Ethical dilemmas surrounding patients´ "unwise" treatment preferences and suboptimal decision quality: case series of three renal cell carcinoma patients who developed local recurrences after non-guideline-concordant care choices

Abstract

Patient engagement and shared decision-making (SDM) between patients and clinicians is the foundation of patient-centered care. It aims to reach a treatment option that fits the patient's preference and is guideline-concordant. We sought to evaluate the possible causes and outcomes of patient's non-guideline-concordant care choices. Using a retrospective analysis of the medical records of patients who underwent cryoablation for small renal masses between January 2010 and January 2023. Inclusion criteria were patients with renal tumor(s) who underwent cryoablation which was not recommended by the multidisciplinary team (MDT). We present three patients with unilateral clear cell renal cell carcinoma. Based on imaging and other findings, the oncology MDT recommended partial/radical nephrectomy. Upon consultation, each refused surgery and preferred cryoablation. Respecting their choice, cryoablation was undertaken. The patients had treatment failure and developed recurrences that could have possibly been avoided with guideline-concordant care. Shared decision-making in healthcare involves several aspects: patient/family; uncertainty of available evidence of various treatments; MDT meetings; and treatment team. For patients to select 'wise' treatment preferences i.e. guideline-concordant care, multi-layered complex intellectual and cognitive processes are required, where experience may play a role. Healthcare professionals require guidance and training on appropriate SDM in clinical settings, and awareness of tools to solicit patient choice to guideline-concordant care whilst observing patient autonomy. Patients and treatment teams need the capacity, knowledge, and skills to reach a 'wise' guideline-concordant care treatment preference jointly. Patients' unwise preference could lead to suboptimal outcomes, in the case of our patients, tumor recurrence.

Keywords: Cryoablation; guideline-concordant therapy; partial nephrectomy; patient-centered medicine; renal cell carcinoma; shared decision-making.

Figure 1

renal masses of three patients by contrasted CT scan; patient 1 (A, B) central right renal upper to mid pole solid lesion (4 x 3.5 x 3.5 cm, red arrows); patient 2 (C, D) heterogeneous enhancing exophytic mass lesion arising from the mid pole posterior cortex of right kidney, protruding into right middle lobe calyx (5.4 x 4.8 x 4 cm, blue arrows); patient 3 (E, F): completely endophytic heterogeneous enhancing lesion arising from lower pole of right kidney (2.5 x 3 x 3 cm, yellow arrows)

Figure 2

recurrence of renal masses of three patients posts cryoablation; patient 1 (A, B) MRI with recurrence at tumor bed (27 x 18 mm, red arrows); patient 2 (C, D) CT scan showing slightly cystic hypoechoic focus posterior to right kidney, suggestive of tumor recurrence (3.6 x 2.9 cm, blue arrows); patient 3 (E, F) MRI showing focal heterogeneous lesion abutting the renal sinus fat, suggestive of tumor recurrence (18 mm, yellow arrows)