Introduction
Decision regret is a multifaceted emotional response encompassing feelings of disappointment and remorse concerning the choices made during the treatment decision-making process (Landman
1987). It can be described as a feeling that opting for a different course of action would have resulted in a more favorable outcome in the current situation (Coricelli et al.
2007). This adverse emotional sensation can arise when uncertainty surrounding the optimal choice remains unresolved or when an undesirable outcome prompts the belief that an alternative decision might have been more beneficial (Joseph-Williams et al.
2011). This phenomenon is particularly pertinent in the field of oncology, where treatment decisions often carry profound implications for patients' lives (Connolly and Reb
2005). Prevalence and determinants of decision regret were studied in several cancer types, such as prostate cancer (Wallis et al.
2022), breast cancer (Martinez et al.
2015), lung cancer (Sullivan et al.
2023), and head-and-neck cancer (Nallani et al.
2022). The Ottawa Decision Regret Scale (DRS) was initially developed by Brehaut and colleagues and has demonstrated its validity and reliability as a measurement tool for decision regret (Brehaut et al.
2003).
Radiotherapy is a cornerstone in cancer treatment, and about 50% of all cancer patients in Europe undergo at least one course of radiotherapy during their disease (Lievens et al.
2020). While numerous studies have explored decision regret in various healthcare settings, its prevalence and determinants in the context of radiotherapy remain underexplored (de Groot et al.
2012; Nallani et al.
2022; Windon et al.
2019; Zoumpou et al.
2023). Decision regret for (1) not omitting radiotherapy after surgery (e.g., in older women with low-risk breast cancer (Kunkler et al.
2023)), (2) for not deciding to undergo primary surgery instead of radical radiotherapy [e.g., in men with localized prostate cancer (Hamdy et al.
2023)], (3) for not opting for a different radiotherapy fractionation schedule [e.g., short-course neoadjuvant radiotherapy instead of long-course neoadjuvant chemoradiation in patients with rectal cancer (Ciseł et al.
2019)] or (4) for a less aggressive radiotherapy regimen (e.g., omitting radiotherapy boost to the tumor bed or omitting coverage of the elective lymph nodes in women with breast cancer (Bartelink et al.
2015)) are only some examples that may occur in patients after radiotherapy. Understanding the factors contributing to decision regret after radiotherapy is crucial not only for enhancing patient satisfaction and well-being but also for refining the shared decision-making process between patients and healthcare providers.
Decision regret may be dependent on cultural differences (Hawley and Morris
2017; López et al.
2014; Shaw et al.
2015), providing a rationale to examine this issue separately for individual countries. However, there is a paucity of studies about decision regret after radiotherapy in cancer patients in Germany (Köksal et al.
2023,
2022). We therefore aimed at investigating the prevalence and determinants of decision regret in cancer patients who were treated with radiotherapy for their disease at a large tertiary German cancer center. Previous studies have found relationships between decision regret and various patient-reported outcomes, such as quality of life (Calderon et al.
2019), distress, depression, anxiety (Sheehan et al.
2007), perception of the decision-making process (Yamauchi et al.
2019), satisfaction with care (Berkowitz et al.
2021), social support (Wallis et al.
2022), and health literacy (Joyce et al.
2020), wherefore we also surveyed these patient-reported psychosocial outcome measures to find potential variables that are associated with decision regret. We also aimed to examine the reliability of the German version of the DRS in a broad group of cancer patients, in order to facilitate its usage in subsequent studies.
Discussion
In this single-center cross-sectional observational study performed at a large German tertiary cancer center, more than half of the investigated patients (56%) reported some form of decision regret, with 18% feeling strong decision regret after radiation treatment. Both comprehensibility and explicitness of the German version of the DRS were considered good by the participating patients, and the internal consistency as assessed with Cronbach’s α was acceptable. Higher ECOG performance status at the follow-up consultation, lower social support, and lower satisfaction with care were associated with decision regret in the multiple regression analysis.
There is a paucity of data regarding the prevalence of decision regret after radiotherapy in the German healthcare system (Köksal et al.
2023,
2022). Köksal et al. reported a strong decision regret prevalence of 13.9% after adjuvant radiotherapy in a cohort of 172 patients with breast cancer treated at a German tertiary cancer center (Köksal et al.
