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Hubbard T, Wright G, Morgan J, Martin C, Walters S, Cheung KL, Audisio R, Reed M, Wyld L. Management and outcomes for older women with early breast cancer treated with primary endocrine therapy (PET). Breast 2024; 77:103768. [PMID: 38996610 PMCID: PMC11301393 DOI: 10.1016/j.breast.2024.103768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 06/28/2024] [Accepted: 07/07/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND This study reports the detailed management and outcomes of women treated with Primary Endocrine Therapy (PET) in a large prospective UK cohort of older women (≥70) with breast cancer. METHODS This was an unplanned secondary analysis of a prospective, multicentre, observational study (The Age Gap study). Data were collected at baseline and regular intervals on patient, tumour and treatment characteristics with tumour RECIST response category recorded. Direct study follow-up was 24 months with longer-term survival data obtained from the UK cancer registry. RESULTS The Age Gap study recruited 3316 women across 56 breast units. Primary endocrine therapy (PET) was initiated for 505/3316 (15 %) women; median age was 84 (IQR 79-88) with median follow-up 41.9 months (IQR 27-60). Death occurred in 205/505(40.6 %) patients, 160/205; 78 % non- Breast Cancer related, 45/205; 21.9 % Breast Cancer related. Multivariate analysis identified older age (HR-1.055(95 % Confidence Interval: 1.029-1.084); P < 0.001) and higher Charlson Index (HR-1.166 (1.086-1.252); P < 0.001) as risk factors for all-cause mortality, but conversion to surgery (HR-0.372(0.152-0.914); P = 0.031) was protective. Grade 3 cancer (G1 vs G3 HR-0.28 (0.094-0.829); P = 0.022 & G2 vs G3 HR-0.469 (0.226-0.973); P = 0.042), axillary positivity (axilla positivity HR-2.548 (1.321-4.816); P = 0.005) and change of endocrine therapy (HR-3.010 (1.532-5.913); P = 0.001) were associated with worse breast cancer specific survival (BCSS). RECIST category was not significantly associated with either overall survival or BCSS (P > 0.05). CONCLUSION Early disease response and change of endocrine therapy are not significantly associated with overall survival, conversion to surgery is linked to improved outcome. Prognosis is largely determined by age and comorbidity in older women treated with PET.
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Affiliation(s)
- Thomas Hubbard
- Royal Devon University Hospital NHS Trust, Exeter, UK; Faculty of Health Sciences, University of Exeter, Exeter, UK
| | | | - Jenna Morgan
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
| | - Charlene Martin
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
| | - Stephen Walters
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Kwok-Leung Cheung
- School of Medicine, University of Nottingham, Royal Derby Hospital, Derby, UK
| | - Riccardo Audisio
- University of Gothenberg, Sahlgrenska Universitetssjukhuset, Göteborg, Sweden
| | - Malcolm Reed
- Brighton and Sussex Medical School, Brighton, UK
| | - Lynda Wyld
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK.
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Liu J, Chan SWC, Guo D, Lin Q, Hunter S, Zhu J, Lee RLT. Decision-making experiences related to mastectomy: A descriptive qualitative study. J Adv Nurs 2024; 80:1967-1983. [PMID: 37974499 DOI: 10.1111/jan.15948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 10/23/2023] [Accepted: 10/28/2023] [Indexed: 11/19/2023]
Abstract
AIM To obtain an in-depth understanding of women's decision-making experiences related to mastectomy. DESIGN A descriptive qualitative interview study. METHODS Individual semi-structured interviews were conducted face-to-face with 27 Chinese women with breast cancer who underwent mastectomy at two tertiary hospitals in mainland China between September 2020 and December 2021 after obtaining the appropriate ethical approvals. Interviews were conducted in Mandarin. Data were analysed using inductive content analysis. RESULTS Mean age of participants was 48 years (range 31-70). Most participants had low education, low monthly family income, had a partner and health insurance, had been diagnosed with early breast cancer, and had not undergone reconstructive surgery. Six categories related to decision-making experiences emerged: (1) Emotions affecting decision-making, (2) Information seeking for decision-making, (3) Beliefs about mastectomy and the breast, (4) Participation in decision-making, (5) People who influence decision-making, and (6) Post-decision reflection. Participants did not mention the role of nurses in their decision-making process for mastectomy. CONCLUSIONS This study adds valuable insights into the limited evidence on women's experience with decision-making about mastectomy from a Chinese perspective, which is important given the continuing high prevalence of mastectomy in many regions. Future studies from other countries and ethnic groups are recommended to gain diverse knowledge. IMPACT The findings of this study are useful for nurses and other healthcare professionals in the multidisciplinary team to better support women with breast cancer in their decision-making process regarding mastectomy. The findings could inform future interventions to support treatment decision-making and may be relevant to women living in similar socio-medical contexts to those in mainland China. REPORTING METHOD The study was reported following the Standards for Reporting Qualitative Research checklist. PATIENT OR PUBLIC CONTRIBUTION No patient or public contribution.
