Uncertainty in Clinical Decision-Making

The appeal of precision medicine is self-evident: who wouldn’t want their medical care as tailored as possible to their personal circumstances? Underlying the promise of precision medicine, however, is the reality that sometimes advances in scientific knowledge can complicate clinical decision-making. A perspective article in the New England Journal of Medicine shows how via a breast cancer clinical trial exploring when to give patients chemotherapy.

When determining whether a breast cancer patient should receive chemotherapy, genetic characteristics of the tumor are now considered in conjunction with traditional clinical factors, such as the stage of the tumor and the age of the patient. Including this genetic information to help guide a medical decision is exactly the type of improvement precision medicine is all about. It allows clinicians to tailor treatment recommendations based on the features of their patients’ tumors, ideally resulting in improved outcomes. However, when a randomized clinical trial compared survival among patients whose clinical information indicated they needed chemotherapy but their genetic information indicated that they did not, the picture becomes murky. The women in this group who were randomized to receive chemotherapy anyway were 22% less likely to experience metastasis and were significantly less likely to experience a progression of their breast cancer. In other words, receiving chemotherapy may provide a benefit to some women whose genetic information indicates they do not need it. Women facing this circumstance would have to weigh the toxicity associated with receiving chemotherapy against the small but consequential chance of experiencing a progression of their disease in the absence of therapy.

As clinical decision-making becomes increasingly influenced by precision medicine approaches, patients and their clinicians will have to determine how to navigate uncertainties like these.  As the article notes, research related to communicating uncertainty in medicine is necessary to help patients make optimal decisions.

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