The Importance of Shared Decision-Making for Patients with Glioblastoma

Survival prediction in glioblastoma: 10-year follow-up from the Dutch Neurosurgery Quality Registry

PURPOSE

Glioblastoma is the most common and treatment-resistant primary malignant brain tumor, with high morbidity and mortality despite standard treatment protocols. This study aims to evaluate survival and prognostic factors, and introduce two pragmatic prognostic models to inform individualized, patient-centered decision-making, using a large Dutch registry.

METHODS

We analyzed a prospective cohort of 7621 patients (2012-2022) in 12 Dutch centers via the Dutch Quality Registry Neurosurgery. Univariate analysis of prognostic factors, Kaplan-Meier survival curves, and funnel plots comparing center performance (30-day and 2-year mortality) were conducted. Two prognostic models using multivariate Cox regression were developed.

RESULTS

Glioblastoma incidence was 3.9/100.000 in The Netherlands. Overall, 30-day mortality was 5.1% and 2-year survival 17.8%. Overall median survival was 10.4 months, with 4.6 months after biopsy and 12.9 months post-resection. Poorer survival correlated with older age, higher ASA classification, lower Karnofsky Performance Status, biopsy over resection (HR 0.49, 95% CI 0.47-0.52), and postoperative complications (HR 1.57 95% CI 1.39-1.79). MGMT promotor methylation (HR 0.58, 95% CI 0.53-0.63) and adjuvant treatment were linked to lower mortality. Treatment variation and outcomes were within expected ranges; surgical volume did not affect survival. The prognostic models had C-indices of 0.704 (6-month) and 0.721 (2-year).

CONCLUSION

Surgical resection and adjuvant therapy improved survival, but prognosis remained poor. Age, premorbid condition, treatment and molecular markers influenced survival. Center variations were within expected range, and higher surgical volume did not improve outcomes. The developed prognostic models could potentially inform clinicians, pending external validation.

Patient feasibility as a novel approach for integrating IRT and LCA statistical models into patient-centric qualitative data-a pilot study

Introduction

Clinical research increasingly recognizes the role and value of patient-centric data incorporation in trial design, aiming for more relevant, feasible, and engaging studies for participating patients. Despite recognition, research on analytical models regarding qualitative patient data analysis has been insufficient.

Aim

This pilot study aims to explore and demonstrate the analytical framework of the "patient feasibility" concept-a novel approach for integrating patient-centric data into clinical trial design using psychometric latent class analysis (LCA) and interval response theory (IRT) models.

Methods

A qualitative survey was designed to capture the diverse experiences and attitudes of patients in an oncological indication. Results were subjected to content analysis and categorization as a preparatory phase of the study. The analytical phase further employed LCA and hybrid IRT models to discern distinct patient subgroups and characteristics related to patient feasibility.

Results

LCA identified three latent classes each with distinct characteristics pertaining to a latent trait defined as patient feasibility. Covariate analyses further highlighted subgroup behaviors. In addition, IRT analyses using the two-parameter logistic model, generalized partial credit model, and nominal response model highlighted further distinct characteristics of the studied group. The results provided insights into perceived treatment challenges, logistic challenges, and limiting factors regarding the standard of care therapy and clinical trial attitudes.

Exploring Patient Preferences Related to Shared Decision-Making in Chronic Disease Management

