shared decision-making and patient control in radiation oncology: implications for patient...

Shared Decision-Making and Patient Controlin Radiation Oncology

Implications for Patient Satisfaction

Jacob E. Shabason, MD1; Jun J. Mao, MD, MSCE2,3,4; Eitan S. Frankel, BA3; and Neha Vapiwala, MD1,2

BACKGROUND: Shared decision-making (SDM) has been linked to important health care quality outcomes. However, to the authors’

knowledge, the value of SDM has not been thoroughly evaluated in the field of radiation oncology. The objective of the current study

was to determine the association between SDM and patient satisfaction during radiotherapy (RT). The authors also explored patient

desire for and perception of control during RT, and how these factors relate to patient satisfaction, anxiety, depression, and fatigue.

METHODS: A cross-sectional survey of 305 patients undergoing definitive RT was conducted. Patients self-reported measured varia-

bles during the last week of RT. Relationships between variables were evaluated using chi-square analyses. RESULTS: Among study

participants, 31.3% of patients experienced SDM, 32.3% perceived control in treatment decisions, and 76.2% reported feeling very sat-

isfied with their care. Patient satisfaction was associated with perceived SDM (84.4% vs 71.4%; P< .02) and patient-perceived control

(89.7% vs 69.2%; P<.001). Furthermore, the perception of having control in treatment decisions was associated with increased satis-

faction regardless of whether the patient desired control. Increased anxiety (44.0% vs 20.0%; P<.02), depression (44.0% vs 15.0%;

P< .01), and fatigue (68.0% vs 32.9%; P<.01) were reported in patients who desired but did not perceive control over their treat-

ments, compared with those who both desired and perceived control. CONCLUSIONS: The findings of the current study emphasize

the value of SDM and patient-perceived control during RT, particularly as it relates to patient satisfaction and psychological distress.

Regardless of a patient’s desire for control, it is important to engage patients in the decision-making process. Cancer 2014;120:1863–

70. VC 2014 American Cancer Society.

KEYWORDS: shared decision-making, participatory decision-making, patient control, patient satisfaction, radiation oncology.

INTRODUCTIONIn 2001, the Institute of Medicine identified that patient-centered care is a key component of quality health care delivery.The committee defined patient-centeredness as an approach that involves “providing care that is respectful of and respon-sive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.”1

The shared decision-making (SDM) process is vital for patient-centered care and for establishing a meaningful andtherapeutic physician-patient relationship. In medicine, and particularly in oncology, SDM has been associated withimproved outcomes related to patient satisfaction, anxiety, and quality of life.2-5 Although still relying heavily on physi-cian expertise, SDM is a significant departure from the paternalism traditionally associated with the physician-patient rela-tionship. SDM is a process in which both a physician and a patient share information about a disease, discuss its actualand potential effects on the patient, review the medically appropriate treatment options, and then ultimately reach a con-sensus together regarding the most appropriate treatment approach for that specific patient.6-8

The national importance of SDM is further evident in the finding that the Patient Protection and Affordable CareAct devotes an entire section to establishing a program for SDM. The program’s goal is to establish “collaborative proc-esses between patients, caregivers or authorized representatives, and clinicians that engage the patient, caregiver or author-ized representative in decision making, provides patients, caregivers or authorized representatives with information abouttrade-offs among treatment options, and facilitates the incorporation of patient preferences and values into the medicalplan.”9 Furthermore, in a recently published report from the Institute of Medicine, the authors emphasize the importance

Corresponding author: Neha Vapiwala, MD, Department of Radiation Oncology, University of Pennsylvania, 3400 Civic Center Blvd, 4th Fl West Pavilion, Philadel-

phia, Pennsylvania 19104; Fax: (215) 349-8975; [email protected]

1Department of Radiation Oncology, University of Pennsylvania Health System, Philadelphia, Pennsylvania; 2Abramson Cancer Center, University of Pennsylvania

