Cluster randomized pilot of the Best Case/Worst Case-Geriatric Oncology (BC/WC-GeriOnc) communication tool for older adults with cancer.
Authors: Wong Melisa L. , Lee Howard Jinsoo , DeBoer Rebecca Jane , Suchman Lauren , Litt Henry Kazunaru , Nicosia Francesca , Boscardin W. John , Loh Kah Poh , Walter Louise Christie , Smith Alexander K. , Huang Li-Wen , Lowenstein Lisa M. , Neuman Heather B. , Volk Robert J. , Hopkins Judith O. , Mohile Supriya Gupta , Mercurio Anne Marie , Schwarze Margaret L. 
Published: September 2024

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Background:
BC/WC-GeriOnc is a conversation framework and graphic aid that supports shared decision making (SDM) between oncologists and older adults with cancer. Oncologists are trained to use scenario planning to discuss treatment options by describing the range of plausible outcomes—including an individualized most-likely case—and to make a patient preference-aligned recommendation.
Methods:
To compare BC/WC-GeriOnc vs enhanced usual care (EUC; usual care plus geriatric assessment), we enrolled 7 medical oncologists from a Comprehensive Cancer Center, Veterans Affairs clinic, and safety-net hospital. For each oncologist, we first enrolled 2 EUC patients age ≥65 with any stage solid tumor and recorded decision-making discussions. Oncologists were then randomized 1:1 to BC/WC-GeriOnc training vs EUC. We enrolled up to 5 additional patients per oncologist and recorded discussions. Patients were followed for 2 months with surveys and a one-on-one semi-structured interview. Primary outcomes were feasibility of patient recruitment/retention and oncologist-reported feasibility of using BC/WC-GeriOnc (surveys and interview). Secondary outcomes were intervention adherence, fidelity, and oncologist- and patient-reported acceptability and appropriateness. Exploratory outcomes included patient-reported SDM, decisional conflict, and regret. We used descriptive statistics to summarize results.
Results:
Among 43 patients (15 intervention, 28 EUC), median age was 71 (IQR 68-77). The most common cancers were gastrointestinal (30%), thoracic (26%), breast (19%), and genitourinary (19%). Treatment was palliative in 58%. Patient recruitment rate was 70%. Retention was 98% post decision, 93% at 1 month, 86% at 2 months, and 73% at the patient interview. Mean oncologist feasibility, acceptability, and appropriateness scores were each 4 out of 5, which corresponds to “agree.” Intervention adherence (93%) and fidelity were high (median score 14 out of 15, IQR 11-15). Oncologists reported that the tool improved communication: “It really kind of crystalized things in my mind and helped me communicate better.” Patients found that the tool clarified options, encouraged deliberation, and supported oncologist communication. Mean patient-reported SDM score was 85.6 (out of 100-best, SD 15) in the intervention arm and 77.5 (SD 22) in EUC (Cohen’s d 0.43). In the intervention arm, 15% of patients had high decisional conflict after the decision was made (score >37.5/100) versus 21% in EUC. At 2 months, 22% in the intervention arm had high decision regret (score >25/100) compared with 45% in EUC.
Conclusions:
It was feasible and acceptable for oncologists to use BC/WC-GeriOnc to support SDM for older adults with cancer. Promising patient-reported SDM and decisional outcomes support testing the tool in a full-scale efficacy trial.

Clinical trial information:
NCT05374304

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