Background and objective Shared decision-making (SDM) in healthcare has transitioned from a paternalistic model to a collaborative approach, particularly significant in chronic disease management. This shift focuses on aligning healthcare decisions with patient preferences and values, thereby enhancing patient engagement and treatment adherence. However, patient preferences regarding involvement in SDM vary widely, influenced by demographic, disease-specific, psychological, cultural, and social factors. This study aimed to explore patient preferences related to SDM in chronic disease management in Saudi Arabia, by assessing attitudes toward SDM, the impact of decision aids, and the role of clinician communication in influencing these preferences. Methods A cross-sectional survey design was employed, involving 409 adult outpatients with chronic diseases attending four public hospitals in Saudi Arabia. Participants were selected using purposive and convenience sampling. The survey, translated into Arabic, collected demographic data and information on preferences and experiences in decision-making, communication, and information sharing. The data were analyzed using SPSS Statistics (IBM Corp., Armonk, NY) to identify patterns and correlations. Results Key findings indicated a strong preference among the participants for involvement in treatment decisions (n=303, 74.2%) and clear communication using layman's terms (n=338, 82.6%). Major barriers to active participation in SDM included lack of time during appointments (n=275, 67.2%), difficulty understanding medical terminology (n=220, 53.9%), and feeling intimidated to ask questions (297, 72.6%). Comfort in SDM was highest in the age group of 41-50 years [mean=4.16, standard deviation (SD)=28.44; F=2.3287, p=0.0739]. Patient satisfaction was significantly higher in the age group of 18-30 years (mean=3.42, SD=1.09; F=3.0503, p=0.0284). Conclusions Our findings highlight the need for incorporating patient preferences into chronic disease management strategies to enhance engagement and satisfaction.

Large language models as decision aids in neuro-oncology: a review of shared decision-making applications

Shared decision-making (SDM) is crucial in neuro-oncology, fostering collaborations between patients and healthcare professionals to navigate treatment options. However, the complexity of neuro-oncological conditions and the cognitive and emotional burdens on patients present significant barriers to achieving effective SDM. This discussion explores the potential of large language models (LLMs) such as OpenAI's ChatGPT and Google's Bard to overcome these barriers, offering a means to enhance patient understanding and engagement in their care. LLMs, by providing accessible, personalized information, could support but not supplant the critical insights of healthcare professionals. The hypothesis suggests that patients, better informed through LLMs, may participate more actively in their treatment choices. Integrating LLMs into neuro-oncology requires navigating ethical considerations, including safeguarding patient data and ensuring informed consent, alongside the judicious use of AI technologies. Future efforts should focus on establishing ethical guidelines, adapting healthcare workflows, promoting patient-oriented research, and developing training programs for clinicians on the use of LLMs. Continuous evaluation of LLM applications will be vital to maintain their effectiveness and alignment with patient needs. Ultimately, this exploration contends that the thoughtful integration of LLMs into SDM processes could significantly enhance patient involvement and strengthen the patient-physician relationship in neuro-oncology care.

What do spouse primary caregivers of patients with glioblastoma want medical providers to know? A qualitative thematic reflexive analysis of letters written by primary caregivers from a secret Facebook support group

OBJECTIVES

To analyse the content of letters written by female spouse primary caregivers of patients with glioblastoma multiforme (GBM), a devastating and terminal primary brain cancer, and give voice to their experiences for medical providers of patients with GBM.

DESIGN

A qualitative study using reflexive thematic analysis of letters written by female spouses/life partners and primary caregivers of patients with GBM.

PARTICIPANTS

101 current or former female spouse primary caregivers of patients with GBM wrote letters to share with the medical community between July 2019 and August 2019.

INCLUSION CRITERIA

(1) the primary caregiver who is a spouse of a patient with glioblastoma, (2) be a member of the secret Facebook group, 'We are the wives of GBM and this is our story', and (3) completed informed consent for the contents of their letter to be included for primary and secondary data analysis. Participants who wrote letters but did not complete the informed consent were excluded from the study.

RESULTS

Themes from the letters included the patient experiences: (1) medical details of the disease trajectory, (2) interactions of the patient/caregiver dyads with healthcare and (3) the changing patient condition over time. Themes focused on the caregiver experiences: (1) caregiver challenges, (2) caregiver responses and (3) caregiver coping strategies, and description of tangible needs that would help other caregivers in the future. Caregiver needs were highest during the living with disease progression phase. Caregivers wanted more education and to be valued as members of the care team.