Health System, Philadelphia, Pennsylvania; 3Department of Family Medicine and Community Health, University of Pennsylvania Health System, Philadelphia, Penn-

sylvania; 4Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania

DOI: 10.1002/cncr.28665, Received: October 31, 2013; Revised: January 20, 2014; Accepted: January 27, 2014, Published online March 19, 2014 in Wiley Online

Library (wileyonlinelibrary.com)

Cancer June 15, 2014 1863

Original Article

of patient-centered communication and SDM as a keycomponent to delivering high-quality cancer care. Unfortu-nately, SDM in oncology is currently suboptimal.10 Overthe past few decades, there have been several studies exam-ining how a patient’s role in the decision-making processrelates to his or her oncologic treatment. Studies report thatpatients experience SDM in 9% to 44% of cases.2,11,12

Furthermore, as medical, surgical, and radiationtreatment options become more complex and varied, itwill become increasingly important to keep cancerpatients fully engaged in the discussions weighing the risksand benefits of all potential treatment modalities. In par-ticular, radiation oncology is a field that is largely unfami-liar to most patients. Thus, there is a significant need toimprove patient education about radiotherapy (RT)options and about what to expect during and after RT,13 aneed that can be at least partly addressed through SDM.

SDM has been correlated with important clinicaloutcomes such as patient satisfaction. Specifically withinradiation oncology, there is evidence that enhanced infor-mation sharing14 and decision aid tools15 lead toenhanced patient satisfaction. However, the endpoints inthese studies were satisfaction during the first week ofRT14 or satisfaction with information shared.15 To ourknowledge, there are no data correlating patient-perceivedSDM with overall satisfaction with RT.

As such, we sought to assess the prevalence of SDMand the perception of control in treatment decisions amongpatients receiving RT at a large, urban, academic medicalcenter. We then examined the association between SDMand patient satisfaction during each patient’s last week ofRT. We also explored the relationship between a patient’sdesire for and perception of control during RT and satisfac-tion, anxiety, depression, and fatigue. Findings from thecurrent study should help to guide future changes to thephysician-patient interaction in radiation oncology, withthe goal of improving patient-centered care.

MATERIALS AND METHODS

Study Population

We conducted a cross-sectional survey study in theDepartment of Radiation Oncology at the Hospital of theUniversity of Pennsylvania in Philadelphia. Potential par-ticipants included patients aged � 18 years who wereundergoing RT for a diagnosis of cancer with a Karnofskyperformance status of � 60. Patients were excluded ifthey were receiving palliative RT, had a known brain tu-mor or abnormal neurologic function, or were unable tounderstand the requirements of the study. Research assis-

tants obtained permission from the treating radiationoncologists, screened medical records, and approachedpotential participants about the study during eachpatient’s last week of RT. The survey was distributed dur-ing the final week of treatment to ensure that all aspects ofthe RT process and all the opportunities that existed forSDM throughout a patient’s RT course were captured inthe survey response. Once informed consent wasobtained, each participant was given a self-administeredsurvey. All protocols and surveys were reviewed andapproved by the University of Pennsylvania InstitutionalReview Board and the Abramson Cancer Center ScientificReview and Monitoring Committee.

Variables

We measured patient perception of his or her radiationoncologist’s SDM style using a previously used 3-itemscale.16-18 As described in Kaplan et al,16 patients wereasked to rate their physicians’ participatory decision stylebased on a 5-point scale, using the following questions: 1)“If there were a choice between treatments, would yourradiation oncologist ask you to help him/her make the de-cision? (definitely yes to definitely no)”; 2) “How oftendoes your radiation oncologist make an effort to give yousome control over your treatment? (very often to never)”;and 3) “How often does your radiation oncologist ask youto take some of the responsibility for your treatment?(very often to not at all).” We tested the reliability of thisquestionnaire by calculating a Cronbach alpha of these 3items in our population, which was .7, indicatingadequate reliability. Based on the responses, a score rang-ing from 0 to 100 was calculated by summing theresponses, dividing by 15 and then multiplying by 100.An SDM score was then dichotomized into a “yes” or“no” variable using a score of� 70 as a cutoff.

