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Laterality and Patient-Reported Outcomes following Autologous Breast Reconstruction with Free Abdominal Tissue: An 8-Year Examination of BREAST-Q Data. Plast Reconstr Surg 2020; 146:964-975. [PMID: 33141527 DOI: 10.1097/prs.0000000000007239] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Despite the rise in rates of contralateral prophylactic mastectomy, few studies have used patient-reported outcomes to assess satisfaction between unilateral and bilateral breast reconstruction with autologous tissue. The purpose of this study was to investigate patient satisfaction and quality of life following autologous reconstruction to determine whether differences exist between unilateral and bilateral reconstructions to better guide clinical decision-making. METHODS The current study examined prospectively collected BREAST-Q results following abdominal free flap breast reconstruction procedures performed at a tertiary academic medical center from 2009 to 2017. The reconstruction module of the BREAST-Q was used to assess outcomes between laterality groups (unilateral versus bilateral) at 1 year, 2 years, 3 years, and more than 3 years. RESULTS Overall, 405 patients who underwent autologous breast reconstruction completed the BREAST-Q. Cross-sectional analysis at 1 year, 2 years, and 3 years revealed similar satisfaction scores between groups; however, bilateral reconstruction patients demonstrated higher satisfaction scores at more than 3 years (p = 0.04). Bilateral reconstruction patients reported lower scores of abdominal well-being at 1 year, 2 years, and more than 3 years (p = 0.01, p = 0.03, and p = 0.01, respectively). CONCLUSIONS These results suggest that satisfaction with breasts does not differ with the laterality of the autologous reconstruction up to 3 years postoperatively but may diverge thereafter. Bilateral reconstruction patients, however, have lower satisfaction with the abdominal donor site. These data can be used in preoperative counseling, informed consent, and expectations management in patients considering contralateral prophylactic mastectomy.
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Bell RJ. Ringing the bell and then falling off a cliff … life after cancer. Climacteric 2019; 22:533-534. [PMID: 31612747 DOI: 10.1080/13697137.2019.1576456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Developing a patient decision aid for women aged 70 and older with early stage, estrogen receptor positive, HER2 negative, breast cancer. J Geriatr Oncol 2019; 10:980-986. [PMID: 31130442 DOI: 10.1016/j.jgo.2019.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/16/2019] [Accepted: 05/03/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Since women ≥70 years with early stage, estrogen receptor positive (ER+), HER2 negative breast cancer face several preference-sensitive treatment decisions, the investigative team aimed to develop a pamphlet decision aid (DA) for such women. MATERIALS AND METHODS The content of the DA was informed by literature review, international criteria, and expert feedback, and includes information on benefits and risks of lumpectomy versus mastectomy, lymph node surgery, radiotherapy after lumpectomy, and endocrine therapy. It considers women's overall health and was written using low literacy principles. Women from two Boston-based hospitals who were diagnosed in the past 6-24 months were recruited to provide feedback on the DA and its acceptability. The DA was iteratively revised based on their qualitative input. RESULTS Of 48 eligible women contacted, 35 (73%) agreed to participate. Their mean age was 74.3 years; 33 (94%) were non-Hispanic white; and 24 (67%) were college graduates. Overall, 26 (74%) thought the length of the DA was just right, 29 (83%) thought all or most of the information was clear, 32 (91%) found the DA helpful, and 33 (94%) would recommend it. In open ended comments, participants noted that the DA was clear, well-organized, and would help women prepare for and participate in treatment decision-making. CONCLUSIONS The investigative team developed a novel breast cancer treatment DA that is acceptable to women ≥70 years with a history of ER+, HER2-, early stage breast cancer. Next, the DA's efficacy needs to be tested with diverse older women newly diagnosed with breast cancer.