CONCLUSION

Shared decision-making through family-centred care would be beneficial for primary caregivers of patients with GBM. These findings provide opportunities to guide more timely and tailored interventions to provide support and improve care for patient/caregiver dyads to help mitigate the burden of this progressive disease and improve quality of life for caregivers.

Understanding how shared decision-making approaches and patient aids influence patients with advanced cancer when deciding on palliative treatments and care: A realist review

BACKGROUND

Patients with advanced incurable cancer face difficult decisions about palliative treatment options towards their end of life. However, they are often not provided with the appropriate information and support that is needed to make informed decisions. This review aimed to identify contexts and mechanisms associated with communication tools, patient decision-aids and shared decision-making (SDM) approaches that influence patient outcomes.

METHODS

We used a realist review method to search for published studies of patients (adults > 18) with advanced cancer who were expected to make a decision about palliative treatment and/or supportive care in consultation with healthcare practitioners. We appraised and synthesised literature describing the contexts of (when and how) decision aids and SDM approaches are used, and how these contexts interact with mechanisms (resources and reasoning) which impact patient outcomes. Stakeholders including academics, palliative healthcare professionals (HCPs) and people with lived experience of supporting people with advanced incurable cancer contributed to identifying explanatory accounts. These accounts were documented, analysed and consolidated to contribute to the development of a programme theory.

RESULTS

From the 33 included papers, we consolidated findings into 20 explanatory accounts to develop a programme theory that explains key contexts and mechanisms that influence patient and SDM. Contexts include underlying patients' and HCPs' attitudes and approaches. These need to be understood in relation to key mechanisms, including presenting information in multiple formats and providing adequate time and opportunities to prepare for and revisit decisions. Contexts influenced mechanisms which then influence the levels of patient decisional satisfaction, conflict and regret.

CONCLUSIONS

Our programme theory highlights mechanisms that are important in supporting shared treatment decisions for advanced noncurative cancer. The findings are informative for developing and evaluating interventions to improve understanding and involvement in SDM for patients with advanced incurable cancer.

PATIENT AND PUBLIC CONTRIBUTION

We included patient and public involvement (PPI) representatives in four stakeholder meetings. PPI helped to define the scope of the review, identify their unique experiences and perspectives, synthesise their perspectives with our review findings, make decisions about which theories we included in our programme theory and develop recommendations for policy and practice and future research.

Status quo of advanced cancer patients participating in shared decision-making in China: a mixed study

PURPOSE

Patients with advanced cancer are usually willing to participate in shared decision-making (SDM), but in clinical practice, patient participation is easily ignored. This study aimed to analyze the current SDM status of advanced cancer patients and related factors.

METHODS

In quantitative research, we administered a cross-sectional survey to 513 advanced cancer patients in 16 tertiary hospitals in China. A sociodemographic information questionnaire, the Control Preference Scale (CPS), and Perceived-Involvement in Care Scale (PICS) were used to analyze current SDM status and influencing factors. Our qualitative research was based on the Ottawa Decision Support Framework (ODSF), and 17 advanced cancer patients were interviewed to explore their perceptions of SDM.

RESULTS

Our quantitative results show that patients' actual and expected decision-making participation differed; statistically significant influencing factors were age, insurance, and whether patients were worried about the therapeutic effects. We also found that dynamic decision-making mode changes, disease information acquisition, decision-making participation obstacles, and family members' roles affected patients' SDM through qualitative interviews.

CONCLUSION

Advanced cancer patients' SDM in China is dominated by sharing and continuously fluctuates. Influenced by Chinese traditional culture, family members play an important role in SDM. In clinical work, we should pay attention to the dynamic changes in patients' participation in decision-making and the role of family members.

