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A Systematic Review of Factors Influencing Older Adults’ Hypothetical Treatment Decisions

Oncology & Hematology Review, 2015;11(1):19–33 DOI:


Purpose: Cancer affects mostly older adults and although research has shown that a significant proportion of seniors do not receive treatment, little is known about the reasons why. Therefore, we conducted a systematic review of reasons why older adults accept or decline cancer treatments. Design: Systematic review of studies reporting on hypothetical cancer treatment scenarios in older patients published between inception of 10 databases and February 2013. Results: Of 17,343 abstracts reviewed, a total of 12 studies were included (sample size 21 to 511). The willingness to be treated varied by the benefits of treatment (ranging from never to always accepting the treatment), the particular side effects of treatment, and previous treatments received/previous treatment experiences (those who were treated previously were more likely to accept the same treatment). Results showed conflicting findings with regard to the impact of age, education (those with lower/higher age/education wanting more benefits before accepting), and family situation (no effect/those who were single were less likely to accept). Conclusion: Willingness among older adults to be treated was most influenced by the extent of benefits and side effects as well as prior treatment experiences. However, little is known about treatment preferences of the oldest old, those with multimorbidity, and preferences for newer agents.
Keywords: Systematic review, geriatric oncology, cancer treatment, treatment decision-making, treatment preferences, treatment refusal
Disclosure: Martine T Puts, RN, PhD, Brianne Tapscott, RN, BScN, Margaret Fitch, RN, PhD, Doris Howell, RN, PhD, Johanne Monette, MD, MSc, Doreen Wan-Chow-Wah, MD, Monika K Krzyzanowska, MD, MPH, Natasha B Leighl, MD, BSc, MSc, Elena Springall, MSc, and Shabbir M Alibhai, MD, MSc have no conflicts of interest to declare. There were no publication charges associated with this article.
Acknowledgments: The authors would like to thank Mr D Stephens who has been involved as a patient representative in this review.
Received: January 16, 2015 Accepted: March 15, 2015
Correspondence: Martine T Puts, RN, PhD, Lawrence S Bloomberg, Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, Ontario, Canada M5T 1P8. E:

Support: This work was supported by a knowledge synthesis grant # 119803 from the Canadian Institutes of Health Research to Martine T Puts, RN, PhD. Martine T Puts, RN, PhD is supported with a New Investigator Award from the Canadian Institutes of Health Research.

Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any noncommercial use, distribution, adaptation, and reproduction provided the original author(s) and source are given appropriate credit.

Cancer is a significant health problem in older persons.1 It is estimated that 42 % of all incident cases and over 60 % of mortality due to cancer occur in persons aged 70 and over.1,2 With the aging of the population there will be a considerable increase in the number of older adults diagnosed with cancer.1,2 Treatment decisions are based on preferences, estimation of the risks and benefits, and costs. An individual makes a trade-off between the benefits and harms. However, there is less known about risks and benefits for older adults as they are underrepresented in clinical trials, particularly the more frail older adults and those with comorbidities,3–7 which complicates treatment decision-making.

Underuse/nonreceipt of cancer treatment is commonly reported, and is more common in older adults.8–10 Recent studies have shown underuse in 46–49 % of older patients.11–13 Undertreatment can lead to negative outcomes, such as increased cancer recurrence rate and poorer survival. Undertreatment has been most extensively studied in older women with breast cancer.8–10,14,15 Yood et al.15 reported a hazard ratio of 6.25 for breast cancer mortality in older women treated for less than 1 year with hormonal therapy compared with those treated for 5 years while Verkooijen et al.8 showed that older women who declined breast cancer surgery had a hazard ratio of breast cancer mortality of 2.1. Considering the impact of undertreatment on outcomes, it is important to understand for what reasons they would accept or decline cancer treatment. Several narrative reviews of treatment decision-making in older adults had been published16–18 but, until now, no systematic review has been performed. One way to study treatment decision-making is by studying preferences for a certain treatment based on studying the benefits and harms of one treatment compared with other alternatives, or about an individual’s preference for a certain health state compared with a perfect health state.19

Therefore, we conducted a systematic review with the primary objective of synthesizing all factors influencing older adults’ decisions to acceptor decline cancer treatment proposed by their physicians. In particular, we were interested to determine if the factors influencing older adults’ decisions to accept or decline cancer treatment varied by cancer stage, cancer type, cancer treatment, and age (younger-old [65–74] versus older-old [75+]). During the conduct of our systematic review on factors influencing the treatment decisions we noticed important methodologic differences between studies studying actual treatment decisions compared with studies using hypothetical treatment decisions. Additionally, examining hypothetical treatment decision-making removes the acute stresses of making decisions while facing a diagnosis of cancer. Therefore, we decided to report the results on actual situations and hypothetical scenarios separately. In this article, we will report on the results of studies examininghypothetical treatment decisions.

Materials and Methods
Search Strategy and Selection Criteria
This review was based on a systematic, comprehensive search of 10 databases from inception to February 2013 and was conducted by an experienced health sciences librarian (ES). A study (any type of design except case studies and editorials and reviews) was eligible for inclusion if it reported on reasons why older adults with cancer (i.e. mean age study population 65 years or over or if the study mean/median age was <65 but reported results on a subgroup analysis of older adults with a mean/median age >65) accepted or declined cancer treatment and was published in English, Dutch, French, or German.

The final studies included in this review were selected in two steps based on screening of the abstract and full-text review performed independently by two reviewers (MP and BT) (see Figure 1). For all articles for which no mean/median age was reported, we contacted the study authors to obtain details on age. If no response was received after at least three attempts, the article was not included.

Data Abstraction
The same reviewers who performed the article-selection processconducted data abstraction independently (MP and BT). The abstracted information included study design, aim of study, location of study, sampling method, source of data, recruitment type and timeline, characteristics of study participants, details on cancer diagnosis and treatment, details on how reasons for accepting/declining cancer treatment were collected, and details of statistical analysis, source of funding, and whether or not the authors had declared any conflict of interest. No meta-analysis was conducted as the studies were too heterogeneous with regard to study population and data collected.

Quality Assessment
Both quantitative and qualitative studies were included in the review. To determine the quality of the studies included in this review the same two reviewers scored the studies using the Mixed Methods Appraisal Tool (MMAT).20 The MMAT scoring system contains five types of mixed methods study components or primary studies, i.e. 1) qualitative; 2) quantitative randomized controlled trials; 3) quantitative nonrandomized; 4) quantitative descriptive; and 5) mixed methodswith each with its own set of methodologic quality criteria based on existing published criteria. For each item the answer categories were ‘yes’, ‘no,’ or ‘can’t tell’ followed by comments. We did not exclude any study based on the quality assessment as we wanted to provide a comprehensive overview of all factors important to older adults reported in the literature.

We reviewed 17,343 titles and abstracts for eligibility in the first step (see Figure 1) in which we selected 545 manuscripts for full text review. Of these 545, 55 manuscripts reporting on 50 unique studies were selected; 40 publications reporting on 38 unique studies examined factors influencing the older adult’s decision to accept or decline treatment examined the actual cancer treatment decision taken by the study participant and reported elsewhere (manuscript submitted). There were 15 manuscripts reporting on 12 unique studies that examined hypothetical treatment decisions and these are included in this review. All manuscripts were written in English.

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Keywords: Systematic review, geriatric oncology, cancer treatment, treatment decision-making, treatment preferences, treatment refusal