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Affiliation(s)
- Jing Liu
- School of Nursing and Midwifery, College of Health, Medicine and Wellbeing, The University of Newcastle, University Drive, Callaghan, New South Wales, Australia
| | - Sally Wai-Chi Chan
- President Office, Tung Wah College, Hong Kong, SAR, People's Republic of China
| | - Dongmei Guo
- Department of Breast Surgery, Zhongshan Hospital Xiamen University, Xiamen, Fujian, People's Republic of China
| | - Qin Lin
- Department of Radiation Oncology, Xiamen Cancer Quality Control Center, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian, People's Republic of China
- School of Medicine, Xiamen University, Xiamen, Fujian, People's Republic of China
| | - Sharyn Hunter
- School of Nursing and Midwifery, College of Health, Medicine and Wellbeing, The University of Newcastle, University Drive, Callaghan, New South Wales, Australia
| | - Jiemin Zhu
- Department of Nursing, School of Medicine, Xiamen University, Xiamen, Fujian, People's Republic of China
| | - Regina Lai Tong Lee
- School of Nursing and Midwifery, College of Health, Medicine and Wellbeing, The University of Newcastle, University Drive, Callaghan, New South Wales, Australia
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China
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Wang Y, Steinke D, Gavan SP, Chen TC, Carr MJ, Ashcroft DM, Cheung KL, Chen LC. Survival Outcomes in Older Women with Oestrogen-Receptor-Positive Early-Stage Breast Cancer: Primary Endocrine Therapy vs. Surgery by Comorbidity and Frailty Levels. Cancers (Basel) 2024; 16:749. [PMID: 38398140 PMCID: PMC10886896 DOI: 10.3390/cancers16040749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
Primary endocrine therapy (PET) offers non-surgical treatment for older women with early-stage breast cancer who are unsuitable for surgery due to frailty or comorbidity. This research assessed all-cause and breast cancer-specific mortality of PET vs. surgery in older women (≥70 years) with oestrogen-receptor-positive early-stage breast cancer by frailty and comorbidity levels. This study used UK secondary data to analyse older female patients from 2000 to 2016. Patients were censored until 31 May 2019 and grouped by the Charlson comorbidity index (CCI) and hospital frailty risk score (HFRS). Cox regression models compared all-cause and breast cancer-specific mortality between PET and surgery within each group, adjusting for patient preferences and covariates. Sensitivity analyses accounted for competing risks. There were 23,109 patients included. The hazard ratio (HR) comparing PET to surgery for overall survival decreased significantly from 2.1 (95%CI: 2.0, 2.2) to 1.2 (95%CI: 1.1, 1.5) with increasing HFRS and from 2.1 (95%CI: 2.0, 2.2) to 1.4 (95%CI 1.2, 1.7) with rising CCI. However, there was no difference in BCSM for frail older women (HR: 1.2; 0.9, 1.9). There were no differences in competing risk profiles between other causes of death and breast cancer-specific mortality with PET versus surgery, with a subdistribution hazard ratio of 1.1 (0.9, 1.4) for high-level HFRS (p = 0.261) and CCI (p = 0.093). Given limited survival gains from surgery for older patients, PET shows potential as an effective option for frail older women with early-stage breast cancer. Despite surgery outperforming PET, surgery loses its edge as frailty increases, with negligible differences in the very frail.