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An Evaluation of the Choice for Contralateral Prophylactic Mastectomy and Patient Concerns About Recurrence in a Reconstructed Cohort. Ann Plast Surg 2019; 80:333-338. [PMID: 29166308 DOI: 10.1097/sap.0000000000001258] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Rising contralateral prophylactic mastectomy rates are a subject of national concern. This study assessed (1) factors critical to patients when deciding on contralateral prophylactic mastectomy and (2) patients' quality of life related to concerns about recurrence after unilateral or bilateral breast reconstruction. METHODS Patients with stage 0 to III breast cancer who underwent unilateral mastectomy or contralateral prophylactic mastectomy and breast reconstruction at a single institution between 2000 and 2012 were identified. Demographic and clinical data were extracted by chart review. Women's fears about breast cancer recurrence were assessed using the Concerns About Recurrence Scale, and motivational factors for contralateral prophylactic mastectomy were identified using the Decisions for Contralateral Prophylactic Mastectomy Survey. RESULTS Survey responses were received from 157 patients (59%) who underwent unilateral reconstruction and 109 (41%) who underwent bilateral reconstruction. The top 3 reasons for choosing contralateral prophylactic mastectomy were (1) decreasing the risk of contralateral breast disease (97%), (2) peace of mind (96%), and (3) improved survival (93%). Women who chose contralateral prophylactic mastectomy reported significantly greater overall fear and worry compared with the unilateral group, specifically, greater fears of dying and worries about adequately fulfilling roles of daily life (P < 0.05). CONCLUSIONS Despite no proven survival benefit, women chose contralateral prophylactic mastectomy primarily to optimize oncologic outcomes. Among breast reconstruction patients, women who underwent contralateral prophylactic mastectomy had greater anxiety and overall fear of breast cancer recurrence compared with those who chose unilateral mastectomy. These findings are important to consider when counseling women contemplating contralateral prophylactic mastectomy.
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Shumway DA, Griffith KA, Hawley ST, Wallner LP, Ward KC, Hamilton AS, Morrow M, Katz SJ, Jagsi R. Patient views and correlates of radiotherapy omission in a population-based sample of older women with favorable-prognosis breast cancer. Cancer 2018; 124:2714-2723. [PMID: 29669187 PMCID: PMC7537366 DOI: 10.1002/cncr.31378] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 01/26/2018] [Accepted: 02/20/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND The omission of radiotherapy (RT) after lumpectomy is a reasonable option for many older women with favorable-prognosis breast cancer. In the current study, we sought to evaluate patient perspectives regarding decision making about RT. METHODS Women aged 65 to 79 years with AJCC 7th edition stage I and II breast cancer who were reported to the Georgia and Los Angeles County Surveillance, Epidemiology, and End Results registries were surveyed (response rate, 70%) regarding RT decisions, the rationale for omitting RT, decision-making values, and understanding of disease recurrence risk. We also surveyed their corresponding surgeons (response rate, 77%). Patient characteristics associated with the omission of RT were evaluated using multilevel, multivariable logistic regression, accounting for patient clustering within surgeons. RESULTS Of 999 patients, 135 omitted RT (14%). Older age, lower tumor grade, and having estrogen receptor-positive disease each were found to be strongly associated with omission of RT in multivariable analyses, whereas the number of comorbidities was not. Non-English speakers were more likely to omit RT (adjusted odds ratio, 5.9; 95% confidence interval, 1.4-24.5). The most commonly reported reasons for RT omission were that a physician advised the patient that it was not needed (54% of patients who omitted RT) and patient choice (41%). Risk of local disease recurrence was overestimated by all patients: by approximately 2-fold among those who omitted RT and by approximately 8-fold among those who received RT. The risk of distant disease recurrence was overestimated by approximately 3-fold on average. CONCLUSIONS To some extent, decisions regarding RT omission are appropriately influenced by patient age, tumor grade, and estrogen receptor status, but do not appear to be optimally tailored according to competing comorbidities. Many women who are candidates for RT omission overestimate their risk of disease recurrence. Cancer 2018;124:2714-2723. © 2018 American Cancer Society.
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Affiliation(s)
- Dean A Shumway
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Kent A Griffith
- Center for Cancer Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Sarah T Hawley
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
- Center for Clinical Management Research, Ann Arbor VA Health Care System, Ann Arbor, Michigan
| | - Lauren P Wallner
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan
| | - Kevin C Ward
- Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Ann S Hamilton
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Monica Morrow
- Breast Surgical Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Steven J Katz
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
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Riedel F, Hennigs A, Hug S, Schaefgen B, Sohn C, Schuetz F, Golatta M, Heil J. Is Mastectomy Oncologically Safer than Breast-Conserving Treatment in Early Breast Cancer? Breast Care (Basel) 2017; 12:385-390. [PMID: 29456470 PMCID: PMC5803719 DOI: 10.1159/000485737] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
AIM To describe and discuss the evidence for oncological safety of different procedures in oncological breast surgery, i.e. breast-conserving treatment versus mastectomy. METHODS Literature review and discussion. RESULTS Oncological safety in breast cancer surgery has many dimensions. Breast-conserving treatment has been established as the standard surgical procedure for primary breast cancer and fits to the preferences of most breast cancer patients concerning oncological safety and aesthetic outcome. CONCLUSIONS Breast-conserving treatment is safe. Nonetheless, the preferences of the individual patients in their consideration of breast conservation versus mastectomy should be integrated into routine treatment decisions.
