Aging a Decade in a Day: Age Cutoff Bias in Adjuvant Therapy Allocation for Early-Stage Breast Cancer.

PURPOSE: Physicians may expedite interpretation of data presented as a continuous variable by binning the data into "high" and "low" subgroups (cutoff heuristic). Use of this cognitive shortcut with age may lead to fewer nuanced or inappropriate decisions. We hypothesized an age cutoff heuristic may lead to non-evidence-based adjuvant treatment allocation among patients with early-stage breast cancer. METHODS AND MATERIALS: Two cohorts with strong indications for adjuvant treatment regardless of age that underwent lumpectomy for early-stage breast cancer between 2004 and 2017 were identified in the National Cancer Database. Cohort 1 had higher-risk features (estrogen receptor negative, endocrine therapy not planned, final margins positive, or size >3 cm; n = 160,990) and was appropriate for radiation. Cohort 2 had hormone receptor positivity with tumors >5 mm (n = 394,946) and was appropriate for endocrine therapy. Multivariable logistic regressions with odds ratios (ORs) and 99.8% confidence intervals (CIs) were performed to determine whether any single year-over-year age difference was independently associated with a difference in likelihood of adjuvant therapy recommendation. RESULTS: In cohort 1, radiation recommendation decreased sharply at age 70, ranging from 90% to 92% between the ages of 50 and 69 years to 81% for those aged 70 years. Multivariable logistic regressions showed year-over-year age difference was an independent predictor for adjuvant radiation recommendation at only age 70 versus 69 (OR, 0.47; CI, 0.39-0.57; P < .001). For cohort 2, endocrine therapy recommendation showed a small decline at age 70, and year-over-year age difference was a predictor of endocrine therapy recommendation at only age 70 versus 69 (OR, 0.86; CI, 0.74-0.99; P = .001). CONCLUSIONS: We observed a unique decline in appropriate adjuvant therapy recommendation between ages 69 and 70. This suggests use of an age cutoff heuristic to process patient age in this population as a categorical, binary variable. This is a previously undescribed phenomenon in early-stage breast cancer.

Do Conflict of Interest Disclosures Facilitate Public Trust?

Lab experiments disagree on the efficacy of disclosure as a remedy to conflicts of interest (COIs). Some experiments suggest that disclosure has perverse effects, although others suggest these are mitigated by real-world factors (eg, feedback, sanctions, norms). This article argues that experiments reporting positive effects of disclosure often lack external validity: disclosure works best in lab experiments that make it unrealistically clear that the one disclosing is intentionally lying. We argue that even disclosed COIs remain dangerous in settings such as medicine where bias is often unintentional rather than the result of intentional corruption, and we conclude that disclosure might not be the panacea many seem to take it to be.

Tainted altruism: when doing some good is evaluated as worse than doing no good at all.

In four experiments, we found that the presence of self-interest in the charitable domain was seen as tainting: People evaluated efforts that realized both charitable and personal benefits as worse than analogous behaviors that produced no charitable benefit. This tainted-altruism effect was observed in a variety of contexts and extended to both moral evaluations of other agents and participants' own behavioral intentions (e.g., reported willingness to hire someone or purchase a company's products). This effect did not seem to be driven by expectations that profits would be realized at the direct cost of charitable benefits, or the explicit use of charity as a means to an end. Rather, we found that it was related to the accessibility of different counterfactuals: When someone was charitable for self-interested reasons, people considered his or her behavior in the absence of self-interest, ultimately concluding that the person did not behave as altruistically as he or she could have. However, when someone was only selfish, people did not spontaneously consider whether the person could have been more altruistic.

The burden of disclosure: increased compliance with distrusted advice.

Professionals often face conflicts of interest that give them an incentive to provide biased advice, and disclosure (informing advisees about the conflict) is frequently proposed as a solution to the problem. We present 6 experiments that reveal a previously unrecognized perverse effect of disclosure: Although disclosure can decrease advisees' trust in the advice, it can also increase pressure to comply with that advice if advisees feel obliged to satisfy their advisors' personal interests. Hence, disclosure can burden those it is ostensibly intended to protect. Beyond demonstrating the effect, we show that this increased pressure to comply with advice is reduced if (a) the disclosure is provided by an external source rather than from the advisor, (b) the disclosure is not common knowledge between the advisor and advisee, (c) the advisee has an opportunity to change his/her mind later, or (d) the advisee is able to make the decision in private.