TREATMENT PREFERENCES OF PATIENTS WITH ENDOMETRIAL CANCER AND CLINICIANS

Purpose: The contribution of vaginal brachytherapy (VBT) to local control in high-intermediate risk endometrial cancer (EC) has been established, but VBT is associated with several side effects and does not improve overall survival. Furthermore, five-year local control, including treatment for relapse, is estimated to be nearly similar for VBT and a watchful waiting policy (WWP). Our aim was to assess treatment preferences of EC-patients and clinicians regarding VBT and WWP.

Methods: Individual face-to-face interviews were held with 95 treated EC patients, half of them treated with surgery alone (low risk) and half of them treated with surgery and post-operative VBT (high-intermediate risk). Patients received information on both VBT and WWP, local recurrence rates, possible harms, and burden of the management strategies. The Treatment Trade-off Method (TTM) was used to assess minimal desired benefit or maximum accepted risk of harm caused by VBT before preferring VBT. Seventy-seven clinicians (25 radiation oncologists, 28 gynecologists, 24 gynecologic oncologists; response rate 38%) completed an online questionnaire assessing their treatment preference and their minimal desired benefit. Patients also reported their involvement preferences.

Results: At an initial 12% absolute local control benefit of VBT, 92% of the radiation oncologists and 91% of the irradiated patients preferred VBT over WWP. Of the gynecologists, gynecologic oncologists, and non-irradiated patients, respectively 43%, 43% and 52% preferred VBT. The median minimal desired benefit in local control of VBT was 4% (radiation oncologists), 0% (irradiated patients), 17% (gynecologists), 8% (gynecologic oncologists) and 6% (non-irradiated patients). Of the irradiated patients, 92% indicated to choose VBT even if there was no additional benefit. Of the non-irradiated patients, 13% preferred WWP even for a local control benefit of 50% from VBT.

   High-intermediate risk patients indicated that at the time of decision-making they had lacked time or space to think about benefits and harms of VBT (42%), give their opinion on these benefits and harms (43%) or participate in decision-making to their preferred extent (45%).

Conclusions: Our research showed a considerable variation between, as well as within, the patient and clinician groups in how they value local control, harms, and burden of treatment. We recommend that clinicians inform patients on the benefits and harms of treatment options, elicit patients’ preferences and support patients in a process of shared decision-making.