An informed decision? Breast cancer patients and their knowledge about treatment

Surgeon recommendations and receipt of mastectomy for treatment of breast cancer

CONTEXT

There is concern that mastectomy is overused in the United States.

OBJECTIVES

To evaluate the association of patient-reported initial recommendations by surgeons and those given when a second opinion was sought with receipt of initial mastectomy; and to assess the use of mastectomy after attempted breast-conserving surgery (BCS).

DESIGN, SETTING, AND PATIENTS

A survey of women aged 20 to 79 years with intraductal or stage I and II breast cancer diagnosed between June 2005 and February 2007 and reported to the National Cancer Institute's Surveillance, Epidemiology, and End Results registries for the metropolitan areas of Los Angeles, California, and Detroit, Michigan. Patients were identified using rapid case ascertainment, and Latinas and blacks were oversampled. Of 3133 patients sent surveys, 2290 responded (73.1%). A mailed survey was completed by 96.5% of respondents and 3.5% completed a telephone survey. The final sample included 1984 female patients (502 Latinas, 529 blacks, and 953 non-Hispanic white or other).

MAIN OUTCOME MEASURES

The rate of initial mastectomy and the perceived reason for its use (surgeon recommendation, patient driven, medical contraindication) and the rate of mastectomy after attempted BCS.

RESULTS

Of the 1984 patients, 1468 had BCS as an initial surgical therapy (75.4%) and 460 had initial mastectomy, including 13.4% following surgeon recommendation and 8.8% based on patient preference. Approximately 20% of patients (n = 378) sought a second opinion; this was more common for those patients advised by their initial surgeon to undergo mastectomy (33.4%) than for those advised to have BCS (15.6%) or for those not receiving a recommendation for one procedure over another (21.2%) (P < .001). Discordance in treatment recommendations between surgeons occurred in 12.1% (n = 43) of second opinions and did not differ on the basis of patient race/ethnicity, education, or geographic site. Among the 1459 women for whom BCS was attempted, additional surgery was required in 37.9% of patients, including 358 with reexcision (26.0%) and 167 with mastectomy (11.9%). Mastectomy was most common in patients with stage II cancer (P < .001).

CONCLUSION

Breast-conserving surgery was recommended by surgeons and attempted in the majority of patients evaluated, with surgeon recommendation, patient decision, and failure of BCS all contributing to the mastectomy rate.

Underuse of breast cancer adjuvant treatment: patient knowledge, beliefs, and medical mistrust

PURPOSE

Little is known about why women with breast cancer who have surgery do not receive proven effective postsurgical adjuvant treatments.

METHODS

We surveyed 258 women who recently underwent surgical treatment at six New York City hospitals for early-stage breast cancer about their care, knowledge, and beliefs about breast cancer and its treatment. As per national guidelines, all women should have received adjuvant treatment. Adjuvant treatment data were obtained from inpatient and outpatient charts. Factor analysis was used to create scales scored to 100 of treatment beliefs and knowledge, medical mistrust, and physician communication about treatment. Bivariate and multivariate analyses assessed differences between treated and untreated women.

RESULTS

Compared with treated women, untreated women were less likely to know that adjuvant therapies increase survival (on a 100-point scale; 66 v 75; P < .0001), had greater mistrust (64 v 53; P = .001), and had less self-efficacy (92 v 97; P < .05); physician communication about treatment did not affect patient knowledge of treatment benefits (r = 0.8; P = .21). Multivariate analysis found that untreated women were more likely to be 70 years or older (adjusted relative risk [aRR], 1.11; 95% CI, 1.00 to 1.13), to have comorbidities (aRR, 1.10; 95% CI, 1.04 to 1.12), and to express mistrust in the medical delivery system (aRR, 1.003; 95% CI, 1.00 to 1.007), even though they were more likely to believe adjuvant treatments were beneficial (aRR, 0.99; 95% CI, 0.98 to 0.99; model c, 0.84; P < or = .0001).

CONCLUSION

Patient knowledge and beliefs about treatment and medical mistrust are mutable factors associated with underuse of effective adjuvant therapies. Physicians may improve cancer care by ensuring that discussions about adjuvant therapy include a clear presentation of the benefits, not just the risks of treatment, and by addressing patient trust in and concerns about the medical system.

Percutaneous needle biopsy for breast diagnosis: how do surgeons decide?

