Survey: Majority of patients would opt for higher-risk, higher-reward treatment

Issue: May 10, 2012

Results from a survey of patients with a variety of cancers showed that more than three in four would take a “hopeful gamble” over a “safe bet” therapy that offered similar average survival but less chance for a big gain.

Researchers presented the survey to 150 patients undergoing treatment at five sites within a national network of independent, community-based oncology practices. Participants were given a hypothetical scenario for the treatment of advanced melanoma or metastatic breast cancer. In both groups, participants compared the hopeful therapy with a hypothetical therapy that provided the same average survival, but with death occurring with 100% certainty at the average survival time of 18 months in breast cancer and 24 months in melanoma.

Although the two treatments offered the same average survival, 77% of respondents took the hopeful gamble over the sure bet. Seven in 10 participants in the melanoma group would give up living 2 years for certain in return for a 20% chance of living for at least 4.5 years, whereas 83% of patients in the breast cancer arm wouldgive up the chance of a guaranteed 1.5 years of survival for a 10% chance of living 4 years or more.

The results were published in the April issue of the journal Health Affairs.

“In the past, everyone from policymakers to insurers to physicians and researchers, for that matter, have all thought about therapy in terms of their benefits to the average, typical or median patient, and that’s what we viewed as the sum total of the benefit associated with that therapy,” said study researcher Darius N. Lakdawalla, PhD, director of research at the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California. “Our research suggests that might be an incomplete view, and maybe even a highly incomplete view. When thinking about the value of therapies, we ought to incorporate the possibility that a therapy gives a modest chance for a big survival gain.”

Darius N. Lakdawalla

Diane E. Meier, MD, director of the Center to Advance Palliative Care, said the conclusions are suspect because the study was funded by a pharmaceutical company.

“It is very much in the pharmaceutical company’s best interest to try to shift public policy so that drugs without clear evidence of benefit are paid for out of taxpayer dollars,” she said. “While hope is an interesting concept and important in the care of seriously ill patients, it is not a basis for public policy. The authors suggest that because patients value hope, because they value swinging for the fences, that should have implications on how taxpayer dollars are spent. That’s a huge leap.”

Most people generally are risk-averse, Lakdawalla said. However, he and colleagues hypothesized that patients facing a life-threatening disease may be more accepting of risk. The results suggest that physicians and policymakers misunderstand patients’ priorities when it comes to choosing treatment, Lakdawalla said.

“Part of the problem is that we haven’t paid any attention to what patients think when they evaluate therapy,” Lakdawalla said. “This study is just scratching the surface, and much more needs to be done to get at these issues in greater detail. We pay physicians to ‘do things’ to patients, like prescribe drugs and perform procedures. We don’t pay them to talk to patients, find out their values and preferences, and clearly explain sometimes very complicated clinical decisions to them. We have to do a much better job of that,” he said.

Diane E. Meier

Meier said patients who are properly informed about the risks inherent to all medical treatments rarely go for the hopeful gamble, and this study did not consider quality of life, which may have a huge influence on decision-making. Also, because the outcomes of treatment are never clear-cut, patient responses to this survey likely have no relation to what a patient might do in a real-life situation.

However, these results raise important questions about the way physicians understand how patients make decisions about their health care, Meier said.

“The study is useful in that it points to the importance of understanding more about hope and hope as a basis for medical decision-making,” she said. “Irrationality is a core component of medical decision-making and hope, particularly when it’s based on illusion, is a form of irrationality. What this study tells us is that we need to pay more attention to unconscious and irrational bases for medical decision-making.” – by Jason Harris

References:

Lakdawalla DN. Health Aff (Millwood). 2012;31:676-682.

Disclosure:

The research was supported by Bristol-Myers Squibb. Dr. Meier reports no relevant financial disclosures. Dr. Lakdawalla is a founding partner at Precision Health Economics, which consults to health care firms, including Bristol-Myers Squibb.