title: Understanding surgeon decision making in the use of radiotherapy as neoadjuvant treatment in rectal cancer.
abstract: BACKGROUND
  Strong evidence supports the use of neoadjuvant radiotherapy in rectal cancer to improve local control. This randomised controlled trial aimed to determine the effect of clinical and non-clinical factors on decision making by colorectal surgeons in patients with rectal cancer.
  
  
  METHODS
  Two surveys comprising vignettes of alternating short (4) and long (12) cues identified previously as important in rectal cancer, were randomly assigned to all members of the CSSANZ. Respondents chose from three possible treatments: long course chemoradiotherapy (LC), short course radiotherapy (SC) or surgery alone to investigate the effects on surgeon decision and confidence in decisions. Choice data were analysed using multinomial logistic regression models.
  
  
  RESULTS
  106 of 165 (64%) surgeons responded. LC was the preferred treatment choice in 73% of vignettes. Surgeons were more likely to recommend LC over SC (OR 1.79) or surgery alone (OR 1.99) when presented with the shorter, four-cue scenarios. There was no significant difference in confidence in decisions made when surgeons were presented with long cue vignettes (P = 0.57). Significant effects on the choice between LC, SC and surgery alone were tumour stage (P < 0.001), nodal status (P < 0.001), tumour position in the rectum (P < 0.001) and the circumferential location of the tumour (P < 0.001). A T4 tumour was the factor most likely associated with a recommendation against surgery alone (OR 335.96) or SC (OR 61.73).
  
  
  CONCLUSIONS
  This study shows that clinical factors exert the greatest influence on surgeon decision making, which follows a "fast and frugal" heuristic decision making model.
authors.affiliation: Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Surgical Outcome Research Centre (SOuRCe), Sydney School of Public Health, The University of Sydney, New South Wales, Australia.
authors.forename: Nabila
authors.initials: N
authors.lastname: Ansari
authors.affiliation: Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia. Electronic address: cyoungnsw@aol.com.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Young
authors.affiliation: Sydney School of Public Health, The University of Sydney, New South Wales, Australia.
authors.forename: Timothy E
authors.initials: TE
authors.lastname: Schlub
authors.affiliation: Centre for Medical Psychology & Evidence-based Decision-making (CeMPED), Sydney Medical School, The University of Sydney, New South Wales, Australia.
authors.forename: Haryana M
authors.initials: HM
authors.lastname: Dhillon
authors.affiliation: Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Surgical Outcome Research Centre (SOuRCe), Sydney School of Public Health, The University of Sydney, New South Wales, Australia.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Solomon
mesh_terms: D000328:Adult; D000368:Aged; D059248:Chemoradiotherapy; D003082:Colectomy; D003463:Cues; D003657:Decision Making; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D012004:Rectal Neoplasms / Q000175:diagnosis / Q000532:radiotherapy* / Q000601:surgery*; D066231:Surgeons / Q000523:psychology*; D011795:Surveys and Questionnaires
keywords: Decision making; Radiotherapy; Rectal cancer