BACKGROUND

Despite the advent of guidelines recommending core needle biopsy (CNB) for diagnosis of breast abnormalities, it is underused in some jurisdictions. We sought to determine those factors influencing surgeons' choices of breast biopsy techniques.

METHODS

We surveyed 385 general surgeons in Ontario to first determine factors influencing the choice of fine-needle aspiration biopsy (FNAB), CNB, both or neither for diagnosis of breast abnormalities in six clinical scenarios with varying risk of malignancy. Second, respondents were asked to rate 15 patient, organizational, and system factors for their impact on choice of biopsy technique. Third, surgeons were asked to describe their three greatest barriers to provision of cancer care.

RESULTS

Response rate was 44%, and 126 provided answers to the survey questions. When there was a high risk of malignancy, CNB and/or FNAB were favored over surgical biopsy (83% to 97% compared with 41% for presumed benign lesions), and CNB was preferred for percutaneous biopsy over FNAB (58% to 79% compared with 1% to 18%). Patient and clinical factors (46% FNAB, 42% CNB), patient preference for biopsy technique (34%, 31%), and delayed access to CNB, rather than lack of equipment (11% FNAB, 8% CNB) or expertise for CNB or FNAB (15%, 12%), had the greatest reported impact on choice of biopsy technique.

CONCLUSIONS

Surgeon preference for CNB is higher than actual use. Further research is needed to establish whether or how CNB use could be improved by support for shared decision making or facilitating access.

Can Women With Early-Stage Breast Cancer Make an Informed Decision for Mastectomy?

Purpose

The purpose of this study was to measure the degree to which informed women chose mastectomy, and to reveal their reasons for this choice.

Patients and Methods

This was a prospective cohort study of patients radiographically and pathologically eligible for either mastectomy or breast-conserving surgery (BCS; n = 125). Participants completed questionnaires at three time points: baseline, after viewing a decision aid, and after a surgical consultation. Questionnaires assessed clinical history, preference for participation in decision making, information comprehension, values, decisional conflict, and preferred treatment.

Results

Of 125 participants, 44 (35%) chose mastectomy. Most understood that BCS and mastectomy offer an equivalent survival benefit (98%) and that BCS has a slightly higher local recurrence risk (63%); most accurately identified the magnitude of ipsilateral local recurrence risk (91%). Values assigned to three treatment attributes/outcomes (“remove breast for peace of mind,” “avoid radiation,” and “keep breast”) clearly discriminated between patients choosing mastectomy or BCS. High decisional conflict scores improved after both the decision aid and surgical consultation.

Conclusion

Although conventional wisdom may view BCS as the preferred treatment, a notable proportion of well informed women choose mastectomy. Whereas prior studies have linked objective factors to treatment choice, this study reveals subjective preferences that underlie decision making. The systematic use of a decision aid before the surgical consultation may help women make informed, values-based decisions, while clearly reducing decisional conflict.

Latina patient perspectives about informed treatment decision making for breast cancer

OBJECTIVE

To evaluate Latina breast cancer patient perspectives regarding informed decision making related to surgical treatment decision making for breast cancer.

METHODS

2030 women with non-metastatic breast cancer diagnosed from 8/05 to 5/06 and reported to the Los Angeles metropolitan SEER registries were mailed a survey shortly after surgical treatment. Latina and African-American women were over-sampled. We conducted regression of four decision outcome to evaluate associations between race/ethnicity, demographic and clinical factors, and mechanistic variables (i.e., health literacy) and decision outcomes.

RESULTS

Our analytic sample was 877 women: 24.5% Latina-Spanish speaking (Latina-SP), 20.5% Latina-English speaking, 24% African-American and 26.6% Caucasian. Approximately 28% of women in each ethnic group reported a surgeon-based, 36% a shared, and 36% a patient-based surgery decision. Spanish-preferent Latina women had the greatest odds of high decision dissatisfaction and regret controlling for other factors (OR 5.5, 95% CI: 2.9, 10.5 and OR 4.1, 95% CI: 2.2, 8.0, respectively). Low health literacy was independently associated with dissatisfaction and regret (OR 5.6, 95% CI: 2.9, 11.1 and OR 3.5, 95% CI 1.8, 7.1, respectively) and slightly attenuated associations between Latina-SP ethnicity and decision outcomes.

