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Rabben J, Vivat B, Fossum M, Rohde GE. Shared decision-making in palliative cancer care: A systematic review and metasynthesis. Palliat Med 2024; 38:406-422. [PMID: 38481012 PMCID: PMC11025308 DOI: 10.1177/02692163241238384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
BACKGROUND Shared decision-making is a key element of person-centred care and promoted as the favoured model in preference-sensitive decision-making. Limitations to implementation have been observed, and barriers and limitations, both generally and in the palliative setting, have been highlighted. More knowledge about the process of shared decision-making in palliative cancer care would assist in addressing these limitations. AIM To identify and synthesise qualitative data on how people with cancer, informal carers and healthcare professionals experience and perceive shared decision-making in palliative cancer care. DESIGN A systematic review and metasynthesis of qualitative studies. We analysed data using inductive thematic analysis. DATA SOURCES We searched five electronic databases (MEDLINE, EMBASE, PsycINFO, CINAHL and Scopus) from inception until June 2023, supplemented by backward searches. RESULTS We identified and included 23 studies, reported in 26 papers. Our analysis produced four analytical themes; (1) Overwhelming situation of 'no choice', (2) Processes vary depending on the timings and nature of the decisions involved, (3) Patient-physician dyad is central to decision-making, with surrounding support and (4) Level of involvement depends on interactions between individuals and systems. CONCLUSION Shared decision-making in palliative cancer care is a complex process of many decisions in a challenging, multifaceted and evolving situation where equipoise and choice are limited. Implications for practice: Implementing shared decision-making in clinical practice requires (1) clarifying conceptual confusion, (2) including members of the interprofessional team in the shared decision-making process and (3) adapting the approach to the ambiguous, existential situations which arise in palliative cancer care.
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Affiliation(s)
- Jannicke Rabben
- Department of Health and Nursing Science, Faculty of Health and Sport Sciences, University of Agder, Kristiansand/Grimstad, Vest-Agder, Norway
| | - Bella Vivat
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Mariann Fossum
- Department of Health and Nursing Science, Faculty of Health and Sport Sciences, University of Agder, Kristiansand/Grimstad, Vest-Agder, Norway
| | - Gudrun Elin Rohde
- Department of Health and Nursing Science, Faculty of Health and Sport Sciences, University of Agder, Kristiansand/Grimstad, Vest-Agder, Norway
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Department of Clinical Research, Sorlandet hospital, Kristiansand, Vest-Agder, Norway
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2
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Chen JJ, Brown AM, Garda AE, Kim E, McAvoy SA, Perni S, Rooney MK, Shiue K, Tonning KL, Warren LE, Golden DW, Croke JM. Patient Education Practices and Preferences of Radiation Oncologists and Interprofessional Radiation Therapy Care Teams: A Mixed-Methods Study Exploring Strategies for Effective Patient Education Delivery. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00332-8. [PMID: 38437924 DOI: 10.1016/j.ijrobp.2024.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 01/02/2024] [Accepted: 02/07/2024] [Indexed: 03/06/2024]
Abstract
PURPOSE Patients' understanding of radiation therapy (RT) and data regarding optimal approaches to patient education (PE) within radiation oncology (RO) are limited. We aimed to evaluate PE practices of radiation oncologists and interprofessional RT care team members to inform recommendations for delivering inclusive and accessible PE. METHODS AND MATERIALS An anonymous survey was administered to all Radiation Oncology Education Collaborative Study Group members (10/5/22-11/23/22). Respondent demographics, individual practices/preferences, and institutional practices were collected. Qualitative items explored strategies, challenges, and desired resources for PE. Descriptive statistics summarized survey responses. The Fisher exact test compared PE practices by respondent role and PE timing. Thematic analysis was used for qualitative responses. RESULTS One hundred thirteen Radiation Oncology Education Collaborative Study Group members completed the survey (28.2% response rate); RO attendings comprised 68.1% of respondents. Most practiced in an academic setting (85.8%) in North America (80.5%). Institution-specific materials were the most common PE resource used by radiation oncologists (67.6%). Almost half (40.2%) reported that their PE practices differed based on clinical encounter type, with paper handouts commonly used for in-person and multimedia for telehealth visits. Only 57.7% reported access to non-English PE materials. PE practices among radiation oncologists differed according to RT clinical workflow timing (consultation versus simulation versus first RT, respectively): one-on-one teaching: 88.5% versus 49.4% versus 56.3%, P < .01, and paper handouts: 69.0% versus 28.7% versus 16.1%, P < .01. Identified challenges for PE delivery included limited time, administrative barriers to the development or implementation of new materials or practices, and a lack of customized resources for tailored PE. Effective strategies for PE included utilization of visual diagrams, multimedia, and innovative education techniques to personalize PE delivery/resources for a diverse patient population, as well as fostering interprofessional collaboration to reinforce educational content. CONCLUSIONS Radiation oncologists and interprofessional RO team members engage in PE, with most using institution-specific materials often available only in English. PE practices differ according to clinical encounter type and RT workflow timing. Increased adoption of multimedia materials and partnerships with patients to tailor PE resources are needed to foster high-quality, patient-centered PE delivery.