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Affiliation(s)
| | | | | | | | | | | | | | - Jörg Heil
- Department of Obstetrics and Gynecology, University of Heidelberg, Medical School, Heidelberg, Germany
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Langius-Eklöf A, Crafoord MT, Christiansen M, Fjell M, Sundberg K. Effects of an interactive mHealth innovation for early detection of patient-reported symptom distress with focus on participatory care: protocol for a study based on prospective, randomised, controlled trials in patients with prostate and breast cancer. BMC Cancer 2017; 17:466. [PMID: 28676102 PMCID: PMC5496395 DOI: 10.1186/s12885-017-3450-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 06/26/2017] [Indexed: 11/12/2022] Open
Abstract
Background Cancer patients are predominantly treated as out-patients and as they often experience difficult symptoms and side effects it is important to facilitate and improve patient-clinician communication to support symptom management and self-care. Although the number of projects within supportive cancer care evaluating mobile health is increasing, few evidence-based interventions are described in the literature and thus there is a need for good quality clinical studies with a randomised design and sufficient power to guide future implementations. An interactive information and communications technology platform, including a smartphone/computer tablet app for reporting symptoms during cancer treatment was created in collaboration with a company specialising in health care management. The aim of this paper is to evaluate the effects of using the platform for patients with breast cancer during neo adjuvant chemotherapy treatment and patients with locally advanced prostate cancer during curative radiotherapy treatment. The main hypothesis is that the use of the platform will improve clinical management, reduce costs, and promote safe and participatory care. Method The study is a prospective, randomised, controlled trial for each patient group and it is based on repeated measurements. Patients are consecutively included and randomised. The intervention groups report symptoms via the app daily, during treatment and up to three weeks after end of treatment, as a complement to standard care. Patients in the control groups receive standard care alone. Outcomes targeted are symptom burden, quality of life, health literacy (capacity to understand and communicate health needs and promote healthy behaviours), disease progress and health care costs. Data will be collected before and after treatment by questionnaires, registers, medical records and biomarkers. Lastly, participants will be interviewed about participatory and meaningful care. Discussion Results will generate knowledge to enhance understanding about how to develop person-centred care using mobile technology. Supporting patients’ involvement in their care to identify problems early, promotes more timely initiation of necessary treatment. This can benefit patients treated outside the hospital setting in regard to maintaining their safety. Clinical trial registration June 12 2015 NCT02477137 (Prostate cancer) and June 12 2015 NCT02479607 (Breast cancer).
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Affiliation(s)
- Ann Langius-Eklöf
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, 141 83 Huddinge, Stockholm, Sweden.
| | - Marie-Therése Crafoord
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, 141 83 Huddinge, Stockholm, Sweden
| | - Mats Christiansen
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, 141 83 Huddinge, Stockholm, Sweden
| | - Maria Fjell
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, 141 83 Huddinge, Stockholm, Sweden
| | - Kay Sundberg
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, 141 83 Huddinge, Stockholm, Sweden
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Affiliation(s)
- Anita Mamtani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065;
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065;
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Freedman RA, Kouri EM, West DW, Rosenberg S, Partridge AH, Lii J, Keating NL. Higher Stage of Disease Is Associated With Bilateral Mastectomy Among Patients With Breast Cancer: A Population-Based Survey. Clin Breast Cancer 2016; 16:105-12. [PMID: 26410475 PMCID: PMC5538374 DOI: 10.1016/j.clbc.2015.08.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 08/14/2015] [Accepted: 08/17/2015] [Indexed: 01/07/2023]
Abstract
BACKGROUND The reasons for increasing rates of bilateral mastectomy for unilateral breast cancer are incompletely understood, and associations of disease stage with bilateral surgery have been inconsistent. We examined associations of clinical and sociodemographic factors, including stage, with surgery type and reconstruction receipt among women with breast cancer. PATIENTS AND METHODS We surveyed a diverse population-based sample of women from Northern California cancer registries with stage 0 to III breast cancer diagnosed during 2010-2011 (participation rate, 68.5%). Using multinomial logistic regression, we examined factors associated with bilateral and unilateral mastectomy (vs. breast-conserving surgery), adjusting for tumor and sociodemographic characteristics. In a second model, we examined factors associated with reconstruction for mastectomy-treated patients. RESULTS Among 487 participants, 58% had breast-conserving surgery, 32% had unilateral mastectomy, and 10% underwent bilateral mastectomy. In adjusted analyses, women with stage III (vs. stage 0) cancers had higher odds of bilateral mastectomy (odds ratio [OR], 8.28; 95% confidence interval, 2.32-29.50); women with stage II and III (vs. stage 0) disease had higher odds of unilateral mastectomy. Higher (vs. lower) income was also associated with bilateral mastectomy, while age ≥ 60 years (vs. < 50 years) was associated with lower odds of bilateral surgery. Among mastectomy-treated patients (n = 206), bilateral mastectomy, unmarried status, and higher education and income were all associated with reconstruction (P < .05). CONCLUSION In this population-based cohort, women with the greatest risk of distant recurrence were most likely to undergo bilateral mastectomy despite a lack of clear medical benefit, raising concern for overtreatment. Our findings highlight the need for interventions to assure women are making informed surgical decisions.