CONCLUSION

Despite similar clinical outcomes, patients report very different experiences with treatment decision making. Latina women, especially those who prefer Spanish, are vulnerable to poor breast cancer treatment decision outcomes.

PRACTICE IMPLICATIONS

Providers need to be aware of the role of ethnicity, acculturation and literacy in breast cancer treatment discussions.

Racial/ethnic disparities in knowledge about risks and benefits of breast cancer treatment: does it matter where you go?

OBJECTIVE

To evaluate the association between provider characteristics and treatment location and racial/ethnic minority patients' knowledge of breast cancer treatment risks and benefits.

DATA SOURCES/DATA COLLECTION

Survey responses and clinical data from breast cancer patients of Detroit and Los Angeles SEER registries were merged with surgeon survey responses (N=1,132 patients, 277 surgeons).

STUDY DESIGN

Cross-sectional survey. Multivariable regression was used to identify associations between patient, surgeon, and treatment setting factors and accurate knowledge of the survival benefit and recurrence risk related to mastectomy and breast conserving surgery with radiation.

PRINCIPAL FINDINGS

Half (51 percent) of respondents had survival knowledge, while close to half (47.6 percent) were uncertain regarding recurrence knowledge. Minority patients and those with lower education were less likely to have adequate survival knowledge and more likely to be uncertain regarding recurrence risk than their counterparts (p<.001). Neither surgeon characteristics nor treatment location attenuated racial/ethnic knowledge disparities. Patient-physician communication was significantly (p<.001) associated with both types of knowledge, but did not influence racial/ethnic differences in knowledge.

CONCLUSIONS

Interventions to improve patient understanding of the benefits and risks of breast cancer treatments are needed across surgeons and treatment setting, particularly for racial/ethnic minority women with breast cancer.

Correlates of patient satisfaction and provider trust after breast-conserving surgery

BACKGROUND

Although breast-conserving therapy (BCS) is considered the standard of care for early-stage breast cancer, up to 20% of patients are dissatisfied. The effect of treatment-related factors on patient satisfaction with their healthcare experiences is unclear.

METHODS

All BCS patients at the University of Michigan Medical Center who were treated between January 2002 and May 2006 were surveyed (n=714; response rate, 79.5%). Patients were queried regarding 4 aspects of their decision for surgery: satisfaction with the decision, decision regret, decisional conflict, and trust in surgeons. Independent variables included the number of re-excisions, the occurrence of postoperative complications, and postoperative breast appearance, which was assessed by using the Breast Cancer Treatment and Outcomes scale. Multiple logistic regression was used to assess the effect of the independent variables on each outcome controlling for demographic and clinical characteristics.

RESULTS

Breast asymmetry after BCS was correlated significantly with patient satisfaction with their treatment experiences and patient distrust in surgeons. Women who reported pronounced asymmetry were significantly less likely to be satisfied with the decision for surgery compared with women who reported minimal asymmetry (odds ratio [OR], 0.43; 95% confidence interval [95% CI], 0.21-0.89). Women with pronounced asymmetry were less likely to be certain about their surgical decision (OR, 0.36; 95% CI, 0.21-0.60) and to believe that they were prepared to make the decision for surgery (OR, 0.25; 95% CI, 0.14-0.43). Increasing breast asymmetry was associated with higher surgeon distrust scores (2.14 vs 2.30 vs 2.35; P= .04) and with the occurrence of postoperative complications (distrust score: 2.23 vs 2.35; P= .03). Reoperation after BCS was not associated with patient satisfaction or trust in providers.

CONCLUSIONS

Esthetic result after BCS was associated more profoundly with aspects of satisfaction than either surgical therapy or the occurrence of postoperative complications. The current findings indicated that surgeons who care for patients with breast cancer should identify the women at an increased risk for breast asymmetry preoperatively to effectively address their expectations of treatment outcomes.

Conflicts in decision-making for breast cancer surgery

BACKGROUND

Little is known about the interaction among surgeons, patients, and other physicians in selecting breast cancer surgery.

METHODS

We contacted attending surgeons (n = 456) of a population-based sample of 2645 breast cancer patients diagnosed in Detroit and Los Angeles from December 2001 to January 2003. Eighty percent completed a written survey with clinical scenarios.

