ReachMD

Announcer:
You’re listening to Project Oncology on ReachMD, and this episode is sponsored by Lilly. Here’s your host, Dr. Charles Turck.

Dr. Turck: 
This is Project Oncology on ReachMD, and I'm Dr. Charles Turck. Here with me today to discuss best practices for integrating shared decision-making into the treatment of chronic lymphocytic leukemia, or CLL for short, is Dr. Adam Kittai. He's an Assistant Professor in the Division of Hematology at the Ohio State University Comprehensive Cancer Center. Dr. Kittai, welcome to the program.

Dr. Kittai:
Thanks for having me. Looking forward to this talk.

Dr. Turck:
Well, to start us off, Dr. Kittai, would you tell us why shared decision-making is so important and how it can impact our patients with CLL?

Dr. Kittai: 
Yeah. So first, let's define what we mean by shared decision-making. So how shared decision-making is defined is by three essential elements. Recognizing and acknowledging that a decision is required, right? So deciding that day that a decision needs to be made with your patients. Knowing and understanding what's available for the patient. So knowing all treatment options and what the pros and cons of each of those options are. And then incorporating what the patient wants to best select the best decision moving forward.

So keeping in mind those three aspects to shared decision-making, what we can imagine is that in patients with CLL who live for a very long time and have a lot of options available to them, we really want to make sure that A, whatever we're selecting for the patient matches what they would want, and B, the patient is most comfortable with what the selection is. And I think that's important because in order for our patients to have a successful outcome and in order for our patients to get the most out of the therapy they receive, they need to stay on the therapy, and they also need to make sure that they're trusting their treating provider so that way they are open and communicative about any difficulties they might have with the treatment. And so if you don't start from a place of shared decision-making where you are incorporating the patient's values into the decision that you are currently making, you're not going to be successful because ultimately, the patient is not going to feel like they have ownership in this decision and also, the treatment that you select may not be in line with what the patient actually wants. And so that's why shared decision-making is so important for our patients with CLL.

Dr. Turck:
So with that being said, let's focus on best practices for integrating shared decision-making into practice. How do you typically approach talking to patients with CLL about their preferences and values?

Dr. Kittai: 
Yeah, so with patients with CLL, because they're living longer and longer, I already have a relationship established with these patients. And so usually when patients are first diagnosed, they go through a phase called watch-and-wait, where they don't require treatment. And so even that is a decision to enter into watch-and-wait, but it's not usually a hard decision after you explain why to the patient.

Usually, the times that really can be difficult are when you need to initiate treatment and what treatment to start because there's a lot of options for patients with CLL. And so by that point, because I've seen them for so long in the watch-and-wait side, I already really have a good idea of what my patients want. Again, I usually go over it with them, but the beauty of CLL is that usually we have time to prep the patient and discuss what is coming and really figure out what is the best treatment for them.

Now if I see a patient for the first time that requires therapy on the day that I see them or at least urgently, I really get to know the patient. I really try my best to understand where the patient's coming from, what they do for a living, and what their family situation is like. And using that information, I can best tailor what is needed for the patient or what I think the patient may be best at or receive.

Dr. Turck:
And are there any tools or resources available that can help facilitate that shared decision-making discussion?

Dr. Kittai:
There are tools that set out a step-by-step guideline on how to make a shared decision. And I'll go over one of the tools with you right now. So one of the tools is just a four-step process. And it sounds intuitive, but oftentimes, we don't go through this process with our patients.

And so the first thing that you have to talk about with the patient is inform the patient that a decision has to be made. And so basically, what you have to tell them is that today, we have to make a decision because we believe that your disease needs treatment or doesn't need treatment, depending on the patient. And then in that sentence, you also have to make sure the patient's opinion is important and let them know that. So start off with something like this: “Today's an important day where we need to decide what treatment to go forward with. And I want to make sure that I keep your opinion in mind because I'd like for you to be as successful as possible with the treatment that we decide.” So that's a good opener for section one.

The second step is to explain the options and what their pros and cons are. And so obviously, when you are preparing to have this kind of conversation with somebody, you need to make sure that you do your research and know what you're recommending and what the pros and cons of each of those recommendations are. That sounds silly, but sometimes, you may be in a circumstance where you're offering a treatment for somebody and maybe something comes up and you don't know the answer; it's best to just say, “You know, I'll get back to you on that one.” So in terms of the second step, I think that coming prepared, knowing all the options, and going through the pros and cons is essential.