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Affiliation(s)
- Yubo Wang
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Stopford Building, Oxford Road, Manchester M13 9PT, UK; (D.S.); (T.-C.C.); (M.J.C.); (D.M.A.); (L.-C.C.)
| | - Douglas Steinke
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Stopford Building, Oxford Road, Manchester M13 9PT, UK; (D.S.); (T.-C.C.); (M.J.C.); (D.M.A.); (L.-C.C.)
| | - Sean P. Gavan
- Manchester Centre for Health Economics, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester M13 9PL, UK;
| | - Teng-Chou Chen
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Stopford Building, Oxford Road, Manchester M13 9PT, UK; (D.S.); (T.-C.C.); (M.J.C.); (D.M.A.); (L.-C.C.)
| | - Matthew J. Carr
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Stopford Building, Oxford Road, Manchester M13 9PT, UK; (D.S.); (T.-C.C.); (M.J.C.); (D.M.A.); (L.-C.C.)
| | - Darren M. Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Stopford Building, Oxford Road, Manchester M13 9PT, UK; (D.S.); (T.-C.C.); (M.J.C.); (D.M.A.); (L.-C.C.)
- NIHR Greater Manchester Patient Safety Research Collaboration (PSRC), The University of Manchester, Manchester M13 9PT, UK
| | - Kwok-Leung Cheung
- Royal Derby Hospital Centre, School of Medicine, University of Nottingham, Uttoxeter Road, Derby DE22 3DT, UK;
| | - Li-Chia Chen
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Stopford Building, Oxford Road, Manchester M13 9PT, UK; (D.S.); (T.-C.C.); (M.J.C.); (D.M.A.); (L.-C.C.)
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Malcolm FL, Howard P, Klukowska AM, Minhas N, Parks RM, Cheung KL. Factors influencing older women's decision-making related to treatment of operable breast cancer: A qualitative systematic review. Psychooncology 2024; 33:e6294. [PMID: 38282220 DOI: 10.1002/pon.6294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 12/22/2023] [Accepted: 01/02/2024] [Indexed: 01/30/2024]
Abstract
OBJECTIVE There is variation in practice in the treatment of older women with breast cancer. International guidelines highlight the importance of patient autonomy in treatment decision-making. The aim of this study is to identify factors which influence decision-making in older women with operable breast cancer, which will enable us to further understand how to support these patients. METHODS Systematic review in accordance with the PRISMA guidelines was performed to identify factors which influence treatment decision-making in older women with operable breast cancer. Medline, Web of Science and SCOPUS were searched. RESULTS The search yielded 5840 results; 13 articles met the inclusion criteria and reported on a total of 1118 women. Thematic analysis identified three key themes in which decision-making factors could be categorised. These were healthcare-related factors, patient-related factors and impact of treatment. Healthcare-related factors included communication with clinicians and provision of information. Patient-related factors were age, pre-existing knowledge, preconceptions of breast cancer and treatment, decision-making style and co-morbidities. The impact of treatment considerations included body image and effect on quality of life. Decision-making style was frequently reported; older women did not demonstrate one preferred style. CONCLUSIONS The findings have highlighted the complex interplay of factors which influence how older women make breast cancer treatment-decisions. Clinicians should have an awareness of the factors highlighted to maximise their ability to provide support and personalised care to older women with breast cancer whilst treatment decisions are made.
