1. Introduction Patients with cancer face difficult treatment decisions during the course of their disease. Time may play an important role in the quality of cancer care and specifically, in decision-making regarding cancer treatment. Patients report a lack of time to gather, process, and reflect on information during consultations (1). Similarly, oncologists and other clinicians treating cancer often report a lack of time as one of the main barriers to optimal patient participation in their treatment decision-making (2-4). Yet, little is known about how patients, decision partners, and clinicians envision time could be spent most effectively for patients with cancer to participate in treatment decision-making, in what ways practice deviates from this ideal, and which strategies can be applied to overcome time-related barriers to patient participation in decision-making. To the best of our knowledge, no review has investigated the role of time in the participation of patients with cancer in their treatment decision-making. 2. Objective The objective of the present scoping review is to 1) describe the role of time in the participation of patients in their treatment decision-making and 2) identify strategies to overcome time-related barriers to patient participation in cancer treatment decision-making. 3. Research questions RQ1: What is reported in the literature about the experiences and views of patients, decision partners, and clinicians on the current and preferred use of time in the process of involving patients in cancer treatment decision-making? RQ2: What is reported in the literature about the association between the use of time for any decision-related activity and patient participation in cancer treatment decision-making? RQ3: Which strategies are reported in the literature to overcome time-related barriers to patient participation in cancer treatment decision-making, and what are their (expected) effects? 4. Methods 4.1 Search strategy We will use a two-step search strategy. As a first step, an initial search strategy is developed by the information specialist (RO) together with the primary investigator (THW) in one database (PubMed) to identify quantitative and qualitative publications relating to the role of time in cancer patients’ participation in treatment decision-making, and strategies to resolve time-related barriers. This initial search is then followed by an analysis of the text words contained in the title and abstract of retrieved papers and of the index terms used to describe the articles. The new search/index terms are added to the search strategy in PubMed. As a second step, after the search strategy in PubMed is judged adequate, it is translated into the search strategies for the other databases (Embase, Cochrane, Emcare, CINAHL, PsycINFO, Web of Science). During this (iterative) process any new relevant search terms that are found in new databases are added to the search strategies of all previous databases. In the case that we are unable to retrieve the full-text publication, we will request these from the authors. 4.2 Eligibility criteria 4.2.1 Types of participants To be eligible, participants should be adult patients (≥18 years) who have been diagnosed with cancer, decision partners of adults who have been diagnosed with cancer, and/or any healthcare professional having responsibility for the cancer treatment in adult patients. We define a decision partner as “a person from the personal environment of a cancer patient who has been or is currently involved in making a treatment decision with the patient” (e.g., a partner, family member, or friend). Publications will be included if results are presented for a (sub)group that exists only of participants that fulfill the above-mentioned criteria. Publications will be excluded if results are presented only for (sub)groups that contain both participants that fulfill the above-mentioned criteria (under “types of participants”) and participants that do not fulfill these criteria. 4.2.2 Concept Reports should be focused on one or more of the following concepts: • Explicit experiences and views of patients, decision partners, and clinicians (or authors in the case of opinion papers) about the current and/or preferred use of time for involving patients in the process of cancer treatment decision-making. We refer to the beginning of the decision-making process as the moment when at least the patient (or surrogate decision-maker, if applicable), clinician, or both become aware that a decision needs to be made and the end of the decision-making process as the moment when a final decision was made. Importantly, we regard a decision to be final when the time to reconsider the decision is over. Therefore, most commonly, we are interested in the (current or preferred) use of time within the interval between receiving the diagnosis and the start of the treatment. Thus, this time use can be both within the encounter (e.g., time to get to know the treatment options and time to discuss patient preferences) and outside of the encounter (e.g., time to discuss the options with family and/or friends and time to search for and going through information about the treatment options). • The explicit association between the use of time for any decision-related activity and the extent of patient participation in cancer treatment decision-making. • Concrete strategies to overcome time-related barriers to patient participation in cancer treatment decision-making and their (expected) effects (e.g., decision aids, communication training, or adjustments to protocol or guidelines). All publications that describe a study (including (systematic) reviews and meta-analyses) should present a new/original analysis of the association between time and the involvement of patients in treatment decision-making, or of the effect of time on the involvement of patients in treatment decision-making. We will only include publications that report on actual or experienced participation in cancer treatment decision making. Therefore, we will exclude publications that exclusively report on preferred participation in decision making or current participation in decision making relative to preferred participation in decision making. 