1 The Case for Shared Decision-Making

Shared decision-making is a collaborative approach to care planning where the patient and their clinicians work together to address a dilemma in the patient's care through an equal conversation [1, 2]. This entails an evaluation of the situation by considering both the insights of the interdisciplinary healthcare team regarding the patient's disease, overall health status, and available treatment options, and the perspectives of the patient and their family regarding values, preferences, and resources [3, 4].

The case for shared decision-making is ethical. The principles of autonomy and informed consent underlie all healthcare. One may argue that not all patients prefer to make the decision or actively take part in the decision-making. Some patients may want to be involved in the decision-making but may not feel capable of making the decision; a next of kin, a legal representative, or a patient navigator or coach may help enable the patient. Some patients may entirely defer to the physician's recommendation but the setting for shared decision-making should be in place and offered to avoid any unintended or unrecognized coercion. However, shared decision-making goes beyond informed consent.

The case for shared decision-making is a matter of cost-effectiveness. In oncology, where treatment has evolved to become highly specialized, multidisciplinary, and personalized, clinical practice guidelines and clinical evaluation tools have been developed to facilitate evidence-based decision-making. However, while much has been put into “personalizing” treatment in terms of the patient's medical profile and disease characteristics, less has been put into personalizing in terms of the person's values and preferences. The costliest treatment is one that does not work; an even costlier treatment is one that the patient does not want or one that the patient did not know they did not want—the cost is decisional regret. Aligning treatment choices to patient values and preferences and managing patient and family expectations of the treatment are both paramount. However, shared decision-making is more than patient-centeredness.

The case for shared decision-making is a matter of efficiency. Fragmented care is inefficient care delivery. The multidisciplinary tumor board is a recognized standard of care; not only does it serve as an avenue for arbitrating differences regarding treatment preferences among clinicians and developing a consensus, but it also serves as a platform for coordinating care delivery. Similarly, shared decision-making is a space where patients and their families are regarded as equals in the decision-making and in co-creating the plan, thus enhancing care coordination and facilitating optimal and timely resource mobilization. Shared decision-making enables patients and their families to become active and equal partners in the implementation of their healthcare.

Finally, the case for shared decision-making is a matter of equity. All patients are enabled to make health decisions and empowered to be the primary agents of their health and health care, regardless of their decisional skills and preferences.

2 Priming Healthcare for Shared Decision-Making

Shared decision-making has been much studied, and increasingly talked about, but less implemented. Clinicians think they do but perhaps they do not or, they would like to do it but are unsure when or how to. A recent nationwide survey on shared decision-making among Filipino oncologists and oncology-related professionals revealed that while nearly everyone favored the concept (99%) and most reported practicing it (96%) and being knowledgeable about it (90%), not as many reported definitions that are concordant with the concept [5]. Healthcare providers in the shared decision-making process should be trained in the process; the American Agency for Healthcare Research and Quality has developed a comprehensive training curriculum, communication tools, and implementation resources for healthcare providers and teams [6]. The American Society of Clinical Oncology has published guidance detailing the different utilities of shared decision-making and appropriate situations [7].

Clinicians may not like shared decision-making because they feel a loss of physician autonomy, or may not be able to do it due to lack of time [8]. However, in the era of evidence-based and interdisciplinary care, physician autonomy is probably becoming a regressive value, and true collaboration more than makes up for a lack of time. Oncology nurses, even patient navigators, through upskill training, may be trained in active coaching [9]. During the COVID-19 pandemic, upskill training partly mitigated the problem of overwhelmed healthcare manpower, as well as provided an opportunity for personal and professional advancement of underutilized support workers and assistant practitioners [10, 11].

Clinicians may not feel that shared decision-making is suitable for all patients due to decisional preferences [8]. In a survey among Filipino patients with advanced cancers, up to 22% reported a preference for passive decisional control [12]. Patient decision aids may enhance patient autonomy and engagement in the decision-making and implementation. Patient decision aids, by incorporating patient-level information summaries, values weighing scales, and guidance on decision-making, serve to supplement clinic discussions as they can be accessed by patients and their families outside consultation times at their own pace and private space [13]. Patient decision aids may require more resources to develop and simpler decision support interventions have been shown to perform just as well [14]. However patient decision aids serve as peer-reviewed materials that can be updated and adapted, and therefore allow for wider implementation and upscaling while maintaining transparency and a minimum standard. Patient decision aids may be translated into other languages, provided in print or as a web-based or mobile application, and developed into simplified or user-responsive designs [15, 16]. Patients with high decision self-efficacy may do well being provided with just a decision aid while those who have lower decision self-efficacy may be assigned a decision coach [17]. Further, the Transition and Patient Empowerment Innovation, Education, and Research Collaboration is an international program that provides education, guidance, and resources to support and empower young and adult patients in shared decision-making [18].