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Affiliation(s)
- Rachel A Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA.
| | - Elena M Kouri
- Harvard Medical School, Department of Health Care Policy, Boston, MA
| | - Dee W West
- Cancer Registry of Greater California, Public Health Institute, Sacramento, CA
| | - Shoshana Rosenberg
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Ann H Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Joyce Lii
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Nancy L Keating
- Harvard Medical School, Department of Health Care Policy, Boston, MA; Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
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Hawley ST, Jagsi R, Morrow M, Janz NK, Hamilton A, Graff JJ, Katz SJ. Social and Clinical Determinants of Contralateral Prophylactic Mastectomy. JAMA Surg 2015; 149:582-9. [PMID: 24849045 DOI: 10.1001/jamasurg.2013.5689] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE The growing rate of contralateral prophylactic mastectomy (CPM) among women diagnosed as having breast cancer has raised concerns about potential for overtreatment. Yet, there are few large survey studies of factors that affect women's decisions for this surgical treatment option. OBJECTIVE To determine factors associated with the use of CPM in a population-based sample of patients with breast cancer. DESIGN, SETTING, AND PARTICIPANTS A longitudinal survey of 2290 women newly diagnosed as having breast cancer who reported to the Detroit and Los Angeles Surveillance, Epidemiology, and End Results registries from June 1, 2005, to February 1, 2007, and again 4 years later (June 2009 to February 2010) merged with Surveillance, Epidemiology, and End Results registry data (n = 1536). Multinomial logistic regression was used to evaluate factors associated with type of surgery. Primary independent variables included clinical indications for CPM (genetic mutation and/or strong family history), diagnostic magnetic resonance imaging, and patient extent of worry about recurrence at the time of treatment decision making. MAIN OUTCOMES AND MEASURES Type of surgery received from patient self-report, categorized as CPM, unilateral mastectomy, or breast conservation surgery. RESULTS Of the 1447 women in the analytic sample, 18.9% strongly considered CPM and 7.6% received it. Of those who strongly considered CPM, 32.2% received CPM, while 45.8% received unilateral mastectomy and 22.8% received breast conservation surgery (BCS). The majority of patients (68.9%) who received CPM had no major genetic or familial risk factors for contralateral disease. Multivariate regression showed that receipt of CPM (vs either unilateral mastectomy or breast conservation surgery) was significantly associated with genetic testing (positive or negative) (vs UM, relative risk ratio [RRR]: 10.48; 95% CI, 3.61-3.48 and vs BCS, RRR: 19.10; 95% CI, 5.67-56.41; P < .001), a strong family history of breast or ovarian cancer (vs UM, RRR: 5.19; 95% CI, 2.34-11.56 and vs BCS, RRR: 4.24; 95% CI, 1.80-9.88; P = .001), receipt of magnetic resonance imaging (vs UM RRR: 2.07; 95% CI, 1.21-3.52 and vs BCS, RRR: 2.14; 95% CI, 1.28-3.58; P = .001), higher education (vs UM, RRR: 5.04; 95% CI, 2.37-10.71 and vs BCS, RRR: 4.38; 95% CI, 2.07-9.29; P < .001), and greater worry about recurrence (vs UM, RRR: 2.81; 95% CI, 1.14-6.88 and vs BCS, RRR: 4.24; 95% CI, 1.80-9.98; P = .001). CONCLUSIONS AND RELEVANCE Many women considered CPM and a substantial number received it, although few had a clinically significant risk of contralateral breast cancer. Receipt of magnetic resonance imaging at diagnosis contributed to receipt of CPM. Worry about recurrence appeared to drive decisions for CPM although the procedure has not been shown to reduce recurrence risk. More research is needed about the underlying factors driving the use of CPM.
