The hard road to patient-centered care: 3 or 6 months of adjuvant chemotherapy for patients with stage III colon cancer?
Authors: P. Trensz, L. Calvel, J.E. Kurtz
Journal: Annals of Oncology (2018)

Sobrero et al. [1.Sobrero A. Grothey A. Iveson T. et al.The hard road to data interpretation: 3 or 6 months of adjuvant chemotherapy for patients with stage III colon cancer?.. 2018; 29: 1099-1107Google Scholar] suggest in their article an interpretation of the most recent data regarding adjuvant chemotherapy in stage III colon cancer. The article provides different expert opinions and the results of a moderated panel discussion between experts. The conclusion of the article is that the main drivers of the duration of adjuvant therapy in stage III colon cancer should be ‘treatment choice and very importantly the patient’s attitude to his/her disease’. In this situation of ‘clinical equipoise’ [2.Freedman B. Equipoise and the ethics of clinical research.N Engl J Med. 1987; 317: 141-145Crossref PubMed Scopus (1697) Google Scholar], we are convinced that patients should be at the center of the decision-making process, and, in this regard, we would like to add comments to this conclusion. For the purpose of a panel discussion between experts, the attitudes of patients have been categorized as either ‘fighters’ or ‘fatalists’ depending on the trade-off they were willing to make between a slightly higher risk of recurrence (1%–2% for fighters versus 3% and above for fatalists) and a decrease in treatment toxicity. We believe that the chosen metaphor inappropriately portrays the difficult trade-off such a decision represents for patients and their oncologists. We should be careful not to influence decision-making or provoke a feeling of guilt in our patients with positive (fighters) and negative (fatalist) terminology. Metaphors are powerful tools which ‘can serve as the basis for the shared understanding of clinical reality’, but we cannot ignore their harmful potential [3.Reisfield G.M. Wilson G.R. Use of metaphor in the discourse on cancer.J Clin Oncol. 2004; 22: 4024-4027Crossref PubMed Scopus (172) Google Scholar]. We believe that the fighter/fatalist metaphor should not be used in this situation. This distinction between patients’ attitudes is derived from a small poll by Prof. Sobrero that is reported in the article. We should keep in mind that polls are a good way to quickly apprehend a reality, but they do not accurately convey the complex nature of patients’ wills and attitudes toward their diseases. When it comes to implementing these results into our practice, should we use a model of clinical decision-making that classifies patients into fixed positions regarding a patient’s attitude to his/her disease? We believe that we should pay attention to not fitting patients into boxes, even for the sake of a discussion. Patient’s role preferences regarding clinical decision-making are dynamic processes and oncologists should adapt to those preferences [4.Tariman J.D. Berry D.L. Cochrane B. et al.Preferred and actual participation roles during health care decision making in persons with cancer: a systematic review.Ann Oncol. 2010; 21: 1145-1151Abstract Full Text Full Text PDF PubMed Scopus (218) Google Scholar]. Shared decision-making has been widely advocated for, and we believe that it is a more suitable model in this situation of ‘clinical equipoise’. Patients should be able to decide whether they want to make their decision considering the various options as explained by their oncologists or let their oncologists make a recommendation they will follow. Therefore, the main driver of the decision-making in adjuvant chemotherapy of stage III colon cancer should be the patient rather than a predefined patient’s attitude to his/her disease. We believe that oncologists should work on how to share and explain the results of clinical trials with their patients. This would help patients understand how these results apply to their clinical situation so they could make the best decision for themselves. This is the hard road we should take rather than discussing which treatment would suit a ‘fatalist’ or a ‘fighter’. Otherwise is it really patient-centered care? None declared.