We developed the questions used to evaluate per-ceived and desired control, satisfaction, fatigue, depres-sion, and anxiety. During the instrument pilot phase,some patients informed us that they did not desire controlof their treatment decisions, which led us to develop itemsfor perception and desire for control in decision-makingbased on the question “How much control do you cur-rently have/would you like to have over decisions regard-ing your radiation treatment?” We measured theseresponses on a 5-point rating scale from “a lot” to “none.”Patient satisfaction was measured based on the question“How satisfied are you with the radiation treatments youhave received?” We measured these responses on a 5-pointrating scale from “very much” to “not at all.” For analysispurposes, responses were dichotomized into “yes” or “no”

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1864 Cancer June 15, 2014

categories, in which only answers that were in the mostpositive response option (eg, “very much” satisfied, or “alot of control”) were placed into the “yes” category for sat-isfaction or control, and the remaining 4 options werecategorized as “no.” Symptoms of anxiety, depression, andfatigue were measured based on the question “Have youexperienced any of the following bothersome symptomsduring radiation treatment for which you would considerseeking treatment?” We measured these responses in sim-ple “yes” or “no” categories.

Patients self-reported the following demographicdata: age, sex, race/ethnicity, marital status, employmentstatus, and education level. Clinical variables such as bodymass index, tumor type, stage of disease, and treatmentregimen were obtained through chart abstraction.

Statistical Analyses

All analyses were performed with Stata statistical software(version 12.2; StataCorp, College Station, Tex). Standarddescriptive statistics were used to report demographic andclinical variables and study outcomes. Relationshipsbetween variables including SDM, desired and perceivedcontrol, satisfaction, anxiety, depression, and fatigue dur-ing the last week of RT were evaluated using chi-squareanalyses. All analyses were 2-sided, with an a< .05 indi-cating statistical significance.

RESULTSBetween July 2009 and July 2010, 380 patients wereapproached for survey enrollment, 324 of whom (85.3%)agreed to participate. Of the 56 patients (14.7%) whodeclined, 47 (12.4%) did not want to participate inresearch and 9 patients (2.4%) reported feeling too sickon the day of the survey. Nine subjects withdrew consent,and 10 did not return a completed survey questionnaire,resulting in a final sample of 305 patients and a finalresponse rate of 80.3%.

The demographic and clinical characteristics of thestudy population are outlined in Tables 1 and 2, respec-tively. The 305 participants were aged 18 years to 87 years(mean, 59.8 years; standard deviation, 12.0 years). A totalof 160 patients were male (52.5%). Two hundred andthirty-one patients (75.7%) were white, 60 patients(19.7%) were black/African American, 8 patients (2.6%)were Asian, 2 patients (0.7%) were Hispanic/Latino, and 4patients (1.3%) reported “other” race/ethnicity. Sixtypatients (19.7%) were diagnosed with prostate cancer, 54patients (17.7%) with breast cancer, 55 patients (18.0%)with head and neck cancer, 46 patients (15.1%) with gas-trointestinal cancer, 41 patients (13.4%) with lung cancer,

and 49 patients (16.1%) with other types of cancer.Patients with all stages of cancer were included, specifically73 patients (23.9%) with stage I, 73 patients (23.9%) withstage II, 77 patients (25.3%) with stage III, and 58 patients(19.0%) with stage IV disease. Of note, the patients withstage IV disease were not receiving palliative RT and weretreated with curative intent. Approximately one-half of thepatients were currently receiving or previously had receivedchemotherapy. Approximately 50% of the patients previ-ously had undergone or were planning to undergo surgeryas part of their therapeutic regimen.