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Affiliation(s)
- Jie Jane Chen
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Anna M Brown
- Aspirus Regional Cancer Center, Wausau, Wisconsin
| | - Allison E Garda
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Ellen Kim
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Sarah A McAvoy
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Subha Perni
- Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael K Rooney
- Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kevin Shiue
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Kristi L Tonning
- Department of Radiation Medicine, Oregon Health and Science University, Portland, Oregon
| | - Laura E Warren
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Daniel W Golden
- Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois
| | - Jennifer M Croke
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.
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Rajeswaran T, Wong HCY, Zhang E, Kennedy SKF, Gojsevic M, Soliman H, Vassiliou V, Rades D, Bonomo P, Lee SF, Chan AW, Rembielak A, Oldenburger E, Maranzano E, Pergolizzi S, Finkelstein JA, Larouche J, Zhang N, Zhang X, Marta GN, Yee AJM, Yu S, van der Velden JM, van der Linden YM, Chow E. Quality of life issues in patients with bone metastases: A systematic review. Support Care Cancer 2023; 32:18. [PMID: 38091116 DOI: 10.1007/s00520-023-08241-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 12/06/2023] [Indexed: 12/18/2023]
Abstract
INTRODUCTION Bones are frequent sites of metastatic disease, observed in 30-75% of advanced cancer patients. Quality of life (QoL) is an important endpoint in studies evaluating the treatments of bone metastases (BM), and many patient-reported outcome tools are available. The primary objective of this systematic review was to compile a list of QoL issues relevant to BM and its interventions. The secondary objective was to identify common tools used to assess QoL in patients with BM, and the QoL issues they fail to address. METHODS A search was conducted on Ovid MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases between 1946 and 27 January 2023 with the keywords "bone metastases", "quality of life", and "patient reported outcomes". Specific QoL issues in original research studies and the QoL tools used were extracted. RESULTS The review identified the QoL issues most prevalent to BM in the literature. Physical and functional issues observed in patients included pain, interference with ambulation and daily activities, and fatigue. Psychological symptoms, such as helplessness, depression, and anxiety were also common. These issues interfered with patients' relationships and social activities. Items not mentioned in existing QoL tools were related to newer treatments of BM, such as pain flare, flu-like symptoms, and jaw pain due to osteonecrosis. CONCLUSIONS This systematic review highlights that QoL issues for patients with BM have expanded over time due to advances in BM-directed treatments. If they are relevant, additional treatment-related QoL issues identified need to be validated prospectively by patients and added to current assessment tools.
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Affiliation(s)
- Thenugaa Rajeswaran
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Henry C Y Wong
- Department of Oncology, Princess Margaret Hospital, Hospital Authority, Kowloon, Hong Kong
| | - Elwyn Zhang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Samantha K F Kennedy
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Milena Gojsevic
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Vassilios Vassiliou
- Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Nicosia, Cyprus
| | - Dirk Rades
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
| | - Pierluigi Bonomo
- Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Shing-Fung Lee
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore
- Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, New Territories, Hong Kong
| | - Adrian Wai Chan
- Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, New Territories, Hong Kong
| | - Agata Rembielak
- The University of Manchester, Manchester, UK
- Department of Clinical Oncology, The Christie HNS Foundation Trust, Manchester, UK
| | - Eva Oldenburger
- Department of Radiation Oncology, University Hospitals Leuven, Louvain, Belgium
| | - Ernesto Maranzano
- Radiotherapy Oncology Centre, Santa Maria Hospital, Terni, Italy
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Stefano Pergolizzi
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Joel A Finkelstein
- Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Jeremie Larouche
- Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Na Zhang
- Liaoning Cancer Hospital and Institute, Shenyang, Liaoning, China
| | - Xiaojing Zhang
- Liaoning Cancer Hospital and Institute, Shenyang, Liaoning, China
| | - Gustavo N Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, Sao Paulo, Brazil
| | - Albert J M Yee
- Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Shengji Yu
- Department of Orthopedics, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Joanne M van der Velden
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Yvette M van der Linden
- Department of Radiotherapy, Leiden University Medical Center, University of Leiden, Leiden, Holland
| | - Edward Chow
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
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Engel M, Kars MC, Teunissen SCCM, van der Heide A. Effective communication in palliative care from the perspectives of patients and relatives: A systematic review. Palliat Support Care 2023; 21:890-913. [PMID: 37646464 DOI: 10.1017/s1478951523001165] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
