Monday, 10 July 2017

Cancer committees - a brake on shared clinical decisions?

Cancer committees are instruments for the coordination of cancer practice that have existed for many years. Now, however, a joint German-US research group (with the collaboration of Glyn Elwyn) wanted to know not only the quality of the work of these committees but also how they address the demand for greater involvement of patients in clinical decisions, and an observational study has been carried out on 15 cancer committees of the University Cancer Center Hamburg-Eppendorf. From the publication of this paper, I would like to highlight two key aspects: a) the reality of the organizational quality of cancer committees, and b) how these committees contemplate patients' preferences.

a) Organizational quality of cancer committees

The first observation is that the majority of the tumour committees’ members are doctors in senior positions and, on the other hand, the presence of young doctors is scarce. The participation of other professionals, also important for cancer patients, such as nurses or psycho-oncologists has not been observed in any of the cases. Researchers believe that the hierarchical influence of key members of the committees and the need to close many cases in a short time are limiting factors for productive and quality multidisciplinary work. In summary, the observation notes that guidelines and recommendations are generally applied with margins too scarce for other considerations.

The article explains that, apart from strictly medical information, the committees are almost only interested in the patient’s age, although, they say, there were sometimes rather sporadic comments about the general state of a patient, type: "are you feeling well?" or "can you walk?".

b) The preferences of the patients in the cancer committees

Taking into account the patients’ preferences is especially important in oncology, since very often the options for treatment have very varied ranges of benefits and risks and as a consequence the decision affects very significantly the quality and quantity of people's lives. In spite of this fact, the observers emphasize that certain contributions that they heard about the preferences of some patients, ended up influencing little or nothing in the clinical decisions of the analyzed committees.

Doctors practicing today, especially in the field of oncology, should review their concepts and methods of acting. They should know that having the support of clinical practice guidelines on one hand and being aware of their own accumulated experience on the other hand are two necessary conditions, but no longer sufficient, because if they are not able to involve patients, if they don’t know how to listen to their preferences, then they might prescribe treatments that are inappropriate to people's way of life, with unsatisfactory results.

How to introduce patient preferences to cancer committees

The same researchers make a few suggestions on how to introduce the shared clinical decision in climates as difficult as the cancer committees:
  1. The doctor presenting the case should report that a frank prior conversation with the patient about treatment options took place; patient’s preferences should be present in committee discussions and should be taken into account in clinical decisions.
  2. Committees should not make a single decision (when there are different options), but should make a gradient of recommendations that would serve as a basis for the referral physician to discuss with the patient after the meeting.
  3. Nurses and psycho-oncologists should be summoned to the meetings in order to expand visions and records on the way each patient has to live the cancer process.
  4. Times scheduled for cancer committee meetings should be adjusted proportionately to the complexity of the scheduled patients.
  5. For selected patients, carefully selected consideration should be given to inviting them to the meeting.

The dynamics of the cancer committees, which have brought so many benefits to the coordination of processes, have become stuck in a medical only view of oncology practice. Everything leads us to believe that it’s time for self-criticism and reinvention.

Jordi Varela

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