Clinical Decisionmaking

Patients refuse lung cancer treatment for complicated social and psychological reasons

Patients who refuse cancer treatment are often labeled as irrational or inexplicably non-compliant. A new study, supported in part by the Agency for Healthcare Research and Quality (HS10876), explored reasons why some informed, competent patients refuse further diagnosis or treatment for lung cancer. Researchers interviewed nine male patients (aged 48 to 80), recruited from a Veterans Affairs hospital over a 2-year period, who had refused doctors' recommendations for further diagnosis or treatment for non-small cell lung cancer.

Non-small cell lung cancer has a median survival of 6 to 12 months, and a 5-year survival rate of 10 to 15 percent. Surgical treatment offers a chance for cure in early stage disease, with a 5-year survival of 40 to 50 percent, and chemotherapy may improve quality of life for incurable cancer. In addition, a newly identified genetic marker can identify a subset of patients with this cancer who are responsive to targeted chemotherapy.

The interviews found many areas of uncertainty for these patients, who are faced with a suspect abnormality or, in the worst case, lung cancer. Analysis of the interviews revealed 16 basic themes, which the researchers then divided into three categories: rationale for decisionmaking, context and relationships, and other concerns.

The rationales for refusing treatment included themes of self-efficacy (belief in one's own internal ability to influence health outcomes), minimizing the threat of the disease, fatalism and faith, distrust of the health care professions, desiring more information, the ability to live without knowing a diagnosis, futility, postponing treatment, concerns about physical discomfort, quality of life priorities, and the will to live. Context and relationship themes included the doctor-patient relationship, social relationships with family and friends, and the health care system. Other concerns included themes of mortality and altruism.

See "A little bitty spot and I'm a big man: Patients' perspectives on refusing diagnosis or treatment for lung cancer," by Barbara F. Sharf, Ph.D., Linda A. Stelljes, M.A., and Howard S. Gordon, M.D., in Psycho-Oncology 14, pp. 636-646, 2005.

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