Physician Bias in Prophylactic Cranial Irradiation Decision Making—An Opportunity for a Patient Decision Aid

Patients with limited-stage small-cell lung cancer have a complex value-laden decision to make when weighing the potential small survival benefit of prophylactic cranial irradiation with the risks of neurocognitive toxicity. Herein, we explore the role physicians play in patient decision making and introduce a patient decision aid to potentially facilitate these discussions. Introduction: Guidelines have recommended prophylactic cranial irradiation (PCI) for patients with limited-stage small-cell lung cancer with at least a partial response after thoracic chemoradiation. However, the survival advantage has been small and was observed in an era before magnetic resonance imaging and surveillance. Neurotoxicity also remains a concern, especially in older adults. Thus, patients have a complex value-laden decision to make. We sought to better understand the role physicians play in patient decision making and introduce a patient decision aid (PDA) to potentially facilitate these discussions. Materials and Methods: An e-mail survey was sent to International Association for the Study of Lung Cancer members querying their personal perspectives and professional recommendations regarding PCI for limited-stage small-cell lung cancer. Results: We received 295 responses. Most were from the United States (35%) and Europe (35%) and were radiation (45%) or medical (43%) oncologists. Of those responding, 88% and 50% reported they would recommend PCI to a 50- and 70-year-old patient, respectively. Also, 79% reported that they would wish to receive PCI if faced with this decision. The physicians who would have chosen PCI if faced with the decision were 27.6 and 12.9 times more likely to recommend PCI to a 50- and 70-year-old patient, respectively, than were physicians who would not undergo PCI themselves. Most of the respondents had positive responses to the proposed PDA. Conclusion: Physician bias appears to play a role in PCI counseling, and most physicians reported that the provided PDA was better than their present method for discussing PCI and would help patients make such value-laden choices.