Asia-Pacific Journal of Clinical Oncology

EDITORIAL

The Case for Shared Decision-making in Oncology and Why

the Philippine Healthcare System is Primed for It
Warren Bacorro1,2,3,4 Clarito Cairo, Jr.5 Kathleen Baldivia3,4 Aida Bautista6 Evelyn Dancel7
Jocelyn Mariano4,8,9 Gil Gonzalez4,9 Teresa Sy Ortin1,3,4 Rodel Canlas1,10

1
The Graduate School, University of Santo Tomas, Manila, Philippines 2 Department of Clinical Epidemiology, Faculty of Medicine and Surgery, University of
Santo Tomas, Manila, Philippines 3 Department of Radiation Oncology, University of Santo Tomas Hospital – Benavides Cancer Institute, Manila, Philippines
4
Gynecologic Oncology Unit, University of Santo Tomas Hospital – Benavides Cancer Institute, Manila, Philippines 5 Management Office, Philippine Cancer
Center, Quezon City, Philippines 6 Department of Obstetrics and Gynecology, Manila Doctors Hospital, Manila, Philippines 7 Department of Nursing
Services, University of Santo Tomas Hospital, Manila, Philippines 8 Department of Obstetrics and Gynecology, Faculty of Medicine and Surgery, University of
Santo Tomas, Manila, Philippines 9 Department of Obstetrics and Gynecology, University of Santo Tomas Hospital, Manila, Philippines 10 Department of
Psychology, College of Science, University of Santo Tomas, Manila, Philippines

Correspondence: Warren Bacorro ([email protected])

Received: 24 October 2024 Accepted: 15 November 2024

Funding: This work was partly subsidized by the Philippine Council for Health and Research Development which has no role in the development and design of
any aspect of the prototype development and evaluation or influence over any decision relating to the conduct of the study and writing and publication of the
study report.

Keywords: Patient decision aids | Philippines | Shared decision-making

1 The Case for Shared Decision-Making unrecognized coercion. However, shared decision-making goes
beyond informed consent.
Shared decision-making is a collaborative approach to care
planning where the patient and their clinicians work together The case for shared decision-making is a matter of cost-
to address a dilemma in the patient’s care through an equal effectiveness. In oncology, where treatment has evolved to
conversation [1, 2]. This entails an evaluation of the situation by become highly specialized, multidisciplinary, and personalized,
considering both the insights of the interdisciplinary healthcare clinical practice guidelines and clinical evaluation tools have been
team regarding the patient’s disease, overall health status, and developed to facilitate evidence-based decision-making. How-
available treatment options, and the perspectives of the patient ever, while much has been put into “personalizing” treatment in
and their family regarding values, preferences, and resources [3, terms of the patient’s medical profile and disease characteristics,
4]. less has been put into personalizing in terms of the person’s
values and preferences. The costliest treatment is one that does
The case for shared decision-making is ethical. The principles not work; an even costlier treatment is one that the patient does
of autonomy and informed consent underlie all healthcare. One not want or one that the patient did not know they did not
may argue that not all patients prefer to make the decision want—the cost is decisional regret. Aligning treatment choices to
or actively take part in the decision-making. Some patients patient values and preferences and managing patient and family
may want to be involved in the decision-making but may not expectations of the treatment are both paramount. However,
feel capable of making the decision; a next of kin, a legal shared decision-making is more than patient-centeredness.
representative, or a patient navigator or coach may help enable
the patient. Some patients may entirely defer to the physician’s The case for shared decision-making is a matter of efficiency.
recommendation but the setting for shared decision-making Fragmented care is inefficient care delivery. The multidisci-
should be in place and offered to avoid any unintended or plinary tumor board is a recognized standard of care; not only

© 2024 John Wiley & Sons Australia, Ltd.