Ninety patients (31.3%) reported experiencingSDM, 98 patients (32.3%) perceived control in treatmentdecisions, and 227 patients (76.2%) reported feeling verysatisfied with their radiation oncology care. Amongpatients who perceived control of radiation treatments,53.2% also experienced SDM, and of those who experi-enced SDM, 55.6% also perceived control. Similarly, ofthe patients who did not perceive control, 79.4% also didnot experience SDM, and of those who did not experienceSDM, 77.8% also did not perceive control. The relation-ships of a variety of demographic and clinical factors wereanalyzed to determine whether there were any factorslinked with increases in SDM, perceived control, andpatient satisfaction. Patients who had a head and neckmalignancy experienced more SDM compared withpatients with other disease sites (P 5 .028). Patients of ayounger age (aged< 55 years) perceived more control oftreatment decisions compared with patients of other agegroups (P 5 .047). Otherwise, there were no significantdifferences noted with regard to SDM, perceived control,or satisfaction based on a variety of demographic or clini-cal factors (Table 1 and Table 2, respectively).

SDM and perceived control of treatment decisionswere each found to be independently associated with anincrease in patient satisfaction. Specifically, 84.4% ofpatients who experienced SDM reported being very satis-fied with their radiation treatments, compared with only71.4% of patients who did not experience SDM(P< .02). The perception of having control in treatmentdecisions was associated with a similar trend of increasedsatisfaction (89.7% vs 69.2; P< .001) (Fig. 1). Impor-tantly, a patient’s perception of control in treatment deci-sions was associated with an increase in satisfactionregardless of whether the patient actually preferred con-trol. Specifically, patients who did not desire control overtheir treatments but who did perceive a sense of controloffered by their physicians were more satisfied with theirtreatments compared with patients who did not perceivecontrol (100% vs 72.8%; P< .02). Similar trends in

Shared Decision-Making in Oncology/Shabason et al


satisfaction were noted in patients who desired control oftheir treatments (87.5% vs 46.2%; P< .001) (Table 3).

Further analysis revealed that patients who desired, butdid not perceive, control of their radiation treatments weremore likely to experience certain detrimental symptoms thatwere severe enough for patients to consider seeking addi-tional treatment for them. In particular, these patients expe-rienced an increase in self-reported anxiety (44.0% vs20.0%; P< .02), depression (44.0% vs 15.0%; P< .01),and fatigue (68.0% vs 32.9%; P< .01) compared with indi-viduals who both desired and perceived control (Fig. 2).

DISCUSSIONThere is a growing trend for patients diagnosed with can-cer to desire a more active role in their treatment deci-

sions. SDM takes into account physician expertise as wellas patient beliefs and values to jointly develop a medicallyacceptable treatment plan. With this evolving patient-provider relationship comes a significant need for themedical community to develop tools and training meth-ods for both physicians and patients to adapt to thismethod of decision-making.19,20

In the current study, comprising a group of radiationoncology patients with diverse demographic and clinicalcharacteristics, only approximately one-third of patientsexperienced SDM or perceived a sense of control in theirradiation treatments. These numbers are consistent withprior studies examining SDM in the oncology setting.11 Itis interesting to note that SDM and perceived control aredistinct variables, in which SDM focuses more on the

TABLE 1. Demographic Characteristics of Participants by Shared Decision-Making, Control, and Satisfaction(N5305)

