Although cancer management is becoming more structured with diseasespecific guidelines and clinical pathways, many decisions remain complex. Contributing to this complexity is the need to make value tradeoffs between benefits and harms across cancer treatment and/or screening options. Since there is no "best" option for everyone, decisions are defined as being of higher quality when informed with the latest scientific evidence and based on patients' informed values associated with outcomes of options. However, clinicians are not good judges of patients' values, and patients often have inadequate knowledge, unrealistic expectations, and decisional conflict that interfere with their involvement in decision making.Effective approaches to support patient involvement into clinical decisions include clinicians trained in shared decision making, question prompt sheets, patient decision aids, and decision coaching by nurses and other allied health professionals. Based on systematic review of 23 randomized trials of cancer patient decision aids, patients exposed to decision aids are more likely to participate in decision making and achieve higher-quality decisions. This review highlights key historical changes leading to patient involvement in decision making, summarizes evidence on effective interventions to support shared decision making, explores strategies to implement these interventions in oncology practices, and identifies future directions. (CA Cancer J Clin 2008;58:293-304.)

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Hypothesis: Metastatic workup for patients newly diagnosed as having breast cancer is variable, especially for early disease (T1-2 N0-1). Routine bone scans and liver imaging are often performed without any evidence to support their usefulness. Design: A retrospective review of patients with breast cancer referred to our center during a 2-year period was performed to determine the value of staging investigations in detecting metastases. Results: Of the total 250 patients referred to our center after initial diagnosis, 25 (10.0%) were diagnosed as having metastases, 23 of whom had either clinical symptoms or signs suggestive of metastatic disease or abnormalities on routine blood work or chest x-ray examinations. Only 2 patients with metastatic disease were diagnosed solely on bone scan results; none were diagnosed solely on liver imaging (either with an ultrasound or radionuclide isotope liver scan). Overall, 3% (5/161) of patients with pathologic T1-2 N0-1 disease had metastases diagnosed compared with 30% (18/61) of patients with pathologic stage T3-4 or N2 disease. Conclusions: Our results confirm the low yield of routine bone scans and liver imaging among patients with asymptomatic, pathologically confirmed, early stage (T1-2 N0-1) breast cancer. Therefore, we do not recommend these tests for such patients, although intensive investigations are appropriate for more advanced (stage T3-4 or N2) tumors.

Radiotherapy is an effective but underutilized treatment modality for cancer patients. We decided to investigate the factors influencing radiotherapy referral among family physicians in our region. A 30-item survey was developed to determine palliative radiotherapy knowledge and factors influencing referral. It was sent to 400 physicians in eastern Ontario (Canada) and the completed surveys were evaluated. The overall response rate was 50% with almost all physicians seeing cancer patients recently (97%) and the majority (80%) providing palliative care. Approximately 56% had referred patients for radiotherapy previously and 59% were aware of the regional community oncology program. Factors influencing radiotherapy referral included the following: waiting times for radiotherapy consultation and treatment, uncertainty about the benefits of radiotherapy, patient age, and perceived patient inconvenience. Physicians who referred patients for radiotherapy were more than likely to provide palliative care, work outside of urban centres, have hospital privileges and had sought advice from a radiation oncologist in the past. A variety of factors influence the referral of cancer patients for radiotherapy by family physicians and addressing issues such as long waiting times, lack of palliative radiotherapy knowledge and awareness of Cancer Centre services could increase the rate of appropriate radiotherapy patient referral.

ObjectiveUsing an interview-guided survey, our descriptive study aimed to document the extent to which cancer patients perceive they are involved in making treatment decisions and the factors that influence patient involvement. Patients and methodsOur study enrolled patients from a Canadian ambulatory oncology program who were undergoing chemotherapy or radiation therapy, or both, for cancer. The adapted Control Preferences Scale was used to survey perceived and preferred roles in decisionmaking. The study survey also included items from the Decisional Conflict Scale and the Preparation for Decision-Making Scale. ResultsOf 192 participants, 98 (51%) perceived that they were offered treatment choices. Of those 98, 47 (48%) thought that the options were presented equally. Compared with the patients not offered choices, those who were given choices were less passive (4% vs. 29%, p < 0.001) and more satisfied (100% vs. 95%, p < 0.03) in decision-making. Participants whose preferred and perceived roles were different would have preferred more involvement in decision-making. To attain the preferred involvement, patients wanted to receive more information on treatment options, to be given a choice, to have more discussion with the health care team, and to have providers better listen to their needs. ConclusionsOnly half of surveyed patients thought that they were offered choices for their cancer treatment. When offered choices, patients were more active in decisionmaking. Further initiatives are required to determine approaches for supporting patients with cancer so that they can be more involved in decision-making.

PURPOSE Dose-escalated radiotherapy (RT) with androgen-deprivation therapy (ADT) is a standard definitive treatment of localized prostate cancer (LPCa). The optimal sequencing of these therapies is unclear. Our phase III trial compared neoadjuvant versus concurrent initiation of ADT in combination with dose-escalated prostate RT (PRT). PATIENTS AND METHODS Patients with newly diagnosed LPCa with Gleason score ≤ 7, clinical stage T1b to T3a, and prostate-specific antigen < 30 ng/mL were randomly allocated to neoadjuvant and concurrent ADT for 6 months starting 4 months before RT (neoadjuvant group) or concurrent and adjuvant ADT for 6 months starting simultaneously with RT (concurrent group). The primary end point was biochemical relapse-free survival (bRFS). Stratified log-rank test was used to compare bRFS and overall survival (OS). Incidence of grade ≥ 3 late RT-related toxicities was compared by log-rank test. RESULTS Overall, 432 patients were randomly assigned to the neoadjuvant (n = 215) or concurrent group (n = 217). At 10 years, bRFS rates for the two groups were 80.5% and 87.4%, respectively. Ten-year OS rates were 76.4% and 73.7%, respectively. There was no significant difference in bRFS ( P = .10) or OS ( P = .70) between the two groups. Relative to the neoadjuvant group, the hazard ratio for the concurrent group was 0.66 (95% CI, 0.41 to 1.07) for bRFS and 0.94 (95% CI, 0.68 to 1.30) for OS. No significant difference was observed in the 3-year incidence of late RT-related grade ≥ 3 GI (2.5% v 3.9%) or genitourinary toxicity (2.9% v 2.9%). CONCLUSION In our study, there was no statistically significant difference in bRFS between the two treatment groups. Similarly, no difference was seen in OS or late RT-related toxicities. On the basis of these results, both neoadjuvant and concurrent initiations of short-term ADT with dose-escalated PRT are reasonable standards of care for LPCa.

Lymphovascular space invasion is an overall poor prognostic factor in T1N0 endometrial cancer. After adjusting for other factors, LVSI remains an independent risk factor for worse overall survival. Therefore, estimation of overall survival in patients with early-stage, node-negative endometrial cancer should take into account LVSI status.

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