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Liver Transplant Organ Quality Decision Aid: Would you consider a less than perfect liver? (Jan-16)

Imagine that you are a patient with end-stage liver disease and you are currently on the liver transplant waiting list.

Available donor livers are limited and vary in quality. Donor characteristics such as age and cause of death can make a difference between a 20% and a 40% rate of liver transplant (graft) failure by 3-years post-transplant.

Now imagine that you and your doctor are discussing the risks and benefits of a liver transplant and whether you might consider a “less than perfect” liver (with a higher risk for graft failure).  To help you in your decision making, you are provided with a decision aid to help you to consider the level of risk you would be willing to accept from a donated liver.

On the following page, consider an image representing your (pretend!) risk of dying or becoming too sick for a liver transplant within the next 3-months if you don’t get a transplant.

Attitudes toward Return of Secondary Results in Genomic Sequencing (Sep-16)

Imagine you are at the doctor’s office because you (or your child) have a serious health condition like heart disease or cancer. To help find out whether any treatment options exist, your doctor suggests that you (or your child) have your genome sequenced.

Genome sequencing may provide information about your (or your child’s) current health condition. However, the genome sequencing could reveal additional and unexpected results not related to the current condition. The doctor wants to know what types of these secondary results you would want to be told.

Bioethics Grand Rounds: Musical Event "When Death Comes Callin"

Wed, October 26, 2016, 12:00pm
Location: 
UH Ford Amphitheater & Lobby

When Death Comes Callin': Songs and Reflections About Death

Charlotte DeVries, Jeanne Mackey, Merilynne Rush, and friends offer a program of songs and brief readings reflecting various perspectives on death - humorous, sad, thoughtful, and quirky.

Lunch is provided on a first-come, first-served basis.

Mon, June 23, 2014

Brian Zikmund-Fisher was interviewed by Reuters Health for the article "Shared decision making still lacking for cancer screening." He discusses his research and trade-offs in cancer screenings. "What this study does is it shows that despite all of the initiatives and the discussion of shared decision making that has been going on, we don't seem to be moving the needle very much," he states. 

His interview also received press in the Chicago Tribune and New York Daily News.

Peter A. Ubel has been selected by the Robert Wood Johnson Foundation as a recipient of a prestigious Investigator Award in Health Policy Research for 2008. Dr. Ubel, who was director of the Center for Bioethics and Social Sciences in Medicine, plans to examine how beliefs about quality of life affect the choices made when patients seek treatment, when payers determine coverage policies, and when policy-makers weigh programmatic or financial options. His project, Emotional Adaptation and the Goals of Health Care Policy, will introduce insights from well-being research, which studies how physical illness and emotional well-being are intertwined, to debates about cost-effectiveness of medical treatments, coverage decisions by payers, and discussions about health care priorities.

PIHCD: Sarah Alvarez

Thu, November 05, 2015, 2:00pm
Location: 
B004E NCRC Building 16

Sarah Alvarez, a fellow at Stanford and formerly of Michigan Radio, will  present her work on creating a news product that can meet the information needs of low-income news consumers. Specifically her focus is on how to use data to discover which issues or systems information gaps exist for low-income news consumers and once the gaps are identified how the information should be presented to help people understand the information and use it to make decisions.

If you plan to attend this meeting please e-mail Nicole Exe at nexe@umich.edu by Monday November 2. If you decide to attend after that date you are still welcome and do not need to e-mail.

Mon, April 16, 2012

When women at high risk of breast cancer viewed a customized web-based decision guide about prevention options, they were more likely to make a choice about prevention and to feel comfortable with their choice.  CBSSM co-director and study senior author Angela Fagerlin is quoted in the press release.  Click here to view a press release about the study, whose authors included current CBSSM faculty member Brian Zikmund-Fisher and CBSSM alumni Peter Ubel and Dylan Smith.

Last Saturday, Dr. Susan Goold had the highly esteemed task of presenting to the AMA House of Delegates on modernizing the Code of Medical Ethics. As the chair of the AMA Committee on Ethical and Judicial Affairs (CEJA), Dr. Goold is very involved in this massive reformatting and modernization effort. More information can be found in the AMA Wire press release.

How much will chemotherapy really help you? (Dec-08)

After breast cancer surgery, additional treatments such as chemotherapy can reduce the risk of cancer coming back. But do women understand how much (or little) benefit chemotherapy provides? Imagine that you're a woman who has recently been diagnosed with breast cancer and then had the cancerous breast tumor surgically removed. While you're at an appointment about 3 weeks after your surgery, your doctor says the following to you:

"Sometimes cancer cells remain after surgery and start to grow again. To try to prevent your cancer from growing again, you should consider having some additional treatment.

"One of our test results shows that you have a type of cancer that is estrogen receptive (ER) positive. This means that your cancer needs the hormone estrogen in order to grow.