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Affiliation(s)
- Sarah T Hawley
- Medical School, University of Michigan, Ann Arbor1VA Ann Arbor Healthcare System, Ann Arbor, Michigan3School of Public Health, University of Michigan, Ann Arbor
| | - Reshma Jagsi
- Medical School, University of Michigan, Ann Arbor
| | - Monica Morrow
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nancy K Janz
- School of Public Health, University of Michigan, Ann Arbor
| | | | - John J Graff
- Rutgers Cancer Institute of New Jersey, New Brunswick
| | - Steven J Katz
- Medical School, University of Michigan, Ann Arbor3School of Public Health, University of Michigan, Ann Arbor
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Bell RJ, Fradkin P, Robinson PJ, Schwarz M, Davis SR. Intended follow up of women with breast cancer at low risk of recurrence and at least 5 years from diagnosis. Intern Med J 2015; 44:332-8. [PMID: 23735033 DOI: 10.1111/imj.12205] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 05/20/2013] [Indexed: 01/21/2023]
Abstract
BACKGROUND Although there is evidence that minimal surveillance is compatible with an optimal outcome in women after early stage breast cancer, little is known of the surveillance that these women receive. AIMS To describe the intended clinical follow up and patterns of use of imaging modalities in low-risk breast cancer survivors who are at least 5 years from diagnosis. METHODS Participants in the Bupa Health Foundation Health and Wellbeing After Breast Cancer Study with stage 1 invasive breast cancer at diagnosis, who had survived free of recurrence or new primary breast cancer for at least 5 years, provided information for this analysis. RESULTS The most common choice of physician follow up was with one doctor only (54%). Within this group, the most frequent choice was a general practitioner (GP) (63%) followed by medical oncologist (23%). Thirty-five per cent of women said that they intended to consult two doctors and within this group, the most common combination was a GP and a medical oncologist (45%). This was despite two out of three women reporting being advised that there was no need to consult a medical oncologist. Over 90% of women reported having a mammogram with, or without, breast ultrasound in the previous 12 months. There was a low rate of use of other imaging tests in the absence of clear indications. CONCLUSIONS Minimising unnecessary medical consultations by women with breast cancer at low risk of recurrence 5 years from diagnosis will require education about the benefits of a minimal surveillance strategy.
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Affiliation(s)
- R J Bell
- Women's Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Katz SJ, Belkora J, Elwyn G. Shared decision making for treatment of cancer: challenges and opportunities. J Oncol Pract 2015; 10:206-8. [PMID: 24839284 DOI: 10.1200/jop.2014.001434] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Treatment recommendations are based on complicated clinical information that is revealed variably over time after initial diagnosis. Integrating this information into a treatment plan is challenging, as different specialists direct the various treatments.
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Affiliation(s)
- Steven J Katz
- University of Michigan Institute for Health Policy Studies, Ann Arbor, MI; University of California, San Francisco, San Francisco, CA; The Dartmouth Center for Health Care Delivery Science; and The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Jeffrey Belkora
- University of Michigan Institute for Health Policy Studies, Ann Arbor, MI; University of California, San Francisco, San Francisco, CA; The Dartmouth Center for Health Care Delivery Science; and The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Glyn Elwyn
- University of Michigan Institute for Health Policy Studies, Ann Arbor, MI; University of California, San Francisco, San Francisco, CA; The Dartmouth Center for Health Care Delivery Science; and The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
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Jagsi R. Debating the Oncologist's Role in Defining the Value of Cancer Care: We Have a Duty to Society. J Clin Oncol 2014; 32:4035-8. [DOI: 10.1200/jco.2014.58.1587] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Killelea BK, Long JB, Chagpar AB, Ma X, Wang R, Ross JS, Gross CP. Evolution of breast cancer screening in the Medicare population: clinical and economic implications. J Natl Cancer Inst 2014; 106:dju159. [PMID: 25031307 DOI: 10.1093/jnci/dju159] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Newer approaches to mammography, including digital image acquisition and computer-aided detection (CAD), and adjunct imaging (e.g., magnetic resonance imaging [MRI]) have diffused into clinical practice. The impact of these technologies on screening-related cost and outcomes remains undefined, particularly among older women. METHODS Using the Surveillance, Epidemiology, and End Results-Medicare linked database, we constructed two cohorts of women without a history of breast cancer and followed each cohort for 2 years. We compared the use and cost of screening mammography including digital mammography and CAD, adjunct procedures including breast ultrasound, MRI, and biopsy between the period of 2001 and 2002 and the period of 2008 and 2009 using χ(2) and t test. We also assessed the change in breast cancer stage and incidence rates using χ(2) and Poisson regression. All statistical tests were two-sided. RESULTS There were 137150 women (mean age = 76.0 years) in the early cohort (2001-2002) and 133097 women (mean age = 77.3 years) in the later cohort (2008-2009). The use of digital image acquisition for screening mammography increased from 2.0% in 2001 and 2002 to 29.8% in 2008 and 2009 (P < .001). CAD use increased from 3.2% to 33.1% (P < .001). Average screening-related cost per capita increased from $76 to $112 (P < .001), with annual national fee-for-service Medicare spending increasing from $666 million to $962 million. There was no statistically significant change in detection rates of early-stage tumors (2.45 vs 2.57 per 1000 person-years; P = .41). CONCLUSIONS Although breast cancer screening-related costs increased substantially from 2001 through 2009 among Medicare beneficiaries, a clinically significant change in stage at diagnosis was not observed.