OBJECTIVES In palliative care, effective communication is essential to adequately meet the needs and preferences of patients and their relatives. Effective communication includes exchanging information, facilitates shared decision-making, and promotes an empathic care relationship. We explored the perspectives of patients with an advanced illness and their relatives on effective communication with health-care professionals. METHODS A systematic review was conducted. We searched Embase, Medline, Web of Science, CINAHL, and Cochrane for original empirical studies published between January 1, 2015 and March 4, 2021. RESULTS In total, 56 articles on 53 unique studies were included. We found 7 themes that from the perspectives of patients and relatives contribute to effective communication: (1) open and honest information. However, this open and honest communication can also trigger anxiety, stress, and existential disruption. Patients and relatives also indicated that they preferred (2) health-care professionals aligning to the patient's and relative's process of uptake and coping with information; (3) empathy; (4) clear and understandable language; (5) leaving room for positive coping strategies, (6) committed health-care professionals taking responsibility; and (7) recognition of relatives in their role as caregiver. Most studies in this review concerned communication with physicians in a hospital setting. SIGNIFICANCE OF RESULTS Most patients and relatives appreciate health-care professionals to not only pay attention to strictly medical issues but also to who they are as a person and the process they are going through. More research is needed on effective communication by nurses, in nonhospital settings and on communication by health-care professionals specialized in palliative care.
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Affiliation(s)
- Marijanne Engel
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marijke C Kars
- Center of Expertise in Palliative Care, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Saskia C C M Teunissen
- Center of Expertise in Palliative Care, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Keij SM, Lie HC, Laidsaar-Powell R, Kunneman M, de Boer JE, Moaddine S, Stiggelbout AM, Pieterse AH. Patient-related characteristics considered to affect patient involvement in shared decision making about treatment: A scoping review of the qualitative literature. PATIENT EDUCATION AND COUNSELING 2023; 111:107677. [PMID: 36857803 DOI: 10.1016/j.pec.2023.107677] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/13/2023] [Accepted: 02/16/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE To identify patient-related characteristics considered to affect patient involvement in shared decision making (SDM) about treatment. METHODS We conducted a scoping review of qualitative studies. We searched for literature across seven databases until March 2022, and included qualitative studies that focused on associations between patient-related characteristics and SDM about treatment in adults. We analyzed studies using an inductive thematic approach. RESULTS The search yielded 5948 articles, of which 70 were included. We identified many different patient-related characteristics, which we grouped into four categories related to: (1) the individual who is facing the decision, (2) the decision, (3) the relationship between the patient and the clinician and others involved in the decision, and (4) the healthcare context. CONCLUSIONS Studies report a variety of patient-related characteristics that may affect patient involvement in SDM. Amongst others, patients may need to feel informed, to understand their role in SDM, and be able to communicate. Involvement may be challenging with characteristics such as perceived time pressure, poor patient-clinician relationships, emotional distress, and severe illness. PRACTICE IMPLICATIONS In order to truly involve patients in SDM, we might need to focus on characteristics such as patient emotions and relationship building, besides information provision and values clarification.
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Affiliation(s)
- Sascha M Keij
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands.
| | - Hanne C Lie
- Department of Behavioural Medicine, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Norway
| | - Rebekah Laidsaar-Powell
- Centre for Medical Psychology and Evidence-Based Decision-Making (CeMPED), School of Psychology, The University of Sydney, Sydney, NSW, Australia
| | - Marleen Kunneman
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands; Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Joyce E de Boer
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands
| | - Saïda Moaddine
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands
| | - Anne M Stiggelbout
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands; Erasmus School of Health Policy and Management, Erasmus University Rotterdam, the Netherlands
| | - Arwen H Pieterse
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands
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Chen JJ, Roldan CS, Nichipor AN, Balboni TA, Krishnan MS, Revette AC, Chen AB, Hertan LM. Prognostic Understanding and Goals of Palliative Radiotherapy: A Qualitative Study. J Pain Symptom Manage 2022; 64:567-576. [PMID: 36007684 DOI: 10.1016/j.jpainsymman.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 08/12/2022] [Accepted: 08/12/2022] [Indexed: 01/04/2023]
Abstract
CONTEXT There is a paucity of data describing patients' expectations of goals of palliative radiotherapy (RT) and overall prognosis. OBJECTIVES To explore patients' perceptions of and preferences for communication surrounding goals of palliative RT and cancer prognosis. METHODS We conducted a qualitative study utilizing semi-structured interviews with seventeen patients with either bone or lung metastases receiving their first course of palliative RT at a comprehensive cancer center. All patient interviews were recorded, transcribed verbatim, and thematically analyzed. RESULTS Themes of goals of palliative RT centered on either restoration, such as through improving quality of life or minimizing pain, or on a desire to combat cancer by eliminating tumor. While most patients perceived that palliative RT would palliate symptoms but not cure their cancer, some patients believed that the goal of palliative RT was to cure. Themes that emerged surrounding patients' understanding of prognosis and what lies ahead included uncertainty and apprehension about the future, a focus on additional treatment, and confronting mortality. Most patients preferred to receive information about goals of treatment and prognosis from their doctors, including radiation oncologists, rather than other members of the medical team. Patients also expressed a desire for written patient education materials on palliative RT. CONCLUSION Unclear perceptions of goals of treatment and prognosis may motivate some patients to pursue unnecessarily aggressive cancer treatments. Patients desire prognostic information from their doctors, including radiation oncologists, who are important contributors to goals of care discussions and may improve patient understanding and well-being by using restorative rather than combat-oriented language.
