Use of implicit persuasion in decision making about adjuvant cancer treatment: A potential barrier to shared decision making |
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| Affiliation: | 1. National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany;2. Department of Radiation Oncology, Technische Universität München, Munich, Germany;3. Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany;4. Department of Urology, University Hospital Heidelberg, Heidelberg, Germany;6. Department of Biostatistics, German Cancer Research Center of Heidelberg, Heidelberg, Germany;5. Department of Radiology, German Cancer Research Center of Heidelberg, Heidelberg, Germany;1. Parasitic Disease Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA 30329, United States;2. IHRC Inc, 2 Ravinia Drive, Suite 1750, Atlanta, GA 30346, United States;3. Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Enteric and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA, 30329, United States;4. Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA 30329, United States;5. Atlanta Research and Education Foundation, 1670 Clairmont Road, Suite 5A104, Decatur, GA 30033, United States. |
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| Abstract: | BackgroundShared decision making (SDM) is widely advocated, especially for preference-sensitive decisions like those on adjuvant treatment for early-stage cancer. Here, decision making involves a subjective trade-off between benefits and side-effects, and therefore, patients' informed preferences should be taken into account. If clinicians consciously or unconsciously steer patients towards the option they think is in their patients' best interest (i.e. implicit persuasion), they may be unwittingly subverting their own efforts to implement SDM. We assessed the frequency of use of implicit persuasion during consultations and whether the use of implicit persuasion was associated with expected treatment benefit and/or decision making.MethodsObservational study design in which consecutive consultations about adjuvant systemic therapy with stage I–II breast cancer patients treated at oncology outpatient clinics of general teaching hospitals and university medical centres were audiotaped, transcribed and coded by two researchers independently.ResultsIn total, 105 patients (median age = 59; range: 35–87 years) were included. A median of five (range: 2–10) implicitly persuasive behaviours were employed per consultation. The number of behaviours used did not differ by disease stage (P = 0.07), but did differ by treatment option presented (P = 0.002) and nodal status (P = 0.01). About 50% of patients with stage I or node-negative disease were steered towards undergoing chemotherapy, whereas 96% of patients were steered towards undergoing endocrine therapy, irrespective of expected treatment benefit. Decisions were less often postponed if more implicit persuasion was used (P = 0.03).InterpretationOncologists frequently use implicit persuasion, steering patients towards the treatment option that they think is in their patients' best interest. Expected treatment benefit does not always seem to be the driving force behind implicit persuasion. Awareness of one's use of these steering behaviours during decision making is a first step to help overcome the performance gap between advocating and implementing SDM. |
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| Keywords: | Implicit persuasion Shared decision making Breast cancer Chemotherapy Endocrine therapy |
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