By Sarah Temin, MSPH, ASCO Guidelines Resource Specialist
Imagine this common clinical scenario:
A 64-year-old woman presents with a
new abnormality on a mammogram.
A core needle biopsy and subsequent
partial mastectomy reveal a 1.8-cm
invasive ductal carcinoma. Sentinel
lymph nodes are negative for cancer.
The tumor is moderately differentiated
and is estrogen receptor–positive, progesterone
receptor–positive, and HER2-
negative. Oncotype DX testing reveals
a recurrence score of 12 (low risk). The
patient completes postlumpectomy
radiation and now presents to your
clinic to discuss adjuvant anti-estrogen
strategies. What are the treatment
options? How do you present them
clearly to your patient? And how do
you ensure that she is a partner in
ASCO Decision Aids can facilitate these
These tools are based on the science in
ASCO’s evidence-based clinical practice
guidelines and incorporate the best
practices of decision aid development
(see Additional Reading). They allow a
clinician to display and explain information
on risk and benefits, and help
the patient to think about his or her
own values and preferences. Research
suggests that the use of decision aids
increases patient knowledge without
increasing anxiety and can increase
Bridging the gap to shared
Decision aids can streamline the
decision-making process and their use
frequently leads to a finalized decision
about care. “When I have used
the ASCO Adjuvant Endocrine Therapy
Decision Aid with women in my practice,
it has cut down on the number
of times I’ve received follow-up phone
calls,” said Michael A. Danso, MD, of
Virginia Oncology Associates and
ASCO Practice Guidelines Implementation
Network (PGIN) Co-Chair.
In the scenario described in the first
paragraph, the patient has more than
one treatment option (outlined in the
ASCO Guideline Update on Adjuvant
Endocrine Therapy for Women with
Hormone Receptor–Positive Breast
Cancer). The options carry benefits
and risks, and none is clearly superior—
a frequent experience in oncology.
Patients in this situation may experience
feelings of uncertainty, difficulty
identifying the best option, and concern
that they will regret their choice
practice guidelines and clinical trials
may guide the clinician, guidelines and
study results are typically not written
with a patient audience in mind,
and circumstances may constrain the
clinician in explaining them. Decision
aids help to bridge this gap and lead to
For example, the ASCO Decision Aid
for this scenario includes data showing
potential benefits and risks or harms
of tamoxifen, aromatase inhibitors, or
a sequential combination. It appeals
to a variety of learning styles, including
visual and auditory. Graphics are
formatted to quickly and comprehensibly
communicate data in text and
pictographs. After the visit, the patient
can use the Decision Aid’s worksheet,
based on the Ottawa Personal Decision Guide, to reflect on the discussion, plan next steps (such as seeking support from others), and make the best choice for her.
ASCO Decision Aids are available for adjuvant endocrine therapy and risk reduction in breast cancer, and adjuvant treatment and treatment of advanced disease in non-small cell lung cancer.
"This information allows me to give my patients a more complete picture of the treatment regimen, potential benefits, and risks, including an excellent summary table on potential chemotherapy toxicities," said James N. Frame, MD, of Charleston Area Medical Center and PGIN Co-Chair, who uses the ASCO Decision Aid on the treatment of advanced non-small cell lung cancer in his practice.
1. O’Brien MA, Whelan TJ, Villasis-Keever M, et al. Are cancer-related decision aids effective? A systematic review and meta-analysis.
J Clin Oncol. 2009;6:974-85. PMID: 19124808.
2. O’Connor A, Jacobsen MJ, Stacey D. An evidence-based approach to managing women’s decisional conflict.
J Obstet Gynecol Neonatal Nurs. 2002;31;570-81. PMID: 12353737.
3. Barry MJ, Edgman-Levitan S. Shared decision making—pinnacle of patient-centered care.
N Engl J Med. 2012;366:780-1. PMID: 22375967
4. Fagerlin A, Zikmund-Fisher BJ, Ubel PA. Helping patients decide: ten steps to better risk communication.
J Natl Cancer Inst. 2011;103:1436-43. PMID: 21931068.
5. Stacey D, Bennett CL, Barry MJ, et al. Decision aids for people facing health treatment or screening decisions.
Cochrane Database Syst Rev. 2011;(10):CD001431. PMID: 21975733.