The third step is having a professional discussion about what the patient's preferences are and how the treatments and the options that you just laid out to the patient might fit with those preferences. And I think that's where the opinion piece comes into play and where the essential part of shared decision-making comes to play. Because you eventually are going to present the medical data on all of the options to the patient, but ultimately, the patient needs to decide to do something. And the only way that you're going to get them to agree to that is by gaining their opinion and trust and aligning their preferences with the treatment that you're deciding on.

And last is to discuss with the patient about making this decision. And sometimes that's difficult, right, where the patient can't make the decision. And that happens sometimes. And so normally, when that happens and a patient can't make a decision, I usually reiterate what my preference for the patient is and also reiterate why my preference meets their preferences and how they meet together and why I'm picking this for this specific patient. And even then, if they can't make a decision after I state what my preference to help the patient with is, I usually say something to the extent of, “Why don't you go ahead and sleep on it, and I'll call you tomorrow and we'll discuss again.” And usually when someone has a good night's rest, and then go home and talk to their family about what the options are, they usually have a decision made by the next day.

Dr. Turck:
For those just tuning in, you're listening to Project Oncology on ReachMD. I'm Dr. Charles Turck, and I'm speaking with Dr. Adam Kittai about shared decision-making in CLL care.

So in addition to the communication tools that we were just discussing, Dr. Kittai, how else could we empower our patients with CLL to be active participants in treatment decision-making?

Dr. Kittai:
So I think that information is key. And so when I first meet a patient, I give them informational material. In our clinic, we have the Leukemia Lymphoma Society CLL booklet, so we give that to patients. If we're going to start patients on a treatment, we give them the up-to-date printout for that treatment so they have that to take home with them, which allows them to go home and inform themselves about the treatment and also CLL.

I also refer them to the CLL Society website, which is a not-for-profit group that has a lot of informational material on their website for patients with CLL. There's also patient support groups that are available through the CLL Society, along with various other societies like the Leukemia Lymphoma Society. And so I do encourage my patients to consider joining a patient support group where they can find out about how other patients with CLL did and the treatments they received.

Lastly, one of the most important things that I recommend to my patients is to have someone come with them to every single appointment if possible. And the reason why I think this is important is because having a cancer diagnosis and talking about treatment options can be very overwhelming. And it's always good to have a second set of ears. If someone can't have somebody with them in the visit,  I allow patients to record our conversations so that way they can go back and listen to them at home. But I really want my patients to be active participants, know all the information, and come with the support system that they need to be successful.

Dr. Turck: 
And once a patient feels empowered and has shared their preferences and priorities, how do you balance all that with your own treatment goals for the patient?

Dr. Kittai: 
I think the most important thing is to align your treatment goals with what the patient's treatment goals are. And what I mean by that is that ultimately, it's the patient living with cancer, it's the patient receiving treatment. And although you may want to reach towards the drug that you think will have the most efficacy, at the end of the day, it may not be the drug that has most efficacy that the patient wants or is in line with their patient preferences.

I think ultimately, you really want to get to a place where the decisions are shared and that your treatment plan is very similar to what the patient wants. And I think that is definitely something that you can attain using shared decision-making and making sure you get to know your patients and understand where they're coming from in terms of their treatment for their CLL.

Dr. Turck:
Now we've certainly covered a lot today, Dr. Kittai, so before we close, are there any key take-home messages on shared decision-making in CLL care that you'd like to share with our audience?

Dr. Kittai: 
Yeah, I think the key is that patients with CLL are living longer and longer, which really highlights the need to having a strong relationship with your physician and it highlights the physician’s relationship with the patient. And the reason why that's important is because in order to be able to gain the best efficacy and also live the longest with this disease with having the least toxicity, it's important for the patient to both trust the person that's treating them, and it's also important for the physician to make sure that they know their patient the best because we are seeing them for many, many years. And given that the treatment paradigm for patients with CLL is rapidly changing, with new drugs being approved all the time, it's just incredibly key to get to know your patient, make sure that you understand where they're coming from, and for the patient to know you and know where you're coming from. And then I think if that connection is strong for our patients, they'll have better outcomes.

Dr. Turck: 
Well, with those key takeaways in mind, I want to thank my guest, Dr. Adam Kittai, for joining me to discuss how we can utilize shared decision-making in the treatment of chronic lymphocytic leukemia. Dr. Kittai, it was great having you on the program.

Dr. Kittai: 
Thanks for having me. This has been wonderful.