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April 29, 2019

Patient explicit consideration of tradeoffs: a Values Clarification Method

By Kirsten Fleming

Submitted by Arwen H. Pieterse

In oncology, as in other healthcare settings, shared decision making (SDM) is increasingly advocated when more than one treatment strategy is available. However, we previously found that cancer patient treatment preferences are often left undiscussed, and that patients are hardly involved in treatment decision making.  If patients are unclear about their preferences, or if these preferences are left unspoken, patients may not receive the treatment that fits them best.

Values clarification methods (VCMs) have been developed to support patients in weighing treatment benefits and harms and harms and to help them voice what matters most to them . We developed a stand-alone VCM that asks patients to make explicit trade-offs between treatment benefits and harms. This VCM is adaptive, in that it ensures that the trade-offs presented to patients are tailored to the preferences of the patient as revealed in the exercise so far.

We tested this VCM in patients newly-diagnosed with rectal cancer who were facing the decision whether or not to undergo short-course pre-operative radiotherapy. Radiotherapy increases the likelihood that the cancer will stay away at the initial site (i.e., local control), however, it also increases the likelihood of fecal incontinence and of sexual dysfunction. We hypothesized that the VCM would aid patients to become more confident on their preferences and to voice them more often during consultations, based on results among treated rectal cancer patients asked to consider the decision hypothetically. We expected that going through the VCM would lead to patients’ preferences to be more often integrated in treatment decisions, and that patients would experience less regret over the decision and would cope better with treatment harms.

Values clarification method

The online VCM was offered in advance of the first encounter of the patient with the radiation oncologist, a visit in which the treatment decision is usually made. The VCM started with lay explanations of the three outcomes (local control, fecal incontinence, and male or female sexual dysfunction), and stated that survival was the same across situations. It then asked patients to rate how important they considered differences between best and worst probabilities of outcomes, that varied within a clinically realistic range (see print screens). Next, the VCM asked patients to indicate their preference for pairs of outcomes, where outcome probabilities differed in each pair. The final page of the VCM showed the patient’s relative importance for the three outcomes in percentages. It did not show which treatment should suit the patient best, as it was meant to support patients in considering the options and they still were to meet with their radiation oncologist.

Patients were initially randomized to be offered the VCM or not. Later on in the study, we offered the VCM to all patients due to practical difficulties and low recruitment rates. We compared the outcomes in patients who agreed to receive the link to the VCM versus those who did not receive the link.


Of the 135 patients who had their consultation audiotaped and completed questionnaires, 35 received and accessed the VCM-link. Patients in the VCM-group slightly more often expressed their views on treatment and treatment outcomes than the patients who had not, although such utterances were still uncommon. This points to very limited discussion between patients and clinicians on how patients consider benefit-harm trade-offs. This may further explain why the questionnaire data showed that patients in the VCM-group did not differ in how clear their values were.

An important finding is that patients who completed the VCM felt less regret over the treatment decision at follow-up, and experienced less impact of faecal incontinence and sexual dysfunction six months after treatment. As hypothesized, explicitly considering trade-offs may have helped patients to better understand the pros and cons involved, and supported them to live with the consequences later on. Of note, the radiation oncologists in this study reported that almost all decisions had been made before the consultation, either by the referring physician or by the tumour board, without input from the patient. Patients clearly lacked room to contribute.


This is the first study to assess the effect of an adaptive conjoint analysis-based VCM on actual patient-clinician communication, and long-term decision regret and impact of treatment harms. Decisions to undergo short-course preoperative radiotherapy in rectal cancer had in almost all cases been made prior to the consultation, without patient input. The VCM hardly could affect final decisions in this setting. Even so, our results suggest a favourable effect of being explicitly invited to think about benefits and harms of treatment on the extent to which patients endorse treatment decisions and can live with treatment consequences.

The full paper was published in Acta Oncologica and can be found here (open access).

This study was made possible by a grant from the Dutch Cancer Society (UL2009-4431).

Arwen H. Pieterse is associate professor in medical decision making at the Leiden University Medical Center, the Netherlands. She studied Cognitive Psychology and graduated (cum laude) in 1998. She obtained her PhD in 2005. She was Research fellow of the Dutch Cancer Society (2008-2011). She published well over 50 international peer-reviewed articles on patient-physician communication, patient and physician treatment preferences, patient-physician (shared) decision making, and psychometric properties of measurement instruments. Based on her research, she co-developed e-learnings to teach shared decision making skills to medical students and clinicians. She received the 2018 Jozien Bensing award from the International Association on Communication in Healthcare (EACH), granted biennially to early-career researchers.

She is Associate editor of Patient Education and Counseling since 2017. She was the scientific co-chair of the 2018 European meeting of the Society of Medical Decision Making. She chairs the EACH standing committee on research since 2018 and is the co-chair of the upcoming EACH Forum, September 16-18 2019, Leiden, the Netherlands.

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