Determining Operative Candidacy and Avoiding Regret

Patients' Reflections on Treatment Decision After Surgery for Laryngeal Cancer

Importance

Clinicians should understand how patients who were treated with laryngeal cancer surgery think about this later on and what factors may be related with regretting surgery.

Objective

To assess variables associated with a positive attitude toward laryngeal cancer surgery.

Design, Setting, and Participants

This combination of 2 cohorts, based on patient interviews and questionnaires, was studied in 16 hospitals in Germany. Participants scheduled for laryngeal cancer surgery were enrolled before surgery and followed up until 1 year after surgery. Data collection began on November 28, 2001, and ended on March 15, 2015. Statistical analysis was performed from August 21, 2023, to January 19, 2024.

Main Outcomes and Measures

The attitude toward surgery was measured with the Psychosocial Adjustment After Laryngectomy Questionnaire (scores range from 0 to 100, with high scores representing a positive attitude toward the surgery) at 1 year after surgery. In multivariate regression analysis, the following variables were investigated: type of surgery, number of surgeries to the larynx, receipt of radiotherapy and chemotherapy, quality of life, speech intelligibility (objectively measured), age, sex, educational level, employment status, having a partner or not, counseling by patient association, and shared decision-making.

Results

Patients (n = 780; mean [SD] age, 60.6 [10.4] years; 701 [90%] male) who had received counseling from the patient association reported a more positive attitude toward surgery (adjusted B = 8.8; 95% CI, 1.0-16.6). Among patients after total laryngectomy, those with a university degree had a less positive attitude toward their surgery (adjusted B = -50.8; 95% CI, -84.0 to -17.6); this result was not observed in patients after partial laryngectomy (adjusted B = -4.8; 95% CI, -15.1 to 5.4). Among patients after partial laryngectomy, the attitude toward surgery was most positive in those who had experienced shared decision-making (mean [SD] questionnaire score, 84 [20] in those without a wish and 83 [20] in those with a wish for shared decision-making). Those who had wished they could decide together with the physician but where this eventually was not experienced expressed the most regret toward surgery (mean [SD] score, 71 [22]). There was no association between attitudes toward surgery and type of surgery (total vs partial laryngectomy) and all other variables tested.

Conclusion and Relevance

In this cohort study, most patients with head and neck cancer reported a positive attitude toward surgery, suggesting low levels of decision regret. Counseling by members of patient associations as well as individualized shared decision-making prior to surgery may have a positive impact on decision regret and is advisable in daily practice.

Post-operative patient perception of decisional regret in cochlear implant recipients

IMPORTANCE

Decision regret post-surgery has has been linked to health outcomes for a number of elective procedures but is understudied in cochlear implantation satisfaction. Theunpredictability in outcomes may lead to unmet expectations by the recipient. This study is the first study to investigate the decision regret concept in cochlear implant recipients.

OBJECTIVE

Tto investigate post-operative decision regret in (CI) recipients.

DESIGN

This was a prospective cohort study using the validated Ottawa Decision Regret Scale, and whether the CI met the patient's expectations. Variables potentially associated with decision regret including patient demographics, post-operative speech perception scores, duration of deafness, duration of CI use and age were analyzed using the logistic regression model.

SETTING

This was a multi-center study. Participants were recruited and enrolled from the University of Miami and the University of Kansas in an outpatient setting.

PARTICIPANTS

Adult, English-speaking CI recipients with at least 6 months of listening experience with their implant.

RESULTS

Out of 173 58% reported no regret, 27% reported mild, and 15% reported moderate-to-strong regret. Expectations were met in 77% while not meeting expectations in 14%. The remaining 8% were neutral. Decisional regret was significantly associated (p = 0.02) with poor post-operative speech perception. No other variables were associated with regret.

CONCLUSIONS

Post-operative decision regret was reported by 42% of CI recipients. Poor speech perception abilities were associated with increased risk of regret. Further research is required to identify regret risks and provide resources to mitigate regret in CI recipients.

Shared Decision-making in Head and Neck Surgery: A Review

Importance

Shared decision-making is a partnership between physicians and patients whereby patient values and preferences are incorporated with the best medical evidence. Shared decision-making may reduce decisional conflict, improve value-choice congruence, and increase patient involvement. Despite potential benefit in many key areas of otolaryngology-head and neck surgery, both clinical and research focuses on shared decision-making are scarce. Head and neck surgical oncology is of particular interest owing to the frequency by which preference-sensitive decisions must be made. Information used in this review was obtained between January 1 and February 1, 2020.

Observations

Various conceptual models have been developed in an attempt to define the concept of shared decision-making. More than 40 instruments have endeavored to measure the construct of shared decision-making. However, in head and neck surgery, few studies to date have explicitly done so. Situations of clinical equipoise, such as in the management of indeterminate thyroid nodules and in the treatment of laryngeal cancer, are frequent. In contrast, value-option incongruence may occur when patient values do not align with the most oncologically sound treatment choice, such as when the resection and reconstruction of oral cancer may leave patients with significant sequelae. Several patient decision aids have been developed to improve shared decision-making in specific clinical scenarios, for example, in considering total laryngectomy or primary chemoradiotherapy.

Conclusions and Relevance

Despite its potential benefit, there is a dearth of research and clinical applications of shared decision-making in head and neck surgery. Shared decision-making represents an area of substantial need in this regard, and additional efforts should be put forth.