2023). This is well comparable to the prevalence of strong decision regret in the subgroup of breast cancer patients in our study (8 out of 84 patients [10%] with strong decision regret). In a further study, Köksal and colleagues examined the prevalence of decision regret in a group of 108 patients with head-and-neck cancer who were treated with surgery and adjuvant radiotherapy (Köksal et al.
2022). While 40.5% reported no decision regret, 30.1% indicated mild decision regret, and 29.4% even strong decision regret. Strong decision regret was reported by about half of head-and-neck cancer patients in our cross-sectional study (47%), but results should be interpreted very cautiously due to the low number of head-and-neck cancer patients in our study (
n = 19). However, a further study also observed relatively high rates of decision regret in head-and-neck cancer patients, namely about one third of patients reporting strong decision regret at 3 and 6 months after cancer treatment (Nallani et al.
2022). The relatively high prevalence of decision regret observed in patients with head-and-neck cancer could be attributed, in part, to the fact that both definitive (chemo)radiation and surgery with risk-adapted adjuvant (chemo)radiation represent comparable treatment approaches for a significant subset of head-and-neck cancer subtypes (Henriques De Figueiredo et al.
2016; Nichols et al.
2022; Pakkanen et al.
2022; Palma et al.
2022), so that the decision-making process is stressful for the patients which increases the risk of subsequent decision regret. It has been shown that higher decisional conflict is a risk factor for later decision regret (Becerra Pérez et al.
2016), making decision support interventions such as patient-centered treatment decision aids a promising strategy to mitigate decisional conflict and subsequent regret (Bigelow et al.
2021; Stacey et al.
2017; Windon et al.
2021). In the observational study concerning decision regret in head-and-neck cancer patients from Nallani and colleagues, higher decision regret was associated with advanced disease stage at presentation, primary non-surgical treatment, and lower health literacy (Nallani et al.
2022). If further studies validate these relatively high rates of decision regret after radiotherapy in head-and-neck cancer patients, there is a need to develop multi-professional strategies to reduce decision regret in this vulnerable population.
Satisfaction with care was found to be inversely correlated with decision regret in our cohort. However, given the cross-sectional observational design of our study, it is not possible to unequivocally indicate a causal effect. While low satisfaction with radiotherapy could in theory causally contribute to higher rates of decision regret, it may also be conceivable that strong decision regret may result in higher post-hoc perceived dissatisfaction with care. A recent large multicenter study observed relatively high satisfaction with radiotherapy care in Germany (Fabian et al.
2023). Tumor entity, treatment center, and quality of life were independent determinants of patient satisfaction with radiotherapy care in this study. The fact that the treatment center itself was reported as a major determinant of patient satisfaction with radiotherapy care in the study of Fabian et al. highlights the importance of regular patient satisfaction assessment as part of the internal quality management. Indeed, regular assessments of patient satisfaction are required in the quality management guideline of the Federal Joint Committee (
Gemeinsamer Bundesausschuss, G-BA) (Boywitt et al.
2022).
Lack of social support which was measured with the SSUK-8 was another variable that was associated with decision regret in the multiple regression analysis. In a recent population-based, prospective cohort study of 2072 patients with localized prostate cancer, social support at baseline was also found to be associated with decision regret after treatment (Wallis et al.
2022). Furthermore, a systematic review by Szproch and Maguire identified lack of social support with higher levels of decision regret after cancer treatment (Szproch and Maguire
2022). Recommending or referring patients to the psycho-oncology service as well as connecting patients with existing support groups may improve perceived social support (Korotkin et al.
2019; Sautier et al.
2014). Psychosocial care in which both the patient and his or her partner and family are addressed may also improve this outcome measure (Hartmann et al.
2010; Lorenz et al.
2019). However, especially cancer patients experiencing loneliness and social isolation remain a challenging population who suffer from low perceived social support, which is difficult to address even with psycho-oncologic interventions (Deckx et al.
2014; Hogan et al.
2002). Further prospective studies in which decision regret is assessed longitudinally are needed to further examine the relationship between social support and decision regret.
