Submitting to the momentum of care: Processes of treatment decision making among older people with colorectal cancer
Bibliographic record
Abstract
In Canada, 46% of new cancer cases and 64% of cancer deaths occur in people 70 years and older. Cancer treatment decision making among older people presents important challenges due to vast variations in health and functional status, changes in cancer pathology, changing social networks and resources, increased tension between quality and quantity of life, and lack of evidence to inform appropriate treatment recommendations. The complexity of this process, involving interactions among patients, healthcare providers, and family members that are shaped by the broader socio-political context, can cause distress to patients and those close to them. As the number of older Canadians is expected to more than double in the next 30 years, the need to optimize cancer treatment decision making for this group is paramount.Colorectal cancer is the second most common cancer diagnosis among older Canadians, with 53% of new cases occurring in men and women aged 70 years or older. With a 5-year net survival rate of 61% and complex trajectories involving multiple treatment modalities and burdensome side effects, colorectal cancer presents an important context within which to understand ongoing processes of treatment decision making among older people. This understanding is urgently needed to address salient age-based disparities and to offer optimal support. Purpose: To gain in-depth understanding of processes of treatment decision making from the perspective of people aged 70 years and older diagnosed with colorectal cancer. Methods: In this longitudinal, prospective, constructivist grounded theory study, participants included 18 people, aged 71 to 88 years, with an initial diagnosis of colon or rectal cancer, receiving care at a university-affiliated cancer centre in Montreal, Quebec, Canada. Participants were interviewed before and after their initial treatment. Between interviews (3 to 18 months), participants documented their thoughts and experiences in diary entries (written/self audio-recorded and/or through phone calls and brief visits). 35 interviews, 234 written or self-recorded diary entries, and 246 audio-recorded phone calls or brief visits with participants were generated. Medical information was collected from electronic health records. Interviews and relevant excerpts from diary entries were transcribed verbatim. Constant comparative methods of data analysis were used, relying on coding, questioning, and memo-writing. NVivo 10 software facilitated data management and analysis.Results: A dynamic, substantive theory of submitting to the momentum of care was constructed. This process began with an early decision point as participants stepped into the healthcare system, and then were swept into and through treatment. All actively worked, in their own ways, to align themselves with this momentum by situating self, managing self and system, and choosing to trust. If they were able to situate themselves and manage the momentum, they chose to trust and came to receive treatment by continuing to submit to the momentum of care. If they were unable, they lost trust and stepped away from the system. Paradoxes within participants’ accounts of decision making, and the role of age, information, existential perspectives, and identity, provided insights into the mechanisms underlying ongoing decision-making processes.Implications and Conclusions: Insights gained from this in-depth inquiry call us to re-examine existing models of treatment decision making. In this theory, cognitive, practical, and relational dimensions of cancer treatment decision making are integrated, highlighting the impact of contextual elements. Findings suggest the need for interventions that support trust relationships and enable older people with colorectal cancer to align themselves with the healthcare system. This theory provides a framework that may be used to inform clinical practice, education, policy, and future research
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.008 | 0.019 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.001 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.009 | 0.007 |
| Scholarly communication | 0.005 | 0.002 |
| Open science | 0.001 | 0.003 |
| Research integrity | 0.001 | 0.003 |
| Insufficient payload (model declined to judge) | 0.001 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".