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Affiliation(s)
- Jie Jane Chen
- Department of Radiation Oncology (J.J.C.), University of San Francisco, San Francisco, California, USA
| | - Claudia S Roldan
- Northwestern Feinberg School of Medicine (C.S.R.), Chicago, Illinois, USA
| | - Alexandra N Nichipor
- Psychosocial Oncology and Palliative Care (A.N.N.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Tracy A Balboni
- Department of Radiation Oncology (T.A.B., M.S.K.), Dana-Farber Cancer Institute/ Brigham and Women's Cancer Center, Boston, Massachusetts, USA
| | - Monica S Krishnan
- Department of Radiation Oncology (T.A.B., M.S.K.), Dana-Farber Cancer Institute/ Brigham and Women's Cancer Center, Boston, Massachusetts, USA
| | - Anna C Revette
- Survey and Data Management Core (A.C.R.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Aileen B Chen
- Department of Radiation Oncology (A.B.C.), MD Anderson Cancer Center, Houston, Texas, USA
| | - Lauren M Hertan
- Department of Radiation Oncology (L.M.H.), Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
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Eggermont F, van der Linden Y, Verdonschot N, Dierselhuis E, Ligthert S, Bitter T, Westhoff P, Tanck E. A Patient-Specific Fracture Risk Assessment Tool for Femoral Bone Metastases: Using the Bone Strength (BOS) Score in Clinical Practice. Cancers (Basel) 2022; 14:cancers14235904. [PMID: 36497388 PMCID: PMC9740241 DOI: 10.3390/cancers14235904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/18/2022] [Accepted: 11/24/2022] [Indexed: 12/04/2022] Open
Abstract
Patients with femoral metastases are at risk of fracturing bones. It is important to prevent fractures in order to maintain mobility and quality of life. The BOne Strength (BOS) score is based on a computed tomography (CT)-based patient-specific finite element (FE) computer model that objectively calculates bone strength. In this pilot study, the added clinical value of the BOS score towards treatment-related decision making was assessed. In December 2019, the BOS score was implemented in four radiotherapy centers. The BOS scores and fracture risks of individual patients were calculated and returned to the physician to assist in treatment decisions. The physicians filled out a questionnaire, which was qualitatively analyzed. A follow-up to identify fractures and/or death was performed after six months. Until June 2021, 42 BOS scores were delivered (20 high, 9 moderate, and 13 low fracture risk). In 48%, the BOS score led to an adaptation of treatment plans. Physicians indicated that the BOS score provided objective insight into fracture risk, was reassuring for physicians and patients, and improved multidisciplinary discussions and shared decision making. In conclusion, the BOS score is an objective tool to assess fracture risk in femoral bone metastases and aids physicians and patients in making a more informed decision regarding the most appropriate treatment.
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Affiliation(s)
- Florieke Eggermont
- Orthopaedic Research Laboratory, Radboud Institute for Health Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
- Correspondence:
| | - Yvette van der Linden
- Department of Radiotherapy, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Netherlands Comprehensive Cancer Organisation (IKNL), 3511 DT Utrecht, The Netherlands
| | - Nico Verdonschot
- Orthopaedic Research Laboratory, Radboud Institute for Health Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
- Laboratory of Biomechanical Engineering, University of Twente, 7522 NB Enschede, The Netherlands
| | - Edwin Dierselhuis
- Department of Orthopedics, Radboud Institute for Health Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Steven Ligthert
- Orthopaedic Research Laboratory, Radboud Institute for Health Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Thom Bitter
- Orthopaedic Research Laboratory, Radboud Institute for Health Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Paulien Westhoff
- Department of Radiation Oncology, Radboud Institute for Health Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Esther Tanck
- Orthopaedic Research Laboratory, Radboud Institute for Health Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
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