"Because you have an ER-positive tumor, you should have hormonal therapy to block estrogen and make it harder for any remaining cancer cells to grow. Hormonal therapy is usually in pill form. It does not cause hair loss or fatigue and generally has very few short-term side effects. You'll start to take hormonal therapy after all other treatments are finished and continue to take it for at least 5 years.

"Although it's clear that you should have hormonal therapy, you'll still need to make a choice about chemotherapy treatments. You could decide to have additional chemotherapy treatments for several months before starting the hormonal therapy. Sometimes, adding chemotherapy can make a big difference in decreasing the risk of dying from cancer. Other times, there's almost no benefit from adding chemotherapy.

"If you decide to have chemotherapy, you'll have 2 to 4 months of fatigue, nausea, hair loss, and other side effects. You'll also face a small risk (less than 1% or less than 1 in 100) of getting a serious infection, a bleeding problem, heart failure, or leukemia. Only you can decide if the benefit of adding chemotherapy to hormonal therapy is worth the risks and side effects."

Next, your doctor shows you a graph that may help you to decide about chemotherapy.

Your doctor says, "The graph below may help you decide if the risk reduction you would get from adding chemotherapy is worth the side effects and risks that the chemotherapy would cause.

  • The green part shows the chance that you'll be alive in 10 years.
  • The red part shows the chance that you'll die because of cancer.
  • The blue part shows the chance that you'll die from other causes.
  • The yellow part shows how much your chance of being alive in 10 years would increase if you add a therapy.
"Remember, given your situation, I think you should definitely take hormonal therapy. What you need to decide is whether to take both chemotherapy and hormonal therapy."
 
In interpreting this graph, imagine that there are two groups of 100 women each. All of these women have the same type of cancer as your hypothetical cancer.
  • The first group all decides to take hormonal therapy only.
  • The second group all decides to take both chemotherapy and hormonal therapy

How many fewer women will die from cancer in the second group, as compared with the first group?

Your doctor continues, "Now, here is another graph that shows the same information in a different way. As before,

  • The green part shows the chance that you'll be alive in 10 years.
  • The red part shows the chance that you'll die because of cancer.
  • The blue part shows the chance that you'll die from other causes.
  • The yellow part shows how much your chance of being alive in 10 years would increase if you add a therapy.
Now we asked you to consider the following question:
How many fewer women will die from cancer in the second group, as compared with the first group?
Do you want to change your answer?
 

About the study

Many participants who saw this graph in a study conducted by CBDSM researchers had similar problems. However, when study participants saw GRAPH B (with the two pictographs), many more were able to correctly calculate the difference.

The CBDSM study compared tools intended to help cancer patients make informed decisions about additional therapies (also called "adjuvant" therapies). The 4 horizontal stacked bars were taken from an online tool called "Adjuvant!" that is often used by physicians to explain risk to cancer patients. The researchers compared comprehension of risk statistics from horizontal bars and from a pictograph format.

They found that study participants who viewed a 2-option pictograph version (GRAPH B in this Decision of the Month) were more accurate in reporting the risk reduction achievable from adding chemotherapy to hormonal therapy for the hypothetical cancer scenario. With GRAPH B, 77% of participants could identify that 2 fewer women out of 100 would die from cancer with both chemotherapy and hormonal therapy. With the 4 horizontal bars (GRAPH A), only 51% of participants could make this calculation. Participants who saw GRAPH B were also much faster at answering this question than participants who saw GRAPH A.
In addition, participants in this study strongly preferred the format of the pictograph you saw (GRAPH B) to the bar graphs you saw (GRAPH A).
The researchers comment:
"While decision support tools such as Adjuvant! use graphical displays to communicate the mortality risks that patients face with different adjuvant therapy options, our research shows that women had difficulty interpreting the 4-option horizontal bar graph format currently used by Adjuvant!. Two simple changes, displaying only risk information related to treatment options that included hormonal therapy...and using pictographs instead of horizontal bars, resulted in significant improvements in both comprehension accuracy and speed of use in our demographically diverse sample....The results...support the concept that simpler information displays can make it easier for decision makers to implement optimal decision strategies. Specifically, focusing patients' attention on those treatment options currently under consideration while removing information related to options which have been already eliminated from consideration (for medically appropriate reasons) may be particularly beneficial. In the context of adjuvant therapy decisions, such an approach would imply that clinicians should discuss the decision in two stages: A first stage in which hormonal therapy is considered and a second stage in which the incremental benefit of chemotherapy is evaluated...Adjuvant! and other online risk calculators enable oncologists and patients to receive individually tailored estimates of mortality and recurrence risks, information that is essential to informed decision making about adjuvant therapy questions. Yet, the full potential of these modeling applications cannot be realized if users misinterpret the statistics provided."
 
Read the article:
Zikmund-Fisher BJ, Fagerlin A, Ubel PA. Cancer 2008;113(12):3382-3390.

 

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