Treatment Decision-making Processes in the Systemic Treatment of Ovarian Cancer: Review of the Scientific Evidence

Discussion

The present analysis is an attempt to give an overview of the factors influencing the decision-making process in patients with primary or relapsed ovarian cancer who are scheduled to undergo a systemic treatment. The overall knowledge and sensitive regarding this important issue is very scarce and only a few studies exist that have systematically evaluated treatment decision-making in patients with ovarian cancer. A better insight into the involved processes will not only contribute to a better understanding of the interaction between patients and physicians, but will also improve patient's compliance.

In the two studies of Elit and colleagues from the 2003 (patients with primary OC) and 2010 (patients with ROC) the expectations and behavior of patients on their way to treatment decision did not follow the shared decision-making model (1) like that described by Charles et al. (3). Elit et al. showed that patients with ovarian cancer usually follow the physician's recommendation without restrictions, are not expecting to know exact details about treatment toxicity or the names of the applied substances. Furthermore, the authors showed that most patients wished to be treated by the same physician who treated them at the initial manifestation of the disease, so that there would be no need to elucidate their beliefs and perspectives in the treatment decision-making again. This continuity facilitates the communication process.

Both studies of Elit et al. share the same background in terms of the patients' attitudes. The difference between these two studies is that patients with recurrent ovarian cancer had different goals compared with patients with primary diagnosis. The primary objective in the primary situation is cure, whereas symptom control and quality of life aspects are generally the aims for recurrent disease.

As expected, the data show that the patients with recurrent disease from the year 2010 appear to be more involved in the treatment decision process than at the time of first diagnosis. However, in both studies, the authors showed that patients feel overwhelmed by the entire decision-making process regardless of their disease stage or status of disease (i.e. primary vs. relapse). The most important influential factors in both studies were the family and friends, as well as other patients with ovarian cancer (6, 9). In almost all studies the physician's treatment recommendation played a decisive role in the patient's treatment decision-making. Moreovers the personal experience of the patient herself seems to play a crucial role in the attitude which is developed towards the disease.

In contrast to the 2003 study, 2010 study of Elit et al. examine the perceptions of patients in the treatment decision process very closely. However, the study does not verify exactly how the patient's perception influences the physician's behavior and communication style (9).

Other studies, like that from Stewart et al. showed that most patients demand shared decision-making processes at every stage of their illness, especially if the disease is progressive.

In another study by Kitamura, the pair-wise comparisons by the analytic hierarchy process (AHP) offers a possibility to understand the patient's choice and it also demonstrates the need to question the importance of various criteria, e.g. social demographic and psychological factors, because they have an effect on the investigation. Such a model supports the treatment decision process of patients in order to quantitatively represent the patient's situations and help the patient to ask specific questions regarding treatment options (5). Recently, the North-Eastern German Society of Gynecological Oncology (NOGGO) finished enrolment of a study in elderly patients with relapsed ovarian cancer (preference trial). Patients had a free choice of the alkylating agent treosulfan given intravenously (i.v.) or as tablets. Interestingly, most patients preferred the i.v. application because most had already been taking many other tablets for their co-morbidities (19).

An international survey on patients' preferences and attitudes regarding physician-patient relationship and cancer management is ongoing (20). A recent interim analysis showed that most patients demand more explanations about side-effects to be able to make a choice of a specific cancer treatment (21). The final analyses of this study, with more than 1500 participants, will be awaited in 2013 and will also try to identify cultural-based differences in the patients' expectations.