Who chooses palliative chemotherapy when a cure is possible? Results of a risk tolerance survey of laypersons.

35 Background: Many patients with acute myeloid leukemia (AML) face a difficult choice about whether to receive palliative chemotherapy or high-dose, potentially-curative chemotherapy that poses a risk of early death. How people weigh these factors in decision-making is unknown. We hypothesized that the possibility of cure primarily drives decision-making, regardless of treatment risk. Methods: We designed an electronic survey describing two treatment paths: (1) high-dose chemotherapy with possibility of cure but a 10% risk of early death, and (2) palliative chemotherapy with no chance of cure but no risk of early death. We recruited respondents via Amazon MTurk and presented 7 scenarios in random order, varying only the likelihood of cure associated with high-dose chemotherapy. Subjects rated their preferred treatment on a 4-point Likert scale. We assessed numeracy and attitudes toward chemotherapy using validated scales, and employed attention checks for quality assurance. Results: 100 subjects completed the survey (median age 30.5; 52 female, 85 Caucasian). 46 (46%) had at least a bachelor’s degree, and numeracy was generally high (median 4.75 out of 6). Respondents’ preferences for intensive chemotherapy varied with likelihood of cure, however some displayed a fixed preference for either curative or palliative treatment throughout, regardless of benefit level. For example, given a 50% likelihood of cure 20 respondents (20%) still preferred palliative therapy; similarly, with only a 1% likelihood of cure 28 respondents (28%) still preferred high-dose chemotherapy. In a multivariable model, preference for palliative chemotherapy was significantly predicted by subjects’ scores on the attitudes toward chemotherapy scale (p < 0.001), controlling for age, education and numeracy. Conclusions: Contrary to our hypothesis, a significant proportion of subjects preferred palliative chemotherapy, even in scenarios where high-dose chemotherapy conferred a high likelihood of cure. Pre-existing attitudes toward chemotherapy appear to drive patients’ decision-making about even potentially curative treatments. This finding may have significant implications for risk communication in oncology.

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