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Affiliation(s)
- Brigid K Killelea
- Affiliations of authors: Department of Surgery (BKK, ABC), Section of General Internal Medicine (JBL, JSR, CPG), and Department of Epidemiology and Public Health (XM, RW), Yale University School of Medicine, New Haven, CT; Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT (BKK, JBL, ABC, XM, RW, JSR, CPG); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (JSR)
| | - Jessica B Long
- Affiliations of authors: Department of Surgery (BKK, ABC), Section of General Internal Medicine (JBL, JSR, CPG), and Department of Epidemiology and Public Health (XM, RW), Yale University School of Medicine, New Haven, CT; Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT (BKK, JBL, ABC, XM, RW, JSR, CPG); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (JSR)
| | - Anees B Chagpar
- Affiliations of authors: Department of Surgery (BKK, ABC), Section of General Internal Medicine (JBL, JSR, CPG), and Department of Epidemiology and Public Health (XM, RW), Yale University School of Medicine, New Haven, CT; Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT (BKK, JBL, ABC, XM, RW, JSR, CPG); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (JSR)
| | - Xiaomei Ma
- Affiliations of authors: Department of Surgery (BKK, ABC), Section of General Internal Medicine (JBL, JSR, CPG), and Department of Epidemiology and Public Health (XM, RW), Yale University School of Medicine, New Haven, CT; Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT (BKK, JBL, ABC, XM, RW, JSR, CPG); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (JSR)
| | - Rong Wang
- Affiliations of authors: Department of Surgery (BKK, ABC), Section of General Internal Medicine (JBL, JSR, CPG), and Department of Epidemiology and Public Health (XM, RW), Yale University School of Medicine, New Haven, CT; Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT (BKK, JBL, ABC, XM, RW, JSR, CPG); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (JSR)
| | - Joseph S Ross
- Affiliations of authors: Department of Surgery (BKK, ABC), Section of General Internal Medicine (JBL, JSR, CPG), and Department of Epidemiology and Public Health (XM, RW), Yale University School of Medicine, New Haven, CT; Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT (BKK, JBL, ABC, XM, RW, JSR, CPG); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (JSR)
| | - Cary P Gross
- Affiliations of authors: Department of Surgery (BKK, ABC), Section of General Internal Medicine (JBL, JSR, CPG), and Department of Epidemiology and Public Health (XM, RW), Yale University School of Medicine, New Haven, CT; Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT (BKK, JBL, ABC, XM, RW, JSR, CPG); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (JSR).
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16
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Jagsi R, Hawley ST, Abrahamse P, Li Y, Janz NK, Griggs JJ, Bradley C, Graff JJ, Hamilton A, Katz SJ. Impact of adjuvant chemotherapy on long-term employment of survivors of early-stage breast cancer. Cancer 2014; 120:1854-62. [PMID: 24777606 DOI: 10.1002/cncr.28607] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 11/11/2013] [Accepted: 12/09/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Many women with early-stage breast cancer are working at the time of diagnosis and survive without disease recurrence. The short-term impact of chemotherapy receipt on employment has been demonstrated, but the long-term impact merits further research. METHODS The authors conducted a longitudinal multicenter cohort study of women diagnosed with nonmetastatic breast cancer between 2005 and 2007, as reported to the population-based Los Angeles and Detroit Surveillance, Epidemiology, and End Results program registries. Of 3133 individuals who were sent surveys, 2290 (73%) completed a baseline survey soon after diagnosis and of these, 1536 (67%) completed a 4-year follow-up questionnaire. RESULTS Of the 1026 patients aged < 65 years at the time of diagnosis whose breast cancer did not recur and who responded to both surveys, 746 (76%) worked for pay before diagnosis. Of these, 236 (30%) were no longer working at the time of the follow-up survey. Women who received chemotherapy as part of their initial treatment were less likely to be working at the time of the follow-up survey (38% vs 27%; P = .003). Chemotherapy receipt at the time of diagnosis (odds ratio, 1.4; P = .04) was found to be independently associated with unemployment during survivorship in a multivariable model. Many women who were not employed during the survivorship period wanted to work: 50% reported that it was important for them to work and 31% were actively seeking work. CONCLUSIONS Unemployment among survivors of breast cancer 4 years after diagnosis is often undesired and appears to be related to the receipt of chemotherapy during initial treatment. These findings should be considered when patients decide whether to receive adjuvant chemotherapy, particularly when the expected benefit is low.
