Evidence-based practice
Older patients and adjuvant therapy for colorectal cancer: surgeon knowledge, opinions and practice.
Mikaela Jorgensen, Jane Young, Michael Solomon
Two-thirds of colorectal cancer cases occur in those over 65 years in Australia, however cancer care issues in older patients are relatively underresearched. Appropriate adjuvant therapy is underutilised in older patients, and surgeons may play a critical role. A survey was sent to all Australian and New Zealand colorectal surgeons to investigate knowledge, opinions and self-reported practice regarding referral of older cancer patients for adjuvant therapy. 70% of surgeons responded. Surgeons were significantly less likely to refer older patients than younger patients for adjuvant therapy in self-reported practice questions. This difference was greatest for patients from rural/remote areas, followed by patients with little social support or poor general health status. Surgeons with greater knowledge and more positive opinions towards older patients were significantly more likely to refer older and younger patients similarly. Findings suggest that sociodemographic factors are important determinants of evidence-based care of older patients, and that interventions targeting surgeon knowledge may improve this aspect of patient care.
Published: Diseases of the Colon & Rectum 2011; 54:335-41
Age differences in cancer patients' adjuvant chemotherapy decision-making
Mikaela Jorgensen, Jane Young, Michael Solomon
Older colorectal cancer patients are less likely than younger patients to receive appropriate adjuvant chemotherapy. This study aimed to explore barriers to adjuvant therapy use by examining the links between patient age, factors of importance in chemotherapy decisions, and information and decision-making preferences. 68 patients who underwent surgery for colorectal cancer within the previous 24 months completed a self-administered survey. Factors that were significantly more important to older participants were fear of dying, maintaining quality of life, age, health status, and understanding benefits and side effects. Reducing the risk of cancer returning and physician trust were factors of highest importance for both age groups. Treatment cost, duration and travel were rated lowest. Participants who preferred less information and less involvement in treatment decision-making were more likely to be older. However these participants still rated many factors as important in chemotherapy decision-making. For older patients, balancing the risks and benefits of treatment may be made more complex by the impact of emotional motivators (e.g. fear), greater health concerns, and conflicts between preferences for information and decision-making. Where perceived barriers to treatment and motivators for treatment choice are better understood, older patients may be supported to make optimal decisions about their care.
Status: Manuscript in preparation
The decision-making process behind defunctioning ileostomies
Ewan MacDermid, Christopher Young,1, Jane Young, Michael Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital
In patients undergoing anterior resection the decision whether or not to create a defunctioning stoma is one that can have significant consequences. Decisions under uncertainty like these are made with a variety of conscious and unconscious tools, known as heuristics. Past experience has been shown to be a powerful heuristic tool in other domains, and we wished to ascertain its effect in the decision to create a defunctioning stoma.
Our aim was to identify whether the misfortune of a recent anastomotic leak, and a surgeon’s propensity to take risks in everyday life would have any effect on their propensity to defunction a range of anastomoses scenarios.
A survey questionnaire was sent to members of the Colorectal Surgical Society of Australia and New Zealand. Participants were asked for demographic information, a series of questions about their propensity for taking risks, when their last anastomotic leak was and whether they would defunction a range of hypothetical rectal anastomoses grouped according to height, age, ASA grade and the use of preoperative radiotherapy.
Results: 110 (75.3%) of 146 surveyed surgeons replied. 72 of these (65.5%) reported an anastomotic leak within the last 12 months. Surgeon’s measured propensity for risk-taking in everyday life was statistically comparable (24.6 vs 27.53, 95% CI, Mann-Whitney U) to previously studied participants in economic models.
The hypothetical patient scenario with the greatest degree of equipoise with 49.1% of respondents choosing to create a stoma was that of a mid rectal anastomosis, in a 60 to 70 year old ASA grade III smoker, who had not received any preoperative radiotherapy.
Hypothetical patient ASA grade, preoperative radiotherapy and anastomotic height were all independent predictors of stoma formation on regression analysis. Surgeon age (<50 years) ( p = 0.0379) and lower propensity for risk-taking (p = 0.04) were demonstrated to be independent predictors of stoma formation on hazard regression analysis.
Conclusion: Our survey suggests that older colorectal surgeons, and those with a higher propensity for risk-taking in their adult lives are less likely to create defunctioning stomas for patients undergoing anterior resection. Although the decision to create a stoma after anterior resection may made in the belief that its foundation derives from evidence base and rational thought, it appears other unrecognised operator factors may exert an effect.
Status: Completed, manuscript in preparation
Decision making when using radiotherapy in the treatment of rectal cancer
Jonathan Hong, Christopher Young1, Michael Solomon, Jane Young
- Department of Colorectal Surgery, Royal Prince Alfred Hospital
There is a vast volume of evidence that supports and refutes the multiple roles of radiotherapy in the treatment of rectal cancer. To make a recommendation for an individual patient the surgeon must assess not only the probability of effectiveness (the evidence and experience) but also the patient’s wishes and fitness, the available resources and the features of the tumour. It is difficult to assimilate all this information to make a decision. Humans tend to use information selectively when confronted with a large volume of variables.
My project seeks to identify which preferences carry most weight with surgeons when making decisions about radiotherapy in the treatment of rectal cancer. It also seeks to clarify how radiotherapy is used and how the evidence is incorporated in this decision, particularly in view of the conflict surrounding many of the uses of radiotherapy. Knowledge of areas of uniform agreement and areas of equipoise can direct future research. It is also hoped that these preferences may be incorporated into a patient decision making tool.
Status: Data collection