Don’t accept advice from physicians until they understand your values

Facing advanced cancer, who among us wouldn’t look to our oncologist for expert advice on whether another round of chemotherapy makes sense?  But do you know what your oncologist cares about, and can you be sure her recommendations map onto your own treatment preferences?

A recent study lead by Michael Kozminski (I was senior author) shows that American oncologists downplay the value of treatments that improve quality of life, compared to the value they place on life prolonging treatments.

In our study, we surveyed oncologists across the United States and presented them with hypothetical treatment scenarios, to see what value they placed on potential treatments for patients with advanced cancer.

In one scenario, we estimated how cost-effective a new life prolonging chemotherapy would need to be before oncologists prescribed it.  We described the chemotherapy as prolonging patients’ lives, but also explained that we had no other data on how it impacted quality of life.  On average, we found that oncologists would be willing to spend as much as $200,000 for every year of life gained by this new treatment.

In another scenario, we described a new chemotherapy that provided the same length of life as existing treatments, but that also substantially improved patients’ quality of life: “improving it from 40 to 90 on a 0-to-100 scale.”  According to standard theories of health economics, each year of life after receiving this treatment brings a half of a quality adjusted life year, or QALY.  When contemplating this life improving drug, however, oncologists weren’t willing to spend as generously.  Maybe $1000,000 for a QALY, but nowhere near the $200,000 they would spend for a QALY produced by a life-prolonging drug.

In cancer treatment, patients and doctors are often faced with the difficult job of balancing the desire for quantity versus quality of life.  Some treatments prolong life but at a major cost to quality of life, with miserable side effects, days and weeks spent in the hospital beds in oncology clinics rather than home with family and friends.  Every patient needs to decide what balance to strike between quantity and quality of life.  In doing so, most patients rely on advice from their oncologists.

Should they rely on this advice?

Medical recommendations often depend on non-medical judgments.  If your oncologist cares primarily about how long you live, and downplays the importance of your quality of life, she might recommend a treatment that doesn’t match your own values.

When getting any kind of medical advice, remember that the right decision often depends as much on your values as on the medical facts at hand.  Don’t seek or accept advice from a physician until you feel they, at a minimum, understand your values, such as how much you care about quantity versus quality of life.

If you ever face an illness forcing you to decide between living long or prospering, make sure it is your values that rule the day, not your doctor’s.

Peter Ubel is a physician and behavioral scientist who blogs at his self-titled site, Peter Ubel and can be reached on Twitter @PeterUbel.  He is the author of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together.

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