Annals of Behavioral Medicine

, Volume 32, Issue 3, pp 172–178 | Cite as

Doing the right thing: Systems support for decision quality in cancer care



Background: There is considerable evidence of problems with the quality of cancer care. Wide variation in rates of interventions suggests that cancer care decisions may not reflect the preferences of informed patients.Purpose: To present a framework for systems support for improving the quality of decisions in cancer.Methods: We outlined the types of decisions faced by cancer patients and categorized them based on the level of evidence available about effectiveness of choices and the amount of variation in patients’ preferences for the key outcomes. Then we describe appropriate strategies to systematically improve the quality of decision making for each category.Results: The types of decisions faced by cancer patients and providers are varied. The appropriate strategy to drive improvements differs for different decisions. For complex, preference-sensitive decisions, improvements in decision quality require increasing patients’ knowledge and the match between patients’ preferences and treatments.Conclusions: Decision making in cancer care is complex. Neither patients nor providers can make treatment decisions alone. System support is needed to improve the quality of decisions.


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  1. (1).
    American Cancer Society:Cancer Facts and Figures 2005. Retrieved June 28, 2006 from STT/content/STT_1x_Cancer_Facts__Figures_2005.aspGoogle Scholar
  2. (2).
    (2)Kahane D:No Less a Woman: Feminity, Sexuality, & Breast Cancer(2nd Ed.). Alameda, CA: Hunter House, 1995.Google Scholar
  3. (3).
    Spiegel D: How do you feel about cancer now?—Survival and psychosocial support.Public Health Report. 1995,110:298–300.Google Scholar
  4. (4).
    Stabiner K:To Dance With the Devil: The New War on Breast Cancer. New York: Delacourte, 1997.Google Scholar
  5. (5).
    (5)Nattinger AB, Gottlieb MS, Veum J, et al.: Geographic variation in the use of breast-conserving treatment for breast cancer.New England Journal of Medicine. 1992,326:1102–1107.PubMedCrossRefGoogle Scholar
  6. (6).
    Fowler FJ, McNaughton Collins M, Albertsen P, et al.: Comparison of recommendations by urologists and radiation oncologists for treatment of clinically localized prostate cancer.Journal of the American Medical Association. 2000,283:3217–3222.PubMedCrossRefGoogle Scholar
  7. (7).
    McNeil BJ,Weischelbaum R, Pauker SG: Speech and survival: Tradeoffs between quality and quantity of life in laryngeal cancer.New England Journal of Medicine. 1981,305:982–987.PubMedCrossRefGoogle Scholar
  8. (8).
    National Institutes of Health:Treatment of Early-Stage Breast Cancer: National Institutes of Health Consensus Development Conference Statement June 18–21, 1990. Retrieved March 8, 2004 from Cancer081html.htmGoogle Scholar
  9. (9).
    Andersen MR, Urban N: Involvement in decision making and breast cancer survivor quality of life.Annals of Behavioral Medicine. 1999,21:201–209.PubMedCrossRefGoogle Scholar
  10. (10).
    Arora NK: Interacting with cancer patients: The significance of physicians’ communication behavior.Social Science & Medicine. 2003,57:791–806.CrossRefGoogle Scholar
  11. (11).
    Jansen SJ, Kievit J, Nooij A, et al.: Stability of patients’ preferences for chemotherapy: The impact of experience.Medical Decision Making. 2001,21:295–306.PubMedCrossRefGoogle Scholar
  12. (12).
    Lin P, Campbell DG, Chaney EF, et al.: The influence of patient preference on depression treatment in primary care.Annals of Behavioral Medicine. 2005,30:164–173.PubMedCrossRefGoogle Scholar
  13. (13).
    Redelmeier D, Rozin P, Kahneman D: Understanding patients’ decisions. Cognitive and emotional perspectives.Journal of the American Medical Association. 1993,270:72–76.PubMedCrossRefGoogle Scholar
  14. (14).
    Tversky A, Kahneman D: The framing of decisions and the psychology of choice.Science. 1981,211:453–458.PubMedCrossRefGoogle Scholar
  15. (15).
    Llewellyn-Thomas HA: Do patients’ evaluations of a future health state change when they actually enter that state?Medical Care. 1993,31:1002–1012.PubMedCrossRefGoogle Scholar
