Weighing up risks and benefits

Every treatment has risks as well as benefits. The best treatment for you may be different from the best treatment for your friend or neighbor. We all have individual needs, and different things matter to each of us.

Research suggests that if you take part in deciding what treatment you have, you're likely to recover more quickly than if you don't take part in decisions.[1] It is even more important to play an active role when doctors don't know which treatment works best.

Doctors should base their treatment recommendations on what the research tells them. This is called practicing evidence-based medicine. This is a good way to practice medicine because it means your doctor is using evidence from medical studies that have looked at what happens to many thousands of people with your condition.

Key points to remember when choosing treatments

Look into all your treatment options.
Make sure you understand the risks and benefits of treatments.
Make sure you understand how the risks and benefits will affect you personally.
Make sure you have enough information to make a choice.
Make sure you understand the risks and benefits of deciding not to have treatment.

You and your doctor should talk about your options for treatment and make a decision together about the best treatment for you. This is called shared decision-making.

There are several questions you should ask before deciding on any treatment.

How involved do I want to be in making decisions about treatment?

Research shows that some people want to take part in deciding what treatment they have.[2] Others don't want to be involved at all. But doctors often suggest one type of treatment when their patients would prefer another.[2] Your doctor may not always know what is important to you.

Fully exploring the risks and benefits of treatment can help you decide what is most important to you, so you can make an informed decision.

What will happen if I don't have treatment?

Many common health problems, such as colds or headaches, go away on their own. But some health problems may get worse if you don't have treatment, such as diabetes and high blood pressure. You can ask your doctor what will happen if you don't have treatment, but sometimes your doctor won't know what will happen.

What are my choices for treatment?

Check out all your options
Your doctor may suggest that you make changes to your lifestyle before trying medicine or other treatment. Lifestyle changes are things like exercising more, eating a healthy diet, and stopping smoking.

If you make changes to your lifestyle, you may be able to avoid taking medicine or having other treatment. For example, exercising more often and cutting back on how much alcohol you drink may help lower your blood pressure. But if you don't want to exercise, it's best to be honest with yourself and your doctor, as you may need medication sooner.

There may be several different treatments available. If your doctor prescribes one treatment, ask if there are others. Is having an operation a possibility? Are there other treatments besides medicine or surgery? You may be able to try treatments such as physiotherapy or acupuncture. It's good to know about all the treatments that might work. This will help you choose the treatment that is best for you.

Listen to other people
You may also want to hear about what other people with your condition have chosen to do and what their experience has been. But remember that just because something hasn't worked for a friend doesn't mean it won't work for you.

What are the risks and benefits of each treatment?

Treatments can have both risks and benefits. Even aspirin and paracetamol can have side effects. You always need to balance the possible benefits with the possible risks.

Sometimes side effects don't show up in research studies and we only find out about them years after a medicine has become available. Even complementary or alternative treatments (such as herbal products or vitamins) can be harmful. Just because something is 'natural' does not necessarily mean it is safe.

How do the risks and benefits balance out for me?
When a treatment has both benefits and possible risks, what matters is whether you think that the benefits outweigh the risk of any side effects. Everyone is different. You need to decide what benefits and risks are important to you.

Here are some things to consider:

Your personal situation: Does the treatment have side effects that will be tough for you to live with? For example, maybe you have small children and can't take tablets that make you sleepy.
How you have to take the medicine: Maybe you don't like taking tablets and would prefer to use a skin patch.
Your preferences for treatment and what you expect from it: Would you find it difficult to live with the risk of any serious side effects, even if the risk is small? Would you find it unbearable to lose your hair, even if the treatment increased your chances of staying alive? What's the most important thing you want the treatment to do? If you have heart failure, for example, what is more important to you? To breathe more easily at night or to have less swelling around your ankles?
How you cope with side effects: If you have high blood pressure, for example, you may decide that you can put up with the annoying dry cough caused by some medicines. For you, the benefit of the treatment (lowering your risk of heart disease and of having a stroke) might outweigh the side effect (the coughing). But many people with high blood pressure don't feel ill. It can be harder to put up with side effects from drugs when you don't feel ill. For example, if you feel well but your tablets make you dizzy, you may not want to put up with that side effect. But if you have a chest infection you may put up with diarrhea that's caused by the antibiotics you're taking. You should talk to your doctor before you stop taking any medicine. Sometimes another treatment may work just as well and have fewer side effects.
How big the benefit may be: Treatments don't always cure you. You may decide that it's not worth taking a drug because the possible benefit is not big enough. You need to make sure you fully understand what the benefit of a treatment is before you stop it. If you have high blood pressure, you may think the tablets you take every day are a waste of time. But if you stop taking them, you may increase your risk of having a stroke or a heart attack.
Your age: If you are 40 and your hip always hurts because of osteoarthritis, you may want to weigh up the benefits and risks of having your hip replaced. If you have a hip replacement your pain will go away and you'll be able to get around better. You won't have to take painkillers all the time. But your artificial hip may need replacing after 10 years to 20 years, as it may wear out. You also have to weigh up the risks of the operation.
Your sexual activity: You may decide that side effects that interfere with your ability to have sex are especially worrying to you. If so, be sure you ask your doctor about any sexual side effects from treatment. If you are a man, you may find that some medicines interfere with your erections. You may also run the risk of erection problems or incontinence after some operations, such as surgery for prostate cancer. (Incontinence is the term doctors use when a person can't always control when they urinate.) Your doctor should be able to talk freely about sexual issues with you. You certainly have the right to discuss them.

