摘要：To assess decision-making for cancer treatment among racial/ethnic minority patients, we systematically reviewed and synthesized evidence from studies of “shared decision-making,” “cancer,” and “minority groups,” using PubMed, PsycInfo, CINAHL, and EMBASE. We identified significant themes that we compared across studies, refined, and organized into a conceptual model. Five major themes emerged: treatment decision-making, patient factors, family and important others, community, and provider factors. Thematic data overlapped categories, indicating that individuals’ preferences for medical decision-making cannot be authentically examined outside the context of family and community. The shared decision-making model should be expanded beyond the traditional patient–physician dyad to include other important stakeholders in the cancer treatment decision process, such as family or community leaders. IN SPITE OF DECLINING CANCER incidence and mortality in the United States, minority patients continue to have lower 5-year survival rates than non-Hispanic Whites. 1 Although differences in stage at diagnosis may partly account for survival differences, a large proportion of the disparity in survival has been attributed to poorer quality of care, delay in receipt of treatment, or no receipt of treatment among minority patients. 2–8 Specific health systems or individual providers no doubt contribute to unnecessary delays in care. However, patients also may have reason to delay or refuse treatment, such as a poor patient–provider relationship or dissatisfaction with the treatment plan. Effective patient-centered communication and a positive patient–provider relationship have been associated with improved treatment adherence, survival, and health-related quality of life among cancer patients. 9,10 Racial and ethnic minority patients are at higher risk than White patients for poor communication and a strained patient–provider relationship, which in turn can lead to delayed or nonstandard care. 11–13 Incorporating cultural and individual patient preferences into cancer treatment planning through shared decision-making (SDM) may improve adherence to treatment recommendations and reduce delays in care. 14 The SDM model emphasizes the physician’s facilitation of the patient’s involvement in treatment decision-making to improve quality of care and patient centeredness, and thereby improve health outcomes. (In health care, “patient centeredness” includes viewing and treating the patient as a whole and unique person, rather than simply focusing on the disease process.) As opposed to the historical paternalistic or informed decision-making models, the SDM model is defined by a 2-way information exchange between the physician and the patient, followed by discussion of treatment preferences by both parties until they reach consensus on a treatment decision. 15 However, cancer patients’ preferred level of involvement in treatment decision-making may vary. A recent review found mixed effects of the impact of SDM interventions on patients’ satisfaction and medication adherence. 16 Alignment between patients’ preferred and actual decisional role may be more important to patients’ satisfaction than decisional autonomy. 17,18 Taken together, these data suggest that the SDM approach may not be right for every cancer patient. Indeed, the available evidence suggests substantial cultural variation in the cancer treatment decision-making process, including culture-specific differences in communication style, desired amount and type of information, and preferred decisional role. 15,19 For patients living in a defined social and cultural context such as an American Indian/Alaska Native (AI/AN) tribe, cultural congruence includes recognition of the decision-making role played by other important stakeholders outside of the patient–physician dyad. 20,21 To better assess SDM among racial/ethnic minority cancer patients, we performed a systematic review of the literature on SDM for cancer treatment in ethnic minority groups. We created a conceptual model to expand the SDM model and to identify the multilevel determinants of cancer treatment decision-making among ethnic minority groups, which include factors at the level of the patient, family and significant others, community, and provider. We summarized the literature at each level of the model to determine what is currently known about cultural variation in cancer treatment decision-making, to expose the relevant gaps in knowledge, and to make recommendations for future research.