No.Participated

(% ofTotal)a

HaveShared

Decision-Making, No. %b Pc

HaveControl of

Treatment,No. %b Pc

VerySatisfied

With

Treatment,No. %b Pc

Total 305 (100%) 90 31.3 98 32.3 227 76.2

Age, y .393 .047d .180

<55 92 (30.2) 27 30.0 37 40.2 66 72.5

55-65 118 (38.7) 39 35.8 40 34.5 95 81.9

>65 95 (31.2) 24 27.0 21 23.3 66 72.5

Sex .101 .617 .285

Male 160 (52.5) 53 35.6 53 34.2 122 78.7

Female 145 (47.5) 37 26.6 45 31.5 105 73.4

Race/

ethnicity

.795 .152 .558

White 231 (75.7) 69 31.7 69 70.4 174 77.0

Non-whited 74 (24.3) 21 30.0 29 29.6 72 73.6

Education

attainment

.639 .237 .730

�High school 88 (28.9) 25 30.9 34 40 68 77.3

Some college

or techni-

cal school

150 (49.2) 42 29.4 46 30.9 111 74.0

�College 67 (22.0) 23 35.9 18 28.12 48 71.6

Employment

status

.369 .769 .217

Not currently

employed

157 (51.5) 50 33.8 50 32.7 114 74.0

Employed

part or full

time

140 (45.9) 38 28.8 47 34.3 109 80.2

Marital status .677 .112 .136

Not currently

married

106 (34.8) 30 29.7 40 38.8 74 71.2

Married/

partnered

199 (65.3) 60 32.1 58 29.7 153 78.9

a Numbers may not add up to 100% due to missing data.b Indicates the percentage of patients with shared decision-making, control, or who were very satisfied within a specific category. Percentages were calculated

based on the number of patients who answered each respective section of the survey.c Derived using the chi-square test.d Bold type indicates statistical significance.e A total of 19.7% of patients were reported as black/African American, 2.6% were reported as Asian, 7% were reported as Hispanic/Latino, and 1.3% were

reported as “other.”

Original Article


joint decision-making process of a physician and patienttogether coming to a mutually acceptable decision andpatient control is more simply a measure of how muchcontrol a patient perceives in his or her treatment deci-sions. Patients who experienced SDM or who perceived asense of control were more likely to report feeling very sat-isfied with their radiation treatments. Importantly, thisincrease in satisfaction was observed in patients who per-ceived control, regardless of whether they expressed adesire for this control. This increase in patient satisfactionconfirms other reports in which improved informationsharing and patient participation led to improved patientsatisfaction.2,5,14,21

In addition, patients with cancer can perceive a lossof control in their lives, which can potentially lead todebilitating psychological effects.22 Other groups havereported that SDM is correlated with a decrease in variouspsychologically detrimental symptoms, such as patientanxiety.2 Although we did not observe an increase in anxi-

ety or depression in patients who did not experience con-trol or SDM (data not shown), we did find a significantincrease in patient anxiety, depression, and fatigue inthose who entered the treatment process with a desire forcontrol, but who did not actually experience a sense ofcontrol in guiding their treatment decisions.

The ideal and highest level of SDM in the oncologydecision-making process involves a patient deciding withhis or her physician between different, but equally effec-tive, treatment modalities. For example, a woman withearly-stage breast cancer can decide between mastectomyand breast conservation therapy (lumpectomy and RT),each of which has similar clinical efficacy.23 However, athorough discussion with the oncology team is importantto address the different risks and benefits of each treat-ment option. Such a clinical scenario has been studied indepth by Whelan et al,5 who randomized patients withearly-stage breast cancer to the use of a specific decisionaid tool during consultation compared with standard

TABLE 2. Clinical Characteristics of Participants by Shared Decision-Making, Control, and Satisfaction(N5305)