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Affiliation(s)
| | - Penny Howard
- School of Health Science, University of Nottingham, Nottingham, UK
| | | | - Nikita Minhas
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Ruth Mary Parks
- School of Medicine, University of Nottingham, Nottingham, UK
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Yeo HY, Liew AC, Chan SJ, Anwar M, Han CHW, Marra CA. Understanding Patient Preferences Regarding the Important Determinants of Breast Cancer Treatment: A Narrative Scoping Review. Patient Prefer Adherence 2023; 17:2679-2706. [PMID: 37927344 PMCID: PMC10625390 DOI: 10.2147/ppa.s432821] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/07/2023] [Indexed: 11/07/2023] Open
Abstract
Objective Conventionally, optimal treatment strategies for breast cancer have been largely determined by physicians, with a scant understanding of patients' treatment values and preferences. Incorporating patient preferences in the decision-making process for breast cancer treatment is gaining recognition and can potentially improve treatment outcomes and compliance. This scoping review aims to synthesize evidence on the key determinants that are most valued by breast cancer patients when deciding on their treatment options. Methods We searched three electronic databases (PubMed/MEDLINE, SCOPUS, and CINAHL Plus) utilizing a systematic scoping review method. Two reviewers independently screened, applied inclusion criteria, reviewed, and synthesized findings. A mixed-method narrative approach combining the inductive thematic analysis and content analysis methodologies was used to synthesize and summarize the findings. Results The review included 22 studies, leading to the conceptualization of 5 overarching themes and 17 sub-themes. Among these, the most frequently cited theme was treatment benefits, followed by treatment-related process, treatment-related risk, quality of life, and cost of treatment. Women with breast cancer highly value treatments that offer good effectiveness, prolong survival, prevent recurrence, and maintain quality of life. Patient concerns include treatment-related side effects, safety, the risk of secondary cancer, and direct or indirect out-of-pocket costs. Additionally, patients also consider treatment duration, mode of administration, physician recommendation, and treatment availability and accessibility when deciding on their preferred treatment. Conclusion The evidence synthesized in this review offers insights into refining breast cancer treatment strategies to align more closely with patient values. Recognizing and integrating patient perspectives in breast cancer care could potentially lead to improved treatment outcomes, enhanced patient compliance, and more personalized care. Healthcare professionals are encouraged to incorporate these key determinants in their treatment decision-making processes, aiming to deliver a patient-centered care that aligns with the unique preferences and values of each patient.
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Affiliation(s)
- Hui Yee Yeo
- School of Pharmacy, University of Otago, Dunedin, New Zealand
- Clinical Research Center, Hospital Seberang Jaya, Penang, Malaysia
| | - Ai Ch’i Liew
- Clinical Research Center, Hospital Seberang Jaya, Penang, Malaysia
| | - Suz Jack Chan
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Mudassir Anwar
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Catherine Hye-Won Han
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Carlo A Marra
- School of Pharmacy, University of Otago, Dunedin, New Zealand
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Neal D, Morgan JL, Ormerod T, Reed MWR. Intervention to reduce age bias in medical students' decision making for the treatment of older women with breast cancer: A novel approach to bias training. J Psychosoc Oncol 2023; 42:48-63. [PMID: 37233450 DOI: 10.1080/07347332.2023.2214548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Objectives: Despite NICE guidelines to 'treat people with invasive breast cancer, irrespective of age, with surgery and appropriate systemic therapy, rather than endocrine therapy alone', older patients receive differential treatment and experience worse outcomes. Research has evidenced the prevalence of ageism and identified the role of implicit bias in reflecting and potentially perpetuating disparities across society, including in healthcare. Yet age bias has rarely been considered as an explanatory factor in poorer outcomes for older breast cancer patients nor, consequentially, has removing age bias been considered as an approach to improving outcomes. Many organizations carry out bias training with the aim of reducing negative impacts from biased decision making, yet the few evaluations of these interventions have mostly seen small or negative effects. This study explores whether a novel intervention to address age bias leads to better quality decision making for the treatment of older women with breast cancer.Methods: An online study compared medical students' treatment recommendations for older breast cancer patients and the reasoning for their decision making before and after a novel bias training intervention. Thirty-one medical students participated in the study.Results: The results show that the bias training intervention led medical students to make better quality decisions for older breast cancer patients. The quality of decision making was measured by decreases in age-based decision making and increased efforts to include patients in decision making. These results suggest there is value in exploring whether if anti-bias training interventions could usefully be applied in other areas of practice where older patients experience poorer outcomes.Conclusions: This study evidences that bias training improves the quality of decision making by medical students in respect of older breast cancer patients. The study findings show promise that this novel approach to bias training might usefully be applied to all medical practitioners making treatment recommendations for older patients.