Disparities in place of death for patients with primary brain tumors and brain metastases in the USA

PURPOSE

Patients with primary or metastatic brain tumors often require intensive end-of-life care, for which place of death may serve as a quality metric. Death at home or hospice is considered a more "ideal" location. Comprehensive information on place of death of people with brain tumors is lacking.

METHODS

Using CDC Wonder Database data, those who died in the USA from a solid cancer from 2003 to 2016 were included and place of death for those with primary brain, brain metastases, and solid non-brain tumors were compared. Multivariate logistic regression tested for disparities in place of death.

RESULTS

By 2016, 51.1% of patients with primary brain tumors and 45.2% with brain metastases died at home. 15.9% of patients with primary brain tumors and 23.6% with brain metastases died in the hospital. Black patients were least likely to die at home or hospice. For patients with primary brain tumors, being married (OR = 2.25 (95%CI 2.16-2.34), p < 0.01) and having an advanced degree (OR = 1.204 (95%CI 1.15-1.26), p < 0.01) increased odds of home/hospice death; older age (OR = 0.50 (95%CI 0.46-0.54), p < 0.01) decreased odds for home/hospice death. For patients with brain metastases, being married (OR = 2.19 (95%CI 2.11-2.26), p < 0.01) increased odds of home/hospice death and male sex (OR = 0.87 (095%CI .85-0.89), p < 0.01) and older age (OR = 0.59 (95%CI 0.47-0.75), p < 0.01) decreased odds of home/hospice death.

CONCLUSION

Disparities exist in place of death in the brain tumor population. Focused interventions are indicated to increase the utilization of hospice in those with metastatic cancer, under-represented minority groups, and the elderly population.

Development of a Patient Decision Aid to Support Shared Decision Making for Patients with Recurrent High-Grade Glioma

When high-grade gliomas recur, patients, their families, and clinicians face difficult medical decisions. There is no curable treatment, and the treatment options all come with a risk of complications and adverse effects. The patients are often cognitively affected, and they need tailored decision support. The objective of this study was to develop a patient decision aid (PtDA) targeted at patients with recurrent high-grade gliomas. Based on existing knowledge and the International Patient Decision Aids Standards, the PtDA was developed through an iterative process. The PtDA was alpha-tested by potential users to assess its acceptability and usability. The development team comprised three clinicians, two patients, two family members, and a researcher. The fifth version of the PtDA was submitted to the alpha test. Eleven patients, nine family members, and eleven clinicians assessed the PtDA and found it acceptable. Three changes were made during the alpha test. Most participants perceived the PtDA to prepare patients for decision making and improve consultations. The involvement of potential users was emphasized during the development and alpha test process. The PtDA was assessed as useful and acceptable by patients, family members, and clinicians in the decision-making situation of recurrent high-grade glioma.

Decisional needs of patients with recurrent high-grade glioma and their families

Background

High-grade gliomas are aggressive and life-threatening brain tumors. At the time of recurrence, the patients and their families need to decide on future treatment. None of the treatment options are curative, and tradeoffs between benefits and harms must be made. This study aimed to explore the patients’ and family members’ decisional needs when making the decision.

Methods

We performed semi-structured individual interviews with patients and family members to explore their experiences during the decision making. A phenomenological hermeneutical analysis was conducted.

Results

A total of 15 patients and 14 family members aged 22-79 years participated in the study. Most of the family members were partners to the patient. The findings were centered around three interrelated and concurrently occurring themes: (I) A patient- and family-centered decision making, including the subtheme of being a supportive family member; (II) Balanced information and a trustful professional encounter; and (III) The value of hope. We found that both the patients and family members preferred to be involved in the decision making and that a trustful relationship with the surgeon, balanced and tailored information, and sufficient time to make the decision were essential. The experience of hope had a significant influence on patients’ decisions.

Conclusion

This study found that patient and family involvement, balanced information, and hope were the primary decisional needs of patients and family members at the time of recurrent high-grade glioma. Patients and family members can have different decisional needs, making individual needs assessment essential to decisional support.