Alberto Sobrero*†
Alessandro PastorinoIntroduction
There is a wide consensus that the best way to practice medicine is evidence-based medicine that results from the merging of three domains: relevant scientific data, the doctor's clinical judgment, and the patient's preferences and values. These concepts were pioneered by Sackett almost 30 years ago (Sackett et al., 1996). It is surprising how little the elaboration of clinical judgment has been investigated in recent years (Charles et al., 2004; Hoffmann et al., 2014). In addition, despite the wide endorsement of shared decision-making by clinicians, patients, and their advocates (Stiggelbout et al., 2015; Elwyn et al., 2017), its translation into practice remains limited (Légaré and Witteman, 2013). This commentary addresses these issues and tries to explain why practicing full shared decision-making is so difficult in oncology.
The challenge of shared decision-making in oncology
Aside from the intrinsic difficulty of the message to be conveyed and the huge skills needed to convey these messages in oncology (Weeks et al., 2012), the complexity of the clinical decision-making process is the major challenge.
In his latest book “Noise: A Flaw in Human Judgment,” Nobel Prize winner Daniel Kahneman demonstrates that whenever a decision must be taken by humans, including medical decisions, an unacceptably high level of variability is present (Kahneman et al., 2021). The biological mechanisms of processing information by the human brain are still largely unknown (Tongtong et al., 2022); however, they are based on the integration of concepts from psychology, behavioral sciences, anthropology, and neurobiology.
According to Kahneman, humans process, analyze, and react to facts, data, and information via two demonstrated mechanisms called systems 1 and 2 (Kahneman and Levitt, 2011). System 1 is automatic, subcortical (amygdala), and effortless, but subjected to bias and errors. In addition, this system tends to simplify things through heuristics that are cognitive shortcuts. For example, “I recently saw my sister dying from pancreatic cancer despite treatments, now that I have breast cancer I do not want to be treated, because the treatments are useless.” System 2 is much more reliable and cortical, but slow. It is typical of any fully rational decision.
We speculate that these two systems present the elaborated information to the two determinants of judgment that in humans are coupled: intelligence (the capacity to rationally solve problems) and conscience (the capacity to feel emotions and sentiments).
Reason and feelings produce judgments that are heavily influenced by a third factor that Kahneman called “narrating self,” an internal function of our mind based on memories, personal values, and preferences (Kahneman and Levitt, 2011). The narrating self is our personal power to “manipulate/re-shape/distort” the information being processed so that our judgment of data and facts fits our personal representation of reality. This is why the interpretation and reaction to the same facts, data, or information are hugely different from doctor to doctor and from patient to patient (“noise” in medicine).
Given this complexity, it is not surprising that the same data explained to patient A produce evaluations that may be completely different from those of patient B. For example, when 150 patients with stage III colon cancer who received adjuvant chemotherapy were asked what percentage cure rate would make them accept the same treatment again, about one-third would accept to be treated again for a 1% absolute reduction in risk recurrence, and about two-third believed that only a 5% reduction would justify treatment (Love et al., 2007).
This process of data interpretation by patients indicates why shared decision-making must be the outcome of evidence-based medicine. Based on decades of research (Henselmans et al., 2018; Josfeld et al., 2021; Marieke, 2022), the concept of shared decision-making is that physicians and patients collaborate in the entire process, with a continuous exchange of information. On one hand, the physician presents scientific data to the patient in the most simplest and understandable manner. On the other hand, as the patient progressively comprehends the clinical situation, he communicates his own values and preferences to the doctor.1
The following are the four steps that can be recognized in the shared decision-making process:
1) The doctor elaborates his own judgment for “that specific patient” on the pros and cons of the options indicated by guidelines.
2) The doctor informs and engages the patient in the most unbiased way, considering the wide range of alternatives (Elwyn et al., 2017).
3) The patient, with his personal intellectual and emotional tools, elaborates his own judgment and discusses that with the doctor (Elwyn et al., 2017).
4) The doctor and the patient come to a shared decision that derives from the two distinct processes of data interpretation and personal beliefs, thereby realizing full patient empowerment.