  16. (16).
    O’Connor AM, Boyd NF, Warde P, et al.: Eliciting preferences for alternative drug therapies in oncology: Influence of treatment outcome description, elicitation technique and treatment experience on preferences.Journal of Chronic Diseases. 1987,40:811–818.PubMedCrossRefGoogle Scholar
  17. (17).
    Mulley A: Assessing patients’ utilities: Can the ends justify the means?Medical Care. 1989,27:S269-S281.PubMedCrossRefGoogle Scholar
  18. (18).
    Ubel PA, Loewenstein G, Schwarz N, et al.: Misimagining the unimaginable: The disability paradox and health care decision making.Health Psychology. 2005,24:S57-S62.PubMedCrossRefGoogle Scholar
  19. (19).
    Llewellyn-Thomas H: Health state descriptions. Purposes, issues, a proposal.Medical Care. 1996,34:DS109-DS118.PubMedGoogle Scholar
  20. (20).
    Llewellyn-Thomas H: Investigating patients’ preferences for different treatment options.The Canadian Journal of Nursing Research. 1997,29:45–64.PubMedGoogle Scholar
  21. (21).
    Knight SJ, Nathan DP, Siston AK, et al.: Pilot study of a utilities- based treatment decision intervention for prostate cancer patients.Clinical Prostate Cancer. 2002,1:105–114.PubMedGoogle Scholar
  22. (22).
    Richardson J, McKie J: Empiricism, ethics and orthodox economic theory: What is the appropriate basis for decision-making in the health care sector?Social Science & Medicine. 2005,60:265–275.CrossRefGoogle Scholar
  23. (23).
    Rowe G, Lambert N, Bowling A, et al.: Assessing patients’ preferences for treatments for angina using a modified repertory grid method.Social Science & Medicine. 2005,60:2585–2595.CrossRefGoogle Scholar
  24. (24).
    Plsek P: Redesigning Health Care with Insights from Science of Complex Adaptive Systems. In Institute of Medicine (ed),Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001, 309–322.Google Scholar
  25. (25).
    Frosch D, Kaplan R, Felitti V: The evaluation of two methods to facilitate shared decision-making for men considering the prostate-specific antigen test.Medical Decision Making. 2000,20:391–398.Google Scholar
  26. (26).
    Wilt T: Prostate cancer (non-metastatic).Clinical Evidence. 2003,10:1023–1038.PubMedGoogle Scholar
  27. (27).
    Fisher B, Anderson S, Bryant J, et al.: Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer.New England Journal of Medicine. 2002,347:1233–1241.PubMedCrossRefGoogle Scholar
  28. (28).
    Veronesi U, Cascinelli N, Mariani L, et al.: Twenty-year follow- up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer.New England Journal of Medicine. 2002,247:1227–1232.CrossRefGoogle Scholar
  29. (29).
    Figueiredo MI, Cullen J, Hwang YT, et al.: Breast cancer treatment in older women: Does getting what you want improve your long-term body image and mental health?Journal of Clinical Oncology. 2004,22:4002–4009.PubMedCrossRefGoogle Scholar
  30. (30).
    Katz SJ, Lantz PM, Janz NK, et al.: Patterns and correlates of local therapy for women with ductal carcinoma-in-situ.Journal of Clinical Oncology. 2005,23:3001–3007.PubMedCrossRefGoogle Scholar
  31. (31).
    Katz SJ, Lantz PM, Zemencuk JK: Correlates of surgical treatment type for women with noninvasive and invasive breast cancer.Journal of Women’s Health & Gender-based Medicine. 2001,10:659–670.CrossRefGoogle Scholar
  32. (32).
    Mandelblatt JS, Hadley J, Kerner JF, et al.: Patterns of breast carcinoma treatment in older women: Patient preference and clinical and physical influences.Cancer. 2000,89:561–573.PubMedCrossRefGoogle Scholar
  33. (33).
    Molenaar S, Oort F, Sprangers M, et al.: Predictors of patients’ choices for breast-conserving therapy or mastectomy: A prospective study.British Journal of Cancer. 2004,90:2123–2130.PubMedGoogle Scholar
  34. (34).
    Nold RJ, Beamer RL, Helmer SD, et al.: Factors influencing a woman’s choice to undergo breast-conserving surgery versus modified radical mastectomy.American Journal of Surgery. 2000,180:413–418.PubMedCrossRefGoogle Scholar
  35. (35).
    Sepucha KR, Ozanne EM, Hughes KS, et al.: New instruments to measure decision quality for breast cancer. 27th Annual Meeting of the Society for Medical Decision Making. San Francisco, CA: 2005.Google Scholar