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Affiliation(s)
- Daisy Neal
- Brighton and Sussex Medical school, Brighton, UK
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Komatsu H, Komatsu Y. The Role of Nurse on the Treatment Decision Support for Older People with Cancer: A Systematic Review. Healthcare (Basel) 2023; 11:546. [PMID: 36833079 PMCID: PMC9956907 DOI: 10.3390/healthcare11040546] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/07/2023] [Accepted: 02/10/2023] [Indexed: 02/15/2023] Open
Abstract
Background: The number of older adults with cancer is increasing worldwide. The role of nurses in supporting patients' decision-making is expanding, as this process is fraught with complexity and uncertainty due to comorbidities, frailty, cognitive decline, etc., in older adults with cancer. The aim of this review was to examine the contemporary roles of oncology nurses in the treatment decision-making process in older adults with cancer. Methods: A systematic review of PubMed, CINAHL, and PsycINFO databases was conducted in accordance with PRISMA guidelines. Results: Of the 3029 articles screened, 56 full texts were assessed for eligibility, and 13 were included in the review. We identified three themes regarding nurses' roles in the decision-making process for older adults with cancer: accurate geriatric assessments, provision of available information, and advocacy. Nurses conduct geriatric assessments to identify geriatric syndromes, provide appropriate information, elicit patient preferences, and communicate efficiently with patients and caregivers, promoting physicians. Time constraints were cited as a barrier to fulfilling nurses' roles. Conclusions: The role of nurses is to elicit patients' broader health and social care needs to facilitate patient-centered decision-making, respecting their preferences and values. Further research focusing on the role of nurses that considers diverse cancer types and healthcare systems is needed.
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Affiliation(s)
- Hiroko Komatsu
- Japanese Red Cross Kyushu International College of Nursing, 1-1 Asty, Munakata-City 811-4157, Fukuoka, Japan
| | - Yasuhiro Komatsu
- Department of Healthcare Quality and Safety, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371-8511, Gunma, Japan
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Neal D, Morgan JL, Kenny R, Ormerod T, Reed MW. Is there evidence of age bias in breast cancer health care professionals' treatment of older patients? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2401-2407. [PMID: 35871030 DOI: 10.1016/j.ejso.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/01/2022] [Accepted: 07/04/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Despite NICE (2009; 2018) guidelines to treat breast cancer patients 'irrespective of age', older women experience differential treatment and worse outcomes beyond that which can be explained by patient health or patient choice. Research has evidenced the prevalence of ageism and identified the role of implicit bias in reflecting and perhaps perpetuating disparities across society, including in healthcare. Yet age bias has rarely been considered as an explanatory factor in poorer outcomes for older breast cancer patients. METHODS This mixed methods study explored age bias amongst breast cancer HCPs through four components: 1) An implicit associations test (31 HCPs) 2) A treatment recommendations questionnaire (46 HCPs). 3) An attitudes about older patients questionnaire (31 HCPs). 4) A treatment recommendations interview (20 HCPs). RESULTS This study showed that breast cancer HCPs held negative implicit associations towards older women; HCPs were less likely to recommend surgery for older patients; some HCPs held assumptions that older patients are more afraid, less willing and able to be involved in decision-making, and are less willing and able to cope with being informed of a poor treatment prognosis; and conditions which disproportionately affect older patients, such as dementia, are not always well understood by breast cancer HCPs. CONCLUSIONS These results indicate that there are elements of age bias present amongst breast cancer HCPs. The study's findings of age-based assumptions and a poorer understanding of conditions which disproportionately affect older patients align with patterns of differential treatment towards older breast cancer patients suggesting that age bias may be, at least in part, driving differential treatment.
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Affiliation(s)
- Daisy Neal
- Brighton and Sussex Medical School. Brighton, UK.
| | | | - Ross Kenny
- Department of Breast Surgery, Surrey and Sussex NHS Trust, UK
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Wyld L, Reed MWR, Collins K, Ward S, Holmes G, Morgan J, Bradburn M, Walters S, Burton M, Lifford K, Edwards A, Brain K, Ring A, Herbert E, Robinson TG, Martin C, Chater T, Pemberton K, Shrestha A, Nettleship A, Richards P, Brennan A, Cheung KL, Todd A, Harder H, Audisio R, Battisti NML, Wright J, Simcock R, Murray C, Thompson AM, Gosney M, Hatton M, Armitage F, Patnick J, Green T, Revill D, Gath J, Horgan K, Holcombe C, Winter M, Naik J, Parmeshwar R. Improving outcomes for women aged 70 years or above with early breast cancer: research programme including a cluster RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2022. [DOI: 10.3310/xzoe2552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
In breast cancer management, age-related practice variation is widespread, with older women having lower rates of surgery and chemotherapy than younger women, based on the premise of reduced treatment tolerance and benefit. This may contribute to inferior outcomes. There are currently no age- and fitness-stratified guidelines on which to base treatment recommendations.
