High-Risk, High-Dollar Cancer Therapies

Posted on Monday, February 26, 2007
Email This Article ... Printer Friendly ... Export to MS Word Document ... Export to plain text document ...

What drives our treatment decisions? by Jeni Baker, Cancer Monthly Staff Writer

In light of today’s skyrocketing health care costs, should cancer patients be allowed to pursue any treatment they want, whenever they want it, as long as they can afford it and agree to assume the risks it entails? What if the treatment is very costly or appears to others to be futile, unreasonable or even unsafe?

This is a current issue of debate in the medical community and among psychologists, economists, policy makers and others and it underscores the need to better understand how and why patients make the treatment decisions they make.

An article in the Journal of Clinical Oncology* examines some of the factors that motivate cancer patients to seek risky or extremely expensive treatments.

Decision Making 101

The cornerstone of this issue is something called prospect theory. Article author Kevin Weinfurt, PhD, of the Duke University Center for Clinical and Genetic Economics, defines prospect theory as the primary context in which we understand the decisions people make when they do not know the outcomes of their choices.

The theory proposes that people, in this case, cancer patients, evaluate possible outcomes of medical care from their own unique points of reference  not in absolute terms, such as years of life that might be saved. Given the variety of people, and the countless different outcomes they hope for, reference points are as individual as patients themselves.

The other important part of prospect theory is the notion of gains and losses. People tend to think of their options as either gains or losses in relation to their reference points and research has shown that people tend to perceive gains differently than they do losses.

These perceptions depend largely on whether options are framed positively or negatively by the conveyor of the information.

When patients are given information about possible outcomes that are framed as gains, they react differently than when the same outcomes are framed as losses  even though they are basing their reactions on what is statistically the same information, Weinfurt says.

Weinfurt’s article uses an example of two 60-year-old men who both receive a diagnosis of pancreatic cancer  and a one-year survival prognosis. The man in outstanding health who expected to live another 25 years views this news as a crushing loss in relation to his reference point. The other man, awaiting a heart transplant after years of cardiac decline views the exact same news as much less of a loss given his fragile health.

In other words, the two men valued the same predicted outcome very differently because of their different reference points and their impressions will undoubtedly influence their treatment decisions.

Patient, Know Thy Self

So what issues might a cancer patient consider when faced with a critical treatment decision?

Weinfurt says it could be valuable for patients who are reviewing information about different treatment options to think about both ways of framing those options. It helps us to understand the statistics associated with different treatments if we try to say them to ourselves in different ways, he says.

Speaking with people who have chosen the options you are considering can also be beneficial.

It could be very helpful to hear from people who have taken those paths and who are in the health state you are considering, Weinfurt says. For example, a prostate cancer support group might play an important role for someone considering prostate surgery.

That said, research has shown that we are not very good at putting ourselves in others shoes or predicting how we might feel in the future. And when we try to visualize what life might be like if we were to choose one option over another, we tend to focus only on what would be different not on the aspects of our lives that would not change.

So seek out the appropriate information and experiences, says Weinfurt, but recognize that your predictions and feelings about how things might be down the road may not be particularly accurate.

Patients might also decide how much medical and treatment information they want (some want every detail; some would rather know nothing) and who they would like to ultimately make treatment decisions and then share those preferences with their care providers.

Cancer patients who seek insight into their own decision-making mechanisms may gain more detailed language for understanding what is going on, Weinfurt says. And by better understanding the tendencies people have when making decisions, they may take steps toward making better treatment decisions.

* Weinfurt KP., Value of high-cost cancer care: a behavioral science perspective. J Clin Oncol. 2007 Jan 10;25(2):223-7.