No.Participated

(% ofTotal)a

HaveShared

Decision-Making, No. %b Pc

HaveControl of

Treatment,No. %b Pc

VerySatisfied

With

Treatment,No. %b Pc

Total 305 (100%) 90 31.3 98 32.3 227 76.2

BMI .166 .768c .064c

Normal (<24.9) 120 (39.3) 41 36.9 41 35.3 87 75.7

Overweight (25-29.9) 106 (34.8) 30 30.6 32 31.1 87 82.9

Obese (�30) 79 (25.9) 19 24.0 25 31.7 53 68.0

Cancer type .028d .38 .372

Prostate 60 (19.7) 13 26.0 19 35.9 44 81.5

Breast 54 (17.7) 12 20.3 19 32.2 48 80.0

Head/neck 55 (18.0) 25 48.1 19 35.9 40 76.9

Gastrointestinal 46 (15.1) 14 32.6 9 20.5 30 69.8

Lung 41 (13.4) 9 23.7 17 42.5 26 65.0

GU/skin/other 49 (16.1) 17 37.0 15 30.6 39 79.6

Disease stage .571 .171 .447

I 73 (23.9) 20 28.6 28 38.9 55 75.3

II 73 (23.9) 19 26.8 20 27.8 57 80.3

III 77 (25.3) 23 32.9 19 25.3 58 76.3

IV 58 (19.0) 21 37.5 22 29.3 38 67.9

Chemotherapy .767 .092 .269

No 145 (47.5) 43 31.6 53 37.6 112 78.9

Yes 158 (51.8) 45 30.0 44 28.4 113 73.4

Surgery .731 .681 .143

No 152 (49.9) 46 31.9 47 31.5 118 79.7

Yes 152 (49.9) 43 30.1 50 33.8 108 72.5

Hormonal therapy .947 .825 .667

No 253 (83.0) 74 31.1 80 32.4 186 75.6

Yes 51 (16.7) 15 30.6 17 34 40 78.4

Abbreviations: BMI, body mass index; GU, genitourinary.a Numbers may not add up to 100% due to missing data.b Indicates the percentage of patients with shared decision-making, control or who were very satisfied within a specific category. Percentages were calculated

based on the number of patients who answered each respective section of the survey.c Derived using the chi-square test.d Bold type indicates statistical significance.



consultation. The decision tool described the differencesand associated side effects of mastectomy and breast con-servation therapy. Patients randomized to the arm usingthe decision aid tool had better knowledge regarding treat-ment options and less decision conflict, and they weremore satisfied.5

The decision for a patient to undergo RT is the firstof many opportunities for SDM. Depending on the stageand type of malignancy, there may be several possibleradiation regimens using different radiation types and dif-ferent fractionation schemes (number of and dose perradiation treatment). One important example is the treat-ment of prostate cancer, in which there have been and arenumerous ongoing studies evaluating different radiationfractionation schemes that can range from as short as 2weeks to as long as 9 weeks.24 In fact, van Tol-Geerdinket al found that offering patients a choice in their radiation

dose with decision aids reviewing the risks and benefits ofeach therapy improved patient knowledge, risk percep-tion, and satisfaction of information compared withpatients who did not have a choice of their radiationdose.15 As various radiation regimens become more estab-lished as acceptable alternatives to standard regimens, andthus more widely available, it will become incumbent onradiation oncologists to thoroughly explain the potentialrisks and benefits of each regimen and to help patientsselect a mutually acceptable treatment plan.

Lastly, while undergoing RT, patients see their radi-ation oncologists weekly for symptom managementrelated to the acute toxicity of radiation. These weekly vis-its offer opportunities for ongoing SDM, because the careteams can actively engage a patient in the management ofhis or her symptoms. For example, pain control shouldinvolve a discussion of the risks and benefits of standardopioid analgesics, as well as the option of potentially effec-tive forms of alternative medicine, such as acupuncture.Because the choice of cancer treatment regimens may of-ten be dictated by the extent of disease and available thera-peutics, involving patients in decisions regardingsymptom management is an opportunity to give themsome sense of control in decision-making.

Importantly, during all of the steps of treatmentdecision-making for a patient undergoing RT, it is para-mount that physicians not allow patients to dictate care toa level that is either potentially unsafe or not within aphysician’s comfort zone. Hence, SDM should take intoaccount both physician and patient preferences.

Figure 1. Shared decision-making (SDM) and perceived controlof radiation treatments are associated with an increase inpatient satisfaction. There was a significant association notedwith patients feeling very satisfied with their radiation treat-ments if they experienced SDM (84.4% vs 71.4%; P<.02) or per-ceived control over their treatment regimen (89.7% vs 69.2%;P<.001).The P values were based on chi-square analyses.

