Shared Decision-Making (SDM) provides a form of decisional support that centres a patient's values in their treatment decisions. Globally, increasing comorbidity, and rising cancer incidence amplify the demand for supported decision-making in surgical oncology. However, services that provide structured perioperative SDM for frail and multimorbid patients are yet to become an established component of standard perioperative care. Patients undergoing cancer surgery describe a perceived lack of meaningful choice when presented with curative-intent surgery, particularly if alternative therapies confer reduced survival (1). These patients could derive significant benefit from a formalised SDM process. Yet, perioperative SDM is not widely available, and some have postulated that opportunities  for SDM in cancer surgery may be limited (2). In 2019, ‘Peter Mac’ initiated a perioperative SDM service to support patients contemplating major high-risk cancer surgery. This case series study describes our care model and outcomes.   

 

This study was approved by the Peter MacCallum Cancer Centre HREC, 73187/PMCC. Patients attended SDM clinic, between 01/2019 and 07/2021, with the objective of identifying the treatment outcomes to which they attributed the greatest personal value. Clinics are staffed by anaesthetists with training in patient-centered communication. Every case underwent review at an SDM multidisciplinary meeting to discuss treatment options and their anticipated natural history. Based on their expressed goals, a treatment recommendation was formulated. The recommendation and rationale was conveyed to patients. Local ethics approval was granted prior to patients being followed up for research purposes. Patient demographics/data were collated from medical records. Those who underwent surgery had  postoperative outcomes assessed. To understand their experience, patients completed evaluations on SDM quality (CollaboRATE-5), decisional support and decision regret.

 

A total of 85 patients (55% male, 45% female) with a median age of 73 (range: 34-93 years) accessed the service. A majority (93%; n=79) had an ASA physical status score 3 or 4.  Median mortality predicted by NSQIP was 5.2%. The largest surgical oncology streams represented were  Colorectal (41%), Upper GI (14%) and Sarcoma (12%). Of the original 85, 67% (n=54) underwent  surgery. The primary reason for not proceeding was surgery no longer being regarded as an appropriate treatment option (71%).  Patient choice not to proceed accounted for 26% (n= 8).  By follow-up, in 2022, 41% (n=35) had died. The median duration from referral to death was 265 days. Mortality was 61% amongst those that elected against surgery (vs. 30 % for those that proceeded to surgery). Amongst those who completed outcome measures, 84% (n=27) indicated high decisional support. High CollaboRATE scores indicate our service was able to reliably deliver SDM across the study period. On the decision regret scale, 93% (n=28) affirmed they would replicate their initial choice.

Conclusion: 

To our knowledge, this is the first description of a perioperative SDM clinic for major cancer surgery. This demonstrates it is feasible to reliably and effectively deliver SDM to a highly co-morbid surgical oncology cohort. Despite high mortality rates, patients reported high satisfaction levels and minimal decision regret. This innovative model provides a blueprint for institutions seeking to establish similar services: A valuable first step towards an evolution of perioperative medicine where structured SDM is widely available and provided at a consistently high quality to all those patients in need.

 

1.     Charles, C. et al (1998). Doing Nothing is No Choice: Lay Constructions of Treatment Decision‐making Among Women with Early‐stage Breast Cancer. Sociology of Health & Illness, 20(1), 71–95. https://doi.org/10.1111/1467-9566.00081

2.     Shaw, S. E. et al (2023). Opportunities for shared decision-making about major surgery with high-risk patients: a multi-method qualitative study. British Journal of Anaesthesia. https://doi.org/10.1016/j.bja.2023.03.022