Conclusion
All these steps account for the complexity that renders fully shared decision-making so difficult on top of the hard content of the information to be conveyed in oncology. Nevertheless, this task is not prohibitive and can be facilitated by a wider knowledge of these mechanisms among clinical oncologists.
Author contributions
All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.
Funding
This work was supported by AIRC (Italian Association for Research against Cancer) Investigator Grant IG 2018.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Footnotes
References
Charles, C., Gafni, A., and Whelan, T. (2004). Self-reported use of shared decision-making among breast cancer specialists and perceived barriers and facilitators to implementing this approach. Health Exp. 7, 338–48. doi: 10.1111/j.1369-7625.2004.00299.x
Elwyn, G., Durand, M. A., and Song, J. A. (2017). Three-talk model for shared decision making: multistage consultation process. BMJ 359, j4891. doi: 10.1136/bmj.j4891
Henselmans, I., Smets, E., and De Haes, J. (2018). A randomized controlled trial of a skills training for oncologists and a communication aid for patients to stimulate shared decision making about palliative systemic treatment (CHOICE): study protocol. BMC Cancer 18, 55. doi: 10.1186/s12885-017-3838-8
Hoffmann, T. C., Montori, V. M., and Del Mar, C. (2014). The connection between evidence-based-medicine and shared decision making. JAMA 312, 1295–6. doi: 10.1001/jama.2014.10186
Josfeld, L., Keinki, C., and Pammer, C. (2021). Cancer patients' perspective on shared decision-making and decision aids in oncology. J. Cancer Res. Clin. Oncol. 147, 1725–1732. doi: 10.1007/s00432-021-03579-6
Kahneman, D., and Levitt, S. D. (2011). Thinking, Fast, and Slow. New York: Farrar, Straus and Giroux.
Kahneman, D., Sibony, O., and Sunstein, C. R. (2021). Noise: A Flaw in Human Judgment. New York: Little: Brown Spark.
Légaré, F., and Witteman, H. O. (2013). Shared decision making: examining key elements and barriers to adoption into routine clinical practice. Health Aff. 32, 276–84. doi: 10.1377/hlthaff.2012.1078
Love, N., Bylund, C., and Meropol, N. (2007). How well do we communicate with our partients? A survey of patients who received adjuvant therapy for colorectal cancer. J. Clin. Oncol. 18, 4020. doi: 10.1200/jco.2007.25.18_suppl.4020
Marieke, M. (2022). Kuijpers, Haske van Veenendaal. Shared decision making in cancer treatment: a Dutch national survey on patients' preferences and perceptions. Eur. J. Cancer Care 31, e13534. doi: 10.1111/ecc.13534
Sackett, D. L., Rosenberg, W. M. C., and Gray, J. A. M. (1996). Evidence based medicine: what it is and what it isn't. BMJ 312, 71–72. doi: 10.1136/bmj.312.7023.71
Stiggelbout, A. M., Pieterse, A. H., and De Haes, J. C. J. M. (2015). Shared decision making: concepts, evidence, and practice. Patient Edu. Couns. 98, 1172–9. doi: 10.1016/j.pec.2015.06.022
Tongtong, L., Yu, Z., and Zhe, W. (2022). Brain information processing capacity modelling. Nature 12, 2174. doi: 10.1038/s41598-022-07499-4
Keywords: shared decision-making, oncology, judgment, psycho oncology, perspectives
Citation: Sobrero A, Martelli V and Pastorino A (2023) Facilitating shared decision-making in oncology. Front. Psychol. 14:1216165. doi: 10.3389/fpsyg.2023.1216165
Received: 03 May 2023; Accepted: 20 September 2023;
Published: 10 October 2023.
Edited by:
Anja Mehnert-Theuerkauf, University Hospital Leipzig, GermanyReviewed by:
Rianne Fijten, Maastricht University, NetherlandsCopyright © 2023 Sobrero, Martelli and Pastorino. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Alberto Sobrero, YWxiZXJ0by5zb2JyZXJvJiN4MDAwNDA7aHNhbm1hcnRpbm8uaXQ=
†These authors have contributed equally to this work