4.2.3 Context The context of our interest is decision-making about the initiation of or change to, a new cancer treatment (end-of-life decisions are not eligible). For the process of treatment decision-making to be eligible, the healthcare professional should play an active role (e.g., it should not be about decision-making processes between patients and informal caregivers). Furthermore, the decision should be about a current patient situation. It should not be about an anticipated decision for a situation that might take place in the future (e.g., in the case of advanced care planning or do-not-resuscitate decisions). We will also exclude decisions that are exclusively about complementary or alternative medicine. To be eligible, a study about clinical trials is only eligible if the clinical trial is presented as one of the treatment options. Furthermore, a study is only eligible if treatment decision-making is explicitly described (e.g., a study about information provision that implicitly seems to be used for treatment decision-making, is not eligible). 4.2.4 Types of evidence sources We will include any peer-reviewed report of original qualitative or quantitative research (regardless of study design). Reports of (systematic) reviews, meta-analyses, case studies, and opinion papers will also be included. As reports need to be peer-reviewed, we will exclude editorials, letters, and correspondences. We will include opinion papers/viewpoints and commentaries as we expect these to be often peer-reviewed. There will be no restrictions regarding language or time of publication. Reports that are written in languages other than English or Dutch will not be included in the analyses but will be listed in the appendix of our final scoping review report. Protocols, guidelines, conference abstracts, non-peer-reviewed publications (e.g., blogs, letters, and websites), and other grey literature will be excluded for the following reasons: • Study protocols: These do not contain new data. • Guidelines: These would usually describe the (recommended) use of actual time, and none of our concepts of interest. Therefore, guidelines do not answer any of our research questions. • Conference abstracts: contain often not enough detail to interpret the findings. • Non-peer-reviewed publications and other grey literature: opinions described have not gone through at least a basic assessment of their sense-making, relevance, or worth to others than the authors. • Dissertations, theses, and (chapters of) books. In the title/abstract screening phase, we will include publications that have no abstract. 4.2.5. Exclusion of intervention studies We will exclude intervention studies as we are interested in the barriers and facilitators related to time for patient participation in treatment decision making in routine care. 4.3 Study selection Varying pairs of independent assessors will screen titles/abstracts. In the case of disagreement between two assessors, the full-text publications will be screened. Next, varying pairs of independent assessors will assess the eligibility of full-text versions of the publications retrieved. If two assessors disagree about inclusion/exclusion or about the reason for exclusion in the full-text screening phase, then a third assessor will arbitrate. We will pilot test the title/abstract screening with 20 publications. The entire review team will calibrate these 20 publications using the eligibility criteria. The review team will discuss discrepancies and modify eligibility criteria if needed. We will start title/abstract screening when all assessors agree on at least 15 articles (75%). The full-text screening will be pilot tested with 10 publications, that will be screened by the entire review team. Again, the review team will discuss discrepancies and modify eligibility criteria if needed. We will start the full-text screening when all assessors agree that the criteria are clear enough and calibration is sufficient to start the full-text screening. We will use Microsoft Excel to document both the title/abstract screening and the full-text screening. 4.4 Data extraction All extractors will pilot test a data extraction form with three articles (one qualitative study, one quantitative study, and one other type of publication, such as an opinion paper/viewpoint). Based on the results, the data extraction form will be refined and adjusted as needed. Subsequently, relevant data from the remaining publications will be extracted. Here, two extractors will independently extract the data. Disagreement about data extraction will be resolved by discussion. If discussion does not lead to consensus, then a third person will arbitrate. 4.5 Outcomes • Experiences and views of patients, decision partners, and clinicians about the current and preferred use of time in the process of cancer treatment decision-making (RQ1). • The observer-reported, patient-reported, decision-partner-reported, or clinician-reported (opinion about or view on) participation of patients with cancer in their treatment decision-making (RQ2). • Strategies to overcome time-related barriers to patient participation in cancer treatment decision-making, and the observer-reported, patient-reported, decision-partner-reported, or physician-reported (opinion about or view on) participation of patients with cancer in their treatment decision-making (RQ3). 4.6 Analyses We will use thematic analyses to analyze both the quantitative and qualitative data. One person will code and analyze the data and a second person will check the coding and analysis. 4.7 Expected results The extraction will result in an overview of: • Patients’, decision partners’, and physicians’ experiences of time use for patient participation in cancer patient decision making. • Patients’, decision partners’, and physicians’ preferred time use for patient participation in cancer treatment decision making. • Associations between the use of time for any decision-related activity and patient participation in cancer treatment decision-making. • Concrete strategies to resolve time-related barriers to patient participation in cancer treatment decision-making. • Effects of concrete strategies to resolve time-related barriers to patient participation in cancer treatment decision-making. References 1. Joseph-Williams, N., Elwyn, G., and Edwards, A. (2014) Knowledge is not power for patients: a systematic review and thematic synthesis of patient-reported barriers and facilitators to shared decision making. Patient Educ Couns 94, 291-309 2. Frerichs, W., Hahlweg, P., Muller, E., Adis, C., and Scholl, I. (2016) Shared Decision-Making in Oncology - A Qualitative Analysis of Healthcare Providers' Views on Current Practice. PLoS One 11, e0149789 3. Mokhles, S., Maat, A., Aerts, J., Nuyttens, J., Bogers, A., and Takkenberg, J. J. M. (2017) Opinions of lung cancer clinicians on shared decision making in early-stage non-small-cell lung cancer. Interact Cardiovasc Thorac Surg 25, 278-284 4. Politi, M. C., Studts, J. L., and Hayslip, J. W. (2012) Shared decision making in oncology practice: what do oncologists need to know? Oncologist 17, 91-100