Non-clinical factors affecting shared decision making

To the Editor

Dr. Spatz and colleagues offered recommendations for effective shared decision making, highlighting clinician engagement.¹ A major challenge for clinicians, however, is addressing factors that significantly affect a patient’s decision beyond the commonly compared clinical benefits and harms of treatment options. Key non-clinical factors can influence a treatment’s accessibility, and subsequently, its preference.

Shared decision making in early breast cancer treatment is one example. In eligible patients, the choices of breast conserving surgery plus radiation vs. mastectomy both render excellent cancer control and survival. Typical comparisons quantify recurrence, treatment toxicity, and cosmesis outcomes,² but these are not the sole factors affecting actual treatment selection. Access and distance to treatment facilities, insurance, and the personal economic burden of treatment (the “financial toxicity” of cancer care³) can affect, even dominate, downstream considerations, such as whether a patient pursues elective reconstruction, completes adjuvant treatment without delay, and returns to work.⁴ Such factors affect the quality of care delivered by the clinician, as well as the quality of life experienced by the patient. Therefore, in a shared decision-making approach, patients’ concerns about the social and economic factors that determine the reality (and disparity) of the treatment options actually accessible to them must be addressed.

Such discussions by treating clinicians alone are potentially limited by both their expertise and time available to counsel patients. Decision aids themselves are inherently limited in addressing these dimensions; in a review of 290 decision aids in the Ottawa Hospital Research Institute’s Decision Aid Library Inventory, only about half mentioned “cost”, in many cases only noting that economic implications could vary but not comprehensively informing patients’ understanding of how treatment options differed.⁵

A multidisciplinary team-based approach would address this gap. We propose that actively engaging multidisciplinary partners is an important component of effective shared decision making. This engagement includes clinical partners in other medical specialties, midlevel clinicians and nurses, as well as team members in social work, clinical psychology, law, patient navigation and advocacy, who can help address complex social and economic factors affecting patients’ values and preferences. In some cases, interventions to facilitate transportation, housing, or work accommodations can meaningfully alter patients’ perceptions of the relative benefits and harms of treatment.