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Affiliation(s)
- Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
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17
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Adunlin G, Diaby V, Montero AJ, Xiao H. Multicriteria decision analysis in oncology. Health Expect 2014; 18:1812-26. [PMID: 24635949 DOI: 10.1111/hex.12178] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2014] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND There has been a growing interest in the development and application of alternative decision-making frameworks within health care, including multicriteria decision analysis (MCDA). Even though the literature includes several reviews on MCDA methods, applications of MCDA in oncology are lacking. AIM The aim of this paper is to discuss a rationale for the use of MCDA in oncology. In this context, the following research question emerged: How can MCDA be used to develop a clinical decision support tool in oncology? METHODS In this paper, a brief background on decision making is presented, followed by an overview of MCDA methods and process. The paper discusses some applications of MCDA, proposes research opportunities in the context of oncology and presents an illustrative example of how MCDA can be applied to oncology. FINDINGS Decisions in oncology involve trade-offs between possible benefits and harms. MCDA can help analyse trade-off preferences. A wide range of MCDA methods exist. Each method has its strengths and weaknesses. Choosing the appropriate method varies depending on the source and nature of information used to inform decision making. The literature review identified eight studies. The analytical hierarchy process (AHP) was the most often used method in the identified studies. CONCLUSION Overall, MCDA appears to be a promising tool that can be used to assist clinical decision making in oncology. Nonetheless, field testing is desirable before MCDA becomes an established decision-making tool in this field.
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Affiliation(s)
- Georges Adunlin
- Division of Economic, Social and Administrative Pharmacy, College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, FL, USA
| | - Vakaramoko Diaby
- Division of Economic, Social and Administrative Pharmacy, College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, FL, USA
| | | | - Hong Xiao
- Division of Economic, Social and Administrative Pharmacy, College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, FL, USA
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18
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Kurian AW, Mitani A, Desai M, Yu PP, Seto T, Weber SC, Olson C, Kenkare P, Gomez SL, de Bruin MA, Horst K, Belkora J, May SG, Frosch DL, Blayney DW, Luft HS, Das AK. Breast cancer treatment across health care systems: linking electronic medical records and state registry data to enable outcomes research. Cancer 2014; 120:103-11. [PMID: 24101577 PMCID: PMC3867595 DOI: 10.1002/cncr.28395] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 08/12/2013] [Accepted: 08/22/2013] [Indexed: 01/07/2023]
Abstract
BACKGROUND Understanding of cancer outcomes is limited by data fragmentation. In the current study, the authors analyzed the information yielded by integrating breast cancer data from 3 sources: electronic medical records (EMRs) from 2 health care systems and the state registry. METHODS Diagnostic test and treatment data were extracted from the EMRs of all patients with breast cancer treated between 2000 and 2010 in 2 independent California institutions: a community-based practice (Palo Alto Medical Foundation; "Community") and an academic medical center (Stanford University; "University"). The authors incorporated records from the population-based California Cancer Registry and then linked EMR-California Cancer Registry data sets of Community and University patients. RESULTS The authors initially identified 8210 University patients and 5770 Community patients; linked data sets revealed a 16% patient overlap, yielding 12,109 unique patients. The percentage of all Community patients, but not University patients, treated at both institutions increased with worsening cancer prognostic factors. Before linking the data sets, Community patients appeared to receive less intervention than University patients (mastectomy: 37.6% vs 43.2%; chemotherapy: 35% vs 41.7%; magnetic resonance imaging: 10% vs 29.3%; and genetic testing: 2.5% vs 9.2%). Linked Community and University data sets revealed that patients treated at both institutions received substantially more interventions (mastectomy: 55.8%; chemotherapy: 47.2%; magnetic resonance imaging: 38.9%; and genetic testing: 10.9% [P < .001 for each 3-way institutional comparison]). CONCLUSIONS Data linkage identified 16% of patients who were treated in 2 health care systems and who, despite comparable prognostic factors, received far more intensive treatment than others. By integrating complementary data from EMRs and population-based registries, a more comprehensive understanding of breast cancer care and factors that drive treatment use was obtained.