RESULTS

The mean surgeon age was 50 years, 50% practiced in a community hospital, and breast cancer averaged 31% of practice volume. The mean number of years in practice was 17.2. Female surgeons made up 14.4% of the sample and 35% of the high-volume surgeons. Conflict with patients and other providers was reported by 58% and 32% of surgeons, respectively. When the patient preferred mastectomy and the surgeon favored BCS, conflict was reported by 49.9% of surgeons. Compared with low-volume surgeons, high-volume surgeons were significantly more likely to report conflict in this scenario (44% vs 62%; P = .047). When another provider preferred mastectomy and the respondent surgeon favored BCS, conflict was reported by 34% of surgeons and was more common for high-volume surgeons (P < .001). In a logistic regression model, surgeon volume and practice setting were strongly associated with conflict in this scenario.

CONCLUSION

High-volume surgeons and those in cancer centers more frequently endorse current clinical guidelines that favor BCS over mastectomy, resulting in greater conflict with patients. These findings support patient reports that patient choice is a key factor in continued mastectomy use.

From Policy To Patients And Back: Surgical Treatment Decision Making For Patients With Breast Cancer

Persistent use of mastectomy for breast cancer has motivated concerns about overtreatment by surgeons and lack of patient involvement in decisions. However, recent studies suggest that patients perceive substantial involvement and that some patients prefer more invasive surgery, while other research suggests that surgical treatment choices might be poorly informed. Decision-making quality can be improved by increasing patients' knowledge about treatments' risks and benefits and by optimizing their involvement. The mastectomy story underscores the limitations of utilization measures as quality indicators. Strategies to improve patient outcomes should focus on tools to improve the quality of decision making and innovations in multispecialty practice.

Decision Aids and Breast Cancer: Do They Influence Choice for Surgery and Knowledge of Treatment Options?

Purpose

To describe the effect of decision aids on the choice for surgery and knowledge of surgical therapy among women with early-stage breast cancer.

Methods

A systematic review was conducted between years 1966 to 2006 of all studies designed to assess the effect of decision aids on surgical therapy. MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health (CINAHL), the Cochrane Network, HAPI databases, and bibliographies were searched. Of the 123 studies screened, 11 studies met criteria. Meta-analyses were performed to assess the pooled relative risk for surgical choice and the pooled mean difference in patient knowledge.

Results

Results from randomized controlled trials indicated that women who used a decision aid were 25% more likely to choose breast-conserving surgery over mastectomy (risk ratio, 1.25; 95% CI, 1.11 to 1.40). Decision aids significantly increased patient knowledge by 24% (P = .024). The data also suggested that decision aids decreased decisional conflict and increased satisfaction with the decision-making process. Decision aids were well received by surgeons and patients, facilitated patients’ desire for shared decision making, and were feasible to implement into practice.

Conclusion

Decision aids are important adjuncts for counseling women with early-stage breast cancer. Their use increases the likelihood that women will choose breast-conserving surgery, and enhances patient knowledge of treatment options.

Factors associated with patient involvement in surgical treatment decision making for breast cancer

OBJECTIVE

To evaluate factors associated with women's reported level of involvement in breast cancer surgical treatment decision making, and the factors associated with the match between actual and preferred involvement in this decision.

METHODS

Survey data from breast cancer patients in Detroit and Los Angeles was merged with surgeon data for an analytic dataset of 1101 patients and 277 surgeons. Decisional involvement and the match between actual and preferred amount of involvement were analyzed as three-level dependent variables using multinomial logistic regression controlling for clustering within surgeons. Independent variables included patient demographic and clinical factors, surgeon demographic and practice factors, cancer program designation, and two measures of patient-surgeon communication.

RESULTS

We found variation in women's actual decisional involvement and match between actual and preferred involvement. Women with a surgeon-based or patient-based (versus shared) decision were significantly (p < or = 0.05) younger. Women who had too little decisional involvement (versus the right amount) were younger, while women with too much involvement had less education. Patient-surgeon communication variables were significantly associated with both involvement and match, and higher surgeon volume as associated with too little involvement.

CONCLUSION

Patient factors and patient-surgeon communication influence women's perception of their involvement in breast cancer surgical treatment decision making.

PRACTICE IMPLICATIONS

Decision tools are needed across surgeons and practice settings to elicit patients' preferences for involvement in treatment decisions for breast cancer.