CenterDurhamUSA

Personalised recommendations