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Affiliation(s)
- Allison W. Kurian
- Department of Medicine, Stanford University
- Department of Health Research & Policy, Stanford University
| | - Aya Mitani
- Department of Medicine, Stanford University
| | | | - Peter P. Yu
- Palo Alto Medical Foundation Research Institute
| | - Tina Seto
- Department of Medicine, Stanford University
| | | | - Cliff Olson
- Palo Alto Medical Foundation Research Institute
| | | | - Scarlett L. Gomez
- Department of Health Research & Policy, Stanford University
- Cancer Prevention Institute of California
| | | | | | - Jeffrey Belkora
- Palo Alto Medical Foundation Research Institute
- University of California, San Francisco
| | | | - Dominick L. Frosch
- Palo Alto Medical Foundation Research Institute
- Department of Medicine, University of California at Los Angeles
- Gordon and Betty Moore Foundation
| | | | - Harold S. Luft
- Palo Alto Medical Foundation Research Institute
- University of California, San Francisco
| | - Amar K. Das
- Department of Medicine, Stanford University
- Department of Psychiatry and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine
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Mrózek E, Povoski SP, Shapiro CL. The challenges of individualized care for older patients with localized breast cancer. Expert Rev Anticancer Ther 2013; 13:963-73. [PMID: 23984898 DOI: 10.1586/14737140.2013.820568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Individualized care is achieved when the appropriate screening and/or evaluative tests are used, the treatment plan is driven by evidence-based data and the patient's functional ability, physical and mental health, preference and social situation are incorporated into treatment decisions. Breast cancer is a disease of aging; yet, the management of breast cancer in older women in most cases lacks evidence from prospective randomized clinical trials (i.e., level 1 evidence) to support treatment recommendations. Older women are underrepresented in therapeutic clinical studies, even though studies show that selected fit older women enrolled on clinical trials derive similar benefits as younger women. Very few studies have focused on the distribution and biological behavior of different molecular subtypes of breast cancer in older women making it difficult to conclude whether old age adds extra biological complexity. A comprehensive geriatric assessment that includes a multidimensional process designed to assess functional ability, physical health, cognitive and mental health, social issues and environmental situation of elderly person should be an integral part of individualized care for older patients with breast cancer. However, incorporation of this tool into standard oncology practice is very slow despite the expected steep increase in older individuals with cancer projected over the next 25 years. All of the factors mentioned above hinder progress in delivering individualized care to older patients with breast cancer. This article provides an overview on progress and challenges of individualized and personalized health care in older women with breast cancer.
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Affiliation(s)
- Ewa Mrózek
- Division of Medical Oncology, The Wexner Medical Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University, Columbus, OH, USA.
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20
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Katz SJ, Morrow M. Addressing overtreatment in breast cancer: The doctors' dilemma. Cancer 2013; 119:3584-8. [PMID: 23913512 DOI: 10.1002/cncr.28260] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 05/17/2013] [Indexed: 11/10/2022]
Affiliation(s)
- Steven J Katz
- University of Michigan Health System, Ann Arbor, Michigan
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Jagsi R, Hayman J. Informing patient decisions regarding management of ductal carcinoma in situ. J Natl Cancer Inst 2013; 105:758-9. [PMID: 23644481 DOI: 10.1093/jnci/djt113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Kaplan M, Mahon SM. Tamoxifen Benefits and CYP2D6 Testing in Women With Hormone Receptor-Positive Breast Cancer. Clin J Oncol Nurs 2013; 17:174-9. [DOI: 10.1188/13.cjon.174-179] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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23
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Lee CI, Bassett LW, Lehman CD. Breast density legislation and opportunities for patient-centered outcomes research. Radiology 2012; 264:632-6. [PMID: 22919037 DOI: 10.1148/radiol.12120184] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Christoph I Lee
- Department of Radiology, University of Washington School of Medicine, Seattle, WA 98109-1023, USA.
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A survey of breast cancer physicians regarding patient involvement in breast cancer treatment decisions. Breast 2012; 22:548-54. [PMID: 23107518 DOI: 10.1016/j.breast.2012.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 10/02/2012] [Accepted: 10/03/2012] [Indexed: 11/22/2022] Open
Abstract
PURPOSE Shared breast cancer treatment decision-making between patients and physicians increases patient treatment satisfaction and compliance and is influenced by physician-related factors. Attitudes and behaviors about patient involvement in breast cancer treatment decisions and treatment-related communication were assessed by specialty among breast cancer physicians of women enrolled in the Breast Cancer Quality of Care Study (BQUAL). RESULTS Of 275 BQUAL physicians identified, 50.0% responded to the survey. Most physicians spend 46-60 min with the patient during the initial consult visit and 51.5% report that the treatment decision is made in one visit. Oncologists spend more time with new breast cancer patients during the initial consult (p = 0.021), and find it more difficult to handle their own feelings than breast surgeons (p = <0.001). CONCLUSION Breast surgeons and oncologists share similar attitudes and behaviors related to patient involvement in treatment decision-making, yet oncologists report more difficulty managing their own feelings during the decision-making process.
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