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Decisional Conflict in Rectal Cancer: Does Quality of Life Measurement Reflect True Preferences?

253 Diseases of the Colon & ReCtum Volume 59: 4 (2016) the treatment of rectal cancer presents one of the most challenging decisional conflicts for patients and clinicians involved in colorectal cancer care. achieving the optimal balance of subjective (eg, quality of life, functional impairment) with objective (eg, survival, local recurrence) outcomes challenges specialists from different disciplines and, in many ways, is analogous to the conflicts seen in prostate cancer treatment. Patients’ collective opinions are rarely analyzed, published, or included in this multidisciplinary thought process. the article by Battersby and the uK laRs study Group in this Journal is a refreshing example of exploring and quantifying the effects of rectal cancer treatment on quality of life. the authors’ conclusions that all patients having anterior resection should be informed that bowel-related quality-oflife impairment is common is strongly endorsed by the results, highlighting the importance of including patients in the decision-making process. although this result seems intuitive to many surgeons, adequately informing patients and involving them in the decision making about their care is highly variable. Patients have the ability to weigh the subjective and objective risks and benefits and make individual decisions, perhaps more so than their clinicians. multiple previous studies of treatment preferences for colorectal cancer and iBD have consistently found that patients and their clinicians generally agree in the direction of the choice of competing therapies. however, universally, patients and clinicians differ in the size of trades they would be willing to make. to achieve better subjective outcomes, patients will often trade objective survival outcomes to a considerably greater degree than their clinicians would be comfortable presenting to them. of greater concern is that clinician specialty groups (medical, radiation, and colorectal surgical oncologists) have significantly different thresholds for choice of one therapy over another. these intergroup differences often represent larger differences than the actual differences in outcomes reported in the literature (eg, local recurrence differences in radiotherapy). the article by Battersby and colleagues raises some interesting challenges in measuring patient choice. Qualityof-life measures in surgery are obtained after the decision between irreversible therapies has been made. although no stoma groups were canvassed in this study for comparison, it is similar to many quality-of-life studies comparing sphincter-saving procedures and permanent stomas, which do not demonstrate improved quality of life in sphincter preservation. Why then do patients with rectal cancer or ulcerative colitis have an overwhelming preference for sphincter preservation when canvassed preoperatively? this disparity between post hoc quality-of-life measurement equivalence to the ad hoc strong preference to avoid a permanent stoma is an example of cognitive dissonance reduction which challenges our ability to rely on quality of life as the sole determinant of subjective outcomes in decisional conflict. Postoperative quality-of-life measures likely reflect the achievement of these expected outcomes rather than the choice if given preoperatively. a fully informed patient’s quality of life usually reflects how close his or her treatment choice matches his or her expected subjective and objective treatment outcomes and the values he or she places on these outcomes. this “acceptance postoperatively” (and the resultant good quality-of-life score) for what a patient would not have chosen preoperatively, if given a fully informed choice, is called cognitive dissonance reduction. this limits the utility of quality-of-life measures to compare outcomes in irreversible conditions such as surgery. Quality-of-life measures broadly fall into 3 important categories that should be included in prospective trials; generic, disease specific, and patient specific. Generic measures such as sf36 allow comparisons across different disease states. the european organization for Research and treatment of Cancer Quality of life Questionnaire Decisional Conflict in Rectal Cancer: Does Quality of Life Measurement Reflect True Preferences?