ECOG performance status at the time of questionnaire completion was found to be linked with decision regret in our study. There are various potential patient and treatment characteristics that can deteriorate patients’ ECOG performance status, e.g., higher age, presence of treatment-related adverse events, higher tumor stage, and tumor recurrence, etc. (Corrêa et al.
2012; Datta et al.
2019). As non-participants of the study exhibited a worse ECOG performance status than participants, the exact rate of decision regret may even be higher, although this remains speculative. Furthermore, it cannot be ruled out that patients at the end of their life tend to exhibit higher decision regret, as they might feel regret to have wasted their lifetime with cancer treatments that did not lead to long-term survival. Again, longitudinal analyses of decision regret including mixed-methods design and with linkage to progression-free survival are required to further elaborate on this issue and to explore reasons for decision regret after radiotherapy in more detail.
Patients who experience regret often retrospectively report being insufficiently informed (Hoffman et al.
2017; Morris et al.
2015), and patients' experiences concerning participation in the decision-making process were inversely correlated with decision regret at least in the univariate analysis of our cross-sectional study (
r = − 0.22,
p < 0.01). The relationship between the extent of patient participation in the decision-making process and the hazard of post-treatment decision regret is considered to be complex. While numerous studies indicate that patients actively participating in decision-making experience lower regret compared to those in passive roles (Wilding et al.
2020; Wollersheim et al.
2020), others reported opposite findings (Livaudais et al.
2013; Wagland et al.
2019). Chichua and colleagues suppose that decisional regret is linked not to the preferred or adopted role in the decision-making process, but to the discrepancy between them (Chichua et al.
2022). Both involuntary passive and active roles can result in increased regret (Mancini et al.
2012; Wagland et al.
2019). While active participation allows realistic expectations and preference expression, patients' health literacy must be considered (Joyce et al.
2020). In a study with 368 early breast cancer patients, too much perceived responsibility was associated with less baseline treatment knowledge and increased decision regret (Livaudais et al.
2013). Clinicians should therefore consider assessing patients' decisional capacity and preferences when offering recommendations and support (Chichua et al.
2022).
The participating patients found the comprehensibility of the German version of the DRS to be good, and the internal consistency, evaluated using Cronbach's
α, was deemed acceptable. In comparison with the original DRS and the Japanese version of the DRS, internal consistency was a bit lower [Cronbach’s
α of 0.76 in our study versus 0.81–0.92 in the original DRS (Brehaut et al.
2003) versus 0.85 in the Japanese version (Tanno et al.
2016)]. The German version of the DRS for caregivers (DRS-C), which was investigated in a cohort of caregivers of deceased people with cancer, also had a good internal consistency with a Cronbach’s
α of 0.83 (Haun et al.
2019). Importantly, the comprehensibility of the DRS was indicated as good or very good by 98% in our cohort, supporting the usage of this questionnaire in subsequent studies.
Even though this cross-sectional study is the largest study examining the prevalence of decision regret after radiotherapy in Germany with a fairly good response rate, there are some limitations of the analysis. First, sampling error could have occurred, as the collected data originate from only a portion of the overall population who received radiotherapy in our institution. We attempted to partly address this issue by comparing the key demographic variables between participants and non-participants. Second, the missing longitudinal analysis of the degree of decision regret over time prevents an in-depth analysis about the duration of decision regret after radiotherapy. In a large longitudinal analysis about decision regret in patients with prostate cancer, the percentage of patients reporting regret increased over time in patients who were treated with radiotherapy, whereas it decreased in patients undergoing active surveillance (Hurwitz et al.
2017). Another study found relatively stable rates of decision regret over time in patients with localized breast cancer (Martinez et al.
2015). Third, given the single-center approach of our study, caution is warranted regarding the generalizability and transferability of our results to other centers in Germany. As patients with breast cancer (41%) and prostate cancer (28%) comprise the majority of patients treated with radiotherapy, our analyses regarding decision regret in patients with other cancer types are limited by the low patient number for those cancer types, so that multi-center studies with larger sample sizes are required. In this context, it has also to be mentioned that patients who had received radiotherapy with palliative intention were underrepresented in our cohort, so that transferability of our findings to this cohort is complicated. Last, recall bias may have occurred when patients were asked about their satisfaction with radiotherapy care as well as their involvement in the decision-making process, as median time between last day of radiotherapy and questionnaire completion was 23 months.
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