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does it serve as an avenue for arbitrating differences regarding and private space [13]. Patient decision aids may require more
treatment preferences among clinicians and developing a consen- resources to develop and simpler decision support interventions
sus, but it also serves as a platform for coordinating care delivery. have been shown to perform just as well [14]. However patient
Similarly, shared decision-making is a space where patients and decision aids serve as peer-reviewed materials that can be updated
their families are regarded as equals in the decision-making and adapted, and therefore allow for wider implementation and
and in co-creating the plan, thus enhancing care coordina- upscaling while maintaining transparency and a minimum stan-
tion and facilitating optimal and timely resource mobilization. dard. Patient decision aids may be translated into other languages,
Shared decision-making enables patients and their families to provided in print or as a web-based or mobile application, and
become active and equal partners in the implementation of their developed into simplified or user-responsive designs [15, 16].
healthcare. Patients with high decision self-efficacy may do well being pro-
vided with just a decision aid while those who have lower decision
Finally, the case for shared decision-making is a matter of equity. self-efficacy may be assigned a decision coach [17]. Further, the
All patients are enabled to make health decisions and empowered Transition and Patient Empowerment Innovation, Education,
to be the primary agents of their health and health care, regardless and Research Collaboration is an international program that
of their decisional skills and preferences. provides education, guidance, and resources to support and
empower young and adult patients in shared decision-making
[18].
2 Priming Healthcare for Shared
Decision-Making Culture development and integration into clinical workflows are
critical in the sustainable implementation and institutionaliza-
Shared decision-making has been much studied, and increas- tion of shared decision-making. The National Health Services
ingly talked about, but less implemented. Clinicians think they England has published guidance for people leading local imple-
do but perhaps they do not or, they would like to do it mentation of shared decision-making [19]. In a clinical trial on
but are unsure when or how to. A recent nationwide survey the use of patient decision aids in shared decision-making among
on shared decision-making among Filipino oncologists and Filipino cervical cancer patients, one of the observed barriers to
oncology-related professionals revealed that while nearly every- participation was the urgency of the clinical situation [8]; outside
one favored the concept (99%) and most reported practicing it of a trial, if the tools and providers are available and the process
(96%) and being knowledgeable about it (90%), not as many is already integrated into the workflow, shared decision-making
reported definitions that are concordant with the concept [5]. will enhance even more and facilitate coordination and optimal
Healthcare providers in the shared decision-making process resource mobilization.
should be trained in the process; the American Agency for
Healthcare Research and Quality has developed a comprehensive Finally, leadership and policy support will be an instrumental
training curriculum, communication tools, and implementation foundation. Many cancer management guidelines now cite the
resources for healthcare providers and teams [6]. The American need for shared decision-making, especially in the case of very
Society of Clinical Oncology has published guidance detailing early disease and advanced disease, where there is equipoise
the different utilities of shared decision-making and appropriate regarding the benefit-harm ratio with adjuvant treatment or
situations [7]. aggressive treatment in the above situations, respectively. Tak-
ing it a step further, the recently published Action Plan for
Clinicians may not like shared decision-making because they feel Efficient Cancer Care Implementation Toolkit includes patient
a loss of physician autonomy, or may not be able to do it due engagement in decision-making as one of eight efficiency metrics
to lack of time [8]. However, in the era of evidence-based and [20]; the toolkit was informed by interviews with 21 upper-
interdisciplinary care, physician autonomy is probably becoming to upper middle-income countries from North America, South
a regressive value, and true collaboration more than makes up for America, Europe, the Middle East, East Asia, and Oceania. Is
a lack of time. Oncology nurses, even patient navigators, through the Philippines, as well as the Asia Pacific, ready for shared
upskill training, may be trained in active coaching [9]. During decision-making?
the COVID-19 pandemic, upskill training partly mitigated the
problem of overwhelmed healthcare manpower, as well as pro-
vided an opportunity for personal and professional advancement
of underutilized support workers and assistant practitioners [10, 3 The Evolution of the Philippine Cancer
11]. Control Strategy

Clinicians may not feel that shared decision-making is suitable Shared decision-making goes together with contextualized
for all patients due to decisional preferences [8]. In a survey evidence-based medicine. The Department of Health of
among Filipino patients with advanced cancers, up to 22% the Philippines has successfully developed national clinical
reported a preference for passive decisional control [12]. Patient practice guidelines for several cancers that also serve to guide
decision aids may enhance patient autonomy and engagement in health financing [21], a testament that the Philippine medical
the decision-making and implementation. Patient decision aids, community already has trained experts in evidence-based
by incorporating patient-level information summaries, values oncology. However, while patient survivors and advocates were
weighing scales, and guidance on decision-making, serve to engaged in the development of these guidelines, guidance on
supplement clinic discussions as they can be accessed by patients the practical implementation of shared decision-making in these
and their families outside consultation times at their own pace guidelines is lacking.

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Our recent survey data indicate that Filipino oncologists and Data Availability Statement
related professionals are open to shared decision-making [5]. Our No data were generated in the preparation of this manuscript.
recent trial among Filipino patients with cervical cancerin private
centers in Manila showed that a locally developedand validated
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