Physician Uncertainty Aversion Impacts Medical Decision Making For Older Patients With Acute Myeloid Leukemia: Results Of A National Survey

International audience; Elderly patients with acute myeloid leukemia can be treated with intensive chemotherapy, low-intensity therapy such as low-dose aracytine or hypomethylating agents, or best supportive care. The choice between these treatments is a function of many patient-related and physician-related factors. We investigated how physicians' behavioral characteristics, in particular their attitudes towards risk and uncertainty affect medical decision-making between intensive and non-intensive therapy in this setting. A nationwide cross-sectional online survey of hematologists collected data on medical decision-making for six clinical vignettes involving older acute myeloid leukemia patients that were representative of routine practice. Questionnaires elicited physicians' demographic and occupational characteristics along with their individual behavioral characteristics according to decision theory framework. From the pattern of responses to the vignettes, a K-means clustering algorithm was used to distinguish those who were likely to prescribe more intensive therapy and those who were likely to prescribe less intensive or no therapy. Multivariate analyses were used to identify physician characteristics predictive of medical decision-making. We obtained 290 answers to the questionnaire, including 230 assessable answers, which represented an adjusted response rate of 45.4%, calculated according to the American Association of Public Opinion Research. A multivariate model (n=210) revealed that uncertainty averse physicians recommend significantly more IC (OR [95% CI] = 1.15 [1.01;1.30], p=0.039), and that male physicians who do not conform to the expected utility model (assumed as economically irrational) tended to recommend more IC (OR [95% CI] = 3.45 [1.34; 8.85], p=0.01). Patient volume per physician also correlated with therapy intensity (OR [95% CI] = 0.98 [0.96; 0.99], p=0.032). The physicians' medical decision-making was not affected by their age, years of experience, or hospital facility. In this cross-sectional survey, attitudes towards uncertainty attitude influenced a physician’s choice between intensive and non-intensive strategies for older patients with acute myeloid leukemia. This significant association identifies a novel non-biological factor that may affect patient outcomes and explain practice variations. It should also encourage the use of validated predictive models and the description of novel biomarkers to best select patients for intensive chemotherapy or low-intensity therapy.