TABLE 3. Percentage of Patients Satisfied Basedon Preference For or Perception of Control

Perceived

Control

Did NotPerceive

Control Pa

Preferred control 87.5% 46.2% <.001

Did not prefer control 100% 72.8% <.02

a Derived using the chi-square test.

Figure 2. Patient-perceived control in treatment decision-making and associated detrimental symptoms are shown.Patients who specifically desired control over their treatmentdecisions, but did not perceive this control, experienced sig-nificantly more anxiety (44.0% vs 20.0%; P< .02), depression(44.0% vs 15.0%; P< .01), and fatigue (68.0% vs 32.9%; P< .01)compared with patients who did perceive a sense of controlin their treatment decisions. The P values were based on chi-square analyses.

Original Article


There are several potential limitations to the currentstudy. First, this is a cross-sectional study, which can onlyidentify the association between measured variables.Without the temporal relationship, we cannot for exam-ple determine whether SDM or patient control actuallyleads to patient satisfaction. It is conceivable that patientswho are more satisfied with their treatment may retroac-tively claim more responsibility for the treatment deci-sions then those who are dissatisfied with theirtreatment.25 This limitation also applies to other meas-ured variables. Second, our measures for control, satisfac-tion, fatigue, anxiety, and depression are brief and may besubject to response bias. Furthermore, the time point ofour survey during the last week of RT could introducesome bias, because the last week of RT is often when sideeffects are the most severe and may affect how a patientresponds to the survey questions. However, we chose thistime point to capture all aspects of SDM in the treatmentprocess and not introduce further recall bias by distribut-ing the survey at a follow-up appointment. A prospectivelongitudinal cohort study may more accurately measurehow SDM throughout the course of RT may impact satis-faction and other outcomes. Last, this study was con-ducted at an urban academic cancer center, and thereforemay not be generalizable to patients in other settings.

Despite the above limitations, the current study sur-veyed a diverse group of patients with a very high partici-pation rate. To our knowledge, this is the first study todate to evaluate the relationship between both patient-perceived SDM and control with satisfaction with RT.We found that less than one-third of patients experiencedSDM, which highlights the critical need for bothphysician-targeted and patient-targeted methods toimprove the participatory decision-making process. Thesefindings also emphasize the value of SDM and patient-perceived control during RT, particularly as it relates topatient satisfaction, anxiety, depression, and fatigue. Irre-spective of a patient’s desire for control, it is important forphysicians to engage patients in the decision-making pro-cess and to allow patients to believe that they have somecontrol in their cancer care. The previously mentionedInstitute of Medicine Report entitled “Delivering High-Quality Cancer Care: Charting a New Course for a Sys-tem in Crisis,” provides excellent guidance in the field.10

Specifically, the authors identify broad methods toimprove patient-centered communication and SDMincluding “. . .(1) making more comprehensive andunderstandable information available to patients and theirfamilies, (2) developing decision aids to facilitate patientcentered communication and shared decision making, (3)

prioritizing clinician training in communication, (4) pre-paring cancer care plans, and (5) using new models of pay-ment to incentivize patient-centered communication andshared decision making.”10 In addition to these helpfulsuggestions, another important method to improve SDMin radiation oncology is to educate physicians about boththe prevalence and relevance of SDM in patient care.Once radiation oncologists become more aware of theissue, they will hopefully be more cognizant to incorpo-rate SDM in their daily practice. Future research may inaddition identify both patient and physician barriers toSDM, and in turn test the feasibility and efficacy of meth-ods to address these barriers to improve patient satisfac-tion and clinical outcomes.

FUNDING SUPPORTSupported in part by the Penn Integrative Oncology Fund.

CONFLICT OF INTEREST DISCLOSURESDr. Mao is a recipient of the National Institutes of Health/NationalCenter for Complementary and Alternative Medicine 5K23AT004112-5 award.

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shared decision-making and patient control in radiation oncology: implications for patient...

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