  36. (36).
    Ward S, Heidrich S, Wolberg W: Factors women take into account when deciding upon type of surgery for breast cancer.Cancer Nursing. 1989,12:344–351.PubMedCrossRefGoogle Scholar
  37. (37).
    Wu ZH, Freeman JL, Greer AL, et al.: The influence of patients’ concerns on surgeons’ recommendations for early breast cancer.European Journal of Cancer Care. 2001,10:100–106.PubMedCrossRefGoogle Scholar
  38. (38).
    The National Institutes of Health Consensus Development Conference: Adjuvant therapy for breast cancer: Proceedings of the National Institutes of Health Consensus Development Conference.Journal of the National Cancer Institute Monographs. 2001,30:1–152.Google Scholar
  39. (39).
    Harris JR, Lippman ME, Morrow M, et al.:Diseases of the Breast (3rd Ed.). Philadelphia: Lippincott Williams &Wilkins, 2004.Google Scholar
  40. (40).
    Peele PB, Siminoff LA, Xu Y, et al.: Decreased use of adjuvant breast cancer therapy in a randomized controlled trial of a decision aid with individualized risk information.Medical Decision Making. 2005,25:301–307.PubMedCrossRefGoogle Scholar
  41. (41).
    Kirschner AJ: Cancer: Finding it and treating it. New York Times. 2002, October 20.Google Scholar
  42. (42).
    Mulley Jr. AG: Industrial quality management science and outcomes research: Responses to unwanted variation in health outcomes and decisions. In Blumenthal D (ed),Improving Clinical Practice: Total Quality Management and the Physician. San Francisco: Jossey-Bass, 1995, 73–107.Google Scholar
  43. (43).
    O’Connor AM, Stacey D, Entwistle V, et al.: Decision aids for people facing health treatment or screening decisions.Cochrane Database of Systematic Reviews. 2003,2:CD001431.Google Scholar
  44. (44).
    Barry M: Involving patients in medical decisions: How can physicians do better?Journal of the American Medical Association. 1999,282:2356–2357.PubMedCrossRefGoogle Scholar
  45. (45).
    Hammond J, Keeney R, Raiffa H:Smart Choices: A Guide to Making Better Decisions. Cambridge, MA: Harvard Business School Press, 1998.Google Scholar
  46. (46).
    Kennedy A: On what basis should the effectiveness of decision aids be judged?Health Expectations. 2003,6:255–268.PubMedCrossRefGoogle Scholar
  47. (47).
    Llewellyn-Thomas H: Patients’ health-care decision making: A framework for descriptive and experimental investigations.Medical Decision Making. 1995,15:101–106.PubMedCrossRefGoogle Scholar
  48. (48).
    O’Connor AM, Mulley Jr. AG, Wennberg JE: Standard consultations are not enough to ensure decision quality regarding preference- sensitive options.Journal of the National Cancer Institute. 2003,95:570–571.PubMedCrossRefGoogle Scholar
  49. (49).
    Ratliff A, Angell M, Dow R, et al.: What is a good decision?Effective Clinical Practice. 1999,2:185–197.PubMedGoogle Scholar
  50. (50).
    International Patient Decision Aids Standards Collaboration:IPDAS Collaboration Background Document. Retrieved December 22, 2005 from pdfGoogle Scholar
  51. (51).
    Sepucha KR, Fowler FJJ, Mulley AJ: Policy support for patient- centered care: The need for measurable improvements in decision quality.Health Affairs. 2004,7:VAR54-VAR62.Google Scholar
  52. (52).
    Kearing S, O’Connor AM, Collins ED, et al.: Integrated decision support in clinical care: Decision making in a cohort of early stage breast cancer patients (Abstract No. 3). 27th Annual Society for Medical Decision Making Meeting. San Francisco, CA: 2005.Google Scholar
  53. (53).
    Wennberg J, Gittlesohn A: Variations in medical care among small areas.Scientific American. 1982,246:120–134.PubMedCrossRefGoogle Scholar

Copyright information

© The Society of Behavioral Medicine 2006

Authors and Affiliations

  • Karen Sepucha
    • 1
  • Elissa Ozanne
    • 2
  • Albert G. Mulley
    • 1
  1. 1.General Medicine Division Health Decision Research UnitMassachusetts General Hospital Harvard Medical SchoolBoston
  2. 2.Institute for Technology AssessmentMassachusetts General Hospital Harvard Medical SchoolBoston

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