Culture development and integration into clinical workflows are critical in the sustainable implementation and institutionalization of shared decision-making. The National Health Services England has published guidance for people leading local implementation of shared decision-making [19]. In a clinical trial on the use of patient decision aids in shared decision-making among Filipino cervical cancer patients, one of the observed barriers to participation was the urgency of the clinical situation [8]; outside of a trial, if the tools and providers are available and the process is already integrated into the workflow, shared decision-making will enhance even more and facilitate coordination and optimal resource mobilization.

Finally, leadership and policy support will be an instrumental foundation. Many cancer management guidelines now cite the need for shared decision-making, especially in the case of very early disease and advanced disease, where there is equipoise regarding the benefit-harm ratio with adjuvant treatment or aggressive treatment in the above situations, respectively. Taking it a step further, the recently published Action Plan for Efficient Cancer Care Implementation Toolkit includes patient engagement in decision-making as one of eight efficiency metrics [20]; the toolkit was informed by interviews with 21 upper- to upper middle-income countries from North America, South America, Europe, the Middle East, East Asia, and Oceania. Is the Philippines, as well as the Asia Pacific, ready for shared decision-making?

3 The Evolution of the Philippine Cancer Control Strategy

Shared decision-making goes together with contextualized evidence-based medicine. The Department of Health of the Philippines has successfully developed national clinical practice guidelines for several cancers that also serve to guide health financing [21], a testament that the Philippine medical community already has trained experts in evidence-based oncology. However, while patient survivors and advocates were engaged in the development of these guidelines, guidance on the practical implementation of shared decision-making in these guidelines is lacking.

Our recent survey data indicate that Filipino oncologists and related professionals are open to shared decision-making [5]. Our recent trial among Filipino patients with cervical cancerin private centers in Manila showed that a locally developedand validated patient decision aid was effective and useful [17, 22, 23]. Content translation into Filipino and simplification according to health literacy levels may enhance user acceptability. Development into a user-responsive, electronic application may enhance effectiveness and allow for patient data collection towards future iterations and improvement. Piloting in select government centers through integration into clinical workflows may provide avenues for training of healthcare provider teams.

The National Integrated Cancer Control Act (Philippine Republic Act 11215) covers cancer care capacity-building and expansion of public health financing to include cancer screening, detection, treatment, supportive care, survivorship follow-up care, rehabilitation, advance care planning, and palliative care, and mandated the creation of the Philippine Cancer Center [24]. The implementing rules and regulations of the National Integrated Cancer Control Act call for multidisciplinary cancer care which will not be complete without individualized care and shared decision-making. The Philippine Cancer Center is committed to its mandate to provide for an organized cancer control strategy and efficient, equitable, and responsive cancer care delivery.

Altogether, the expertise in evidence-based oncology has been established, the culture seems favorable for shared decision-making, the initial steps towards tools development have been taken, and the national strategy and leadership are committed. The Philippines is primed for shared decision-making.

Author Contributions

Warren Bacorro made substantial contributions to the study conception and design, literature review, data collection, and analysis, and was mainly responsible for drafting the manuscript. Clarito Cairo and Rodel Canlas made substantial contributions to the study conception design and drafting of the manuscript. Kathleen Baldivia, Aida Bautista, Jocelyn Mariano, Gil Gonzalez, and Teresa Sy Ortin contributed to the critical review of the manuscript. All authors read and approved the final manuscript.

Ethics Statement

The preparation of this manuscript did not entail human participation or the use of human health data.

Informed Consent

The authors have nothing to report.

Conflicts of Interest

Dr. Clarito Cairo is part of the Cancer Control Technical Services and Information Resources Management Division of the Philippine Cancer Center.