Do I know enough to make a decision?

To make well-informed decisions about benefits and risks, you need reliable information about how likely it is that a benefit or a side effect will happen to you.

If your doctor makes vague statements like, "The risks of this operation are small," then you probably need more information. Is there a 1 in 100 chance the surgery will cause a stroke or a 1 in 1000 chance? What your doctor considers a small and acceptable risk may be unacceptable to you.

The way statistics like these are described to you can make a difference to how you feel about them. If you are told that a treatment will cut your risk of having a stroke by 50 percent (what doctors call a reduction in relative risk) this may sound great to you. But if this 50 percent reduction actually cuts your risk of having a stroke over the next five years from 2 percent to 1 percent (a reduction in absolute risk), then that doesn't sound quite so great.

Similarly, hearing that using a drug doubles your risk of developing leukemia in 20 years may sound scary. But if your risk of getting leukemia is small to start with (say, a 2 in 100,000 chance), then even if the risk is doubled, it is still very small (4 in 100,000). However, if you are worried about any risk of getting leukemia, even this risk may be too high for you.

How can I make a decision?

Let's look at an example. Say you are a 50-year-old woman and you find a lump in your breast. The lump is about the size of a cherry.

Your mammogram (an X-ray of your breast) shows that something isn't normal. You have a needle biopsy (in which a thin needle is inserted into your lump to remove some cells). The biopsy shows that you have breast cancer.

When deciding on treatment, here are some of the questions you might ask.

What will happen if I don't have treatment?
There are only a few studies that show what happens if you don't have treatment for breast cancer. It would not be ethical for a doctor to do nothing for a woman with breast cancer because there is enough evidence to suggest that her cancer will get bigger.

What are my choices for treatment?
The main options for treatment are to remove the breast or to remove the cancer and leave most of the normal breast tissue behind. Removing the breast is called a mastectomy. The other type of surgery is called breast-conserving surgery.

After surgery, there are other treatment choices to consider depending on whether your breast cancer has spread to the lymph nodes in your armpit. Also, if you have breast-conserving surgery, you may need radiotherapy afterwards.

What are the risks and benefits of each treatment?
Is removing the whole breast a more effective way of getting rid of all of your cancer than just removing the lump? It's not an easy question to answer, and it can depend on the individual. All types of surgery also carry a risk of complications. So how big is this risk, and what are the possible complications?

The team treating you will be able to give you answers to these questions. But the treatment you choose will not just be based on statistics, evidence, and what is right for other people.

How do the risks and benefits balance out for me?
The treatment you choose for breast cancer will be about your own values - how you feel about surgery and about your body, and how much treatment you are prepared to have. You will probably be interested in the risks and benefits as they affect most people. But you will be making a choice that affects you.

You can talk with your doctor and specialist nurse about the operation. You may also want to talk with other women who have had operations for breast cancer. They may help you make up your mind.

Related BMJ Blogs

Is balancing risk the most important skill in clinical medicine?

References

Arora NK. McHorney CA Patient preferences for medical decision making: who really wants to participate? Medical Care. 38(3):335-41, 2000
Deber RB, Kraetschmer N, Irvine J. What role do patients wish to play in treatment decision making? Archives of Internal Medicine. 1996; 156: 1414-1420.