Aim
We aimed to optimise treatment choice and outcomes for older women (aged ≥ 70 years) with operable breast cancer.
Objectives
Our objectives were to (1) determine the age, comorbidity, frailty, disease stage and biology thresholds for endocrine therapy alone versus surgery plus adjuvant endocrine therapy, or adjuvant chemotherapy versus no chemotherapy, for older women with breast cancer; (2) optimise survival outcomes for older women by improving the quality of treatment decision-making; (3) develop and evaluate a decision support intervention to enhance shared decision-making; and (4) determine the degree and causes of treatment variation between UK breast units.
Design
A prospective cohort study was used to determine age and fitness thresholds for treatment allocation. Mixed-methods research was used to determine the information needs of older women to develop a decision support intervention. A cluster-randomised trial was used to evaluate the impact of this decision support intervention on treatment choices and outcomes. Health economic analysis was used to evaluate the cost–benefit ratio of different treatment strategies according to age and fitness criteria. A mixed-methods study was used to determine the degree and causes of variation in treatment allocation.
Main outcome measures
The main outcome measures were enhanced age- and fitness-specific decision support leading to improved quality-of-life outcomes in older women (aged ≥ 70 years) with early breast cancer.
Results
(1) Cohort study: the study recruited 3416 UK women aged ≥ 70 years (median age 77 years). Follow-up was 52 months. (a) The surgery plus adjuvant endocrine therapy versus endocrine therapy alone comparison: 2854 out of 3416 (88%) women had oestrogen-receptor-positive breast cancer, 2354 of whom received surgery plus adjuvant endocrine therapy and 500 received endocrine therapy alone. Patients treated with endocrine therapy alone were older and frailer than patients treated with surgery plus adjuvant endocrine therapy. Unmatched overall survival and breast-cancer-specific survival were higher in the surgery plus adjuvant endocrine therapy group (overall survival: hazard ratio 0.27, 95% confidence interval 0.23 to 0.33; p < 0.001; breast-cancer-specific survival: hazard ratio 0.41, 95% confidence interval 0.29 to 0.58; p < 0.001) than in the endocrine therapy alone group. In matched analysis, surgery plus adjuvant endocrine therapy was still associated with better overall survival (hazard ratio 0.72, 95% confidence interval 0.53 to 0.98; p = 0.04) than endocrine therapy alone, but not with better breast-cancer-specific survival (hazard ratio 0.74, 95% confidence interval 0.40 to 1.37; p = 0.34) or progression-free-survival (hazard ratio 1.11, 95% confidence interval 0.55 to 2.26; p = 0.78). (b) The adjuvant chemotherapy versus no chemotherapy comparison: 2811 out of 3416 (82%) women received surgery plus adjuvant endocrine therapy, of whom 1520 (54%) had high-recurrence-risk breast cancer [grade 3, node positive, oestrogen receptor negative or human epidermal growth factor receptor-2 positive, or a high Oncotype DX® (Genomic Health, Inc., Redwood City, CA, USA) score of > 25]. In this high-risk population, there were no differences according to adjuvant chemotherapy use in overall survival or breast-cancer-specific survival after propensity matching. Adjuvant chemotherapy was associated with a lower risk of metastatic recurrence than no chemotherapy in the unmatched (adjusted hazard ratio 0.36, 95% confidence interval 0.19 to 0.68; p = 0.002) and propensity-matched patients (adjusted hazard ratio 0.43, 95% confidence interval 0.20 to 0.92; p = 0.03). Adjuvant chemotherapy improved the overall survival and breast-cancer-specific survival of patients with oestrogen-receptor-negative disease. (2) Mixed-methods research to develop a decision support intervention: an iterative process was used to develop two decision support interventions (each comprising a brief decision aid, a booklet and an online tool) specifically for older women facing treatment choices (endocrine therapy alone or surgery plus adjuvant endocrine therapy, and adjuvant chemotherapy or no chemotherapy) using several evidence sources (expert opinion, literature and patient interviews). The online tool was based on models developed using registry data from 23,842 patients and validated on an external data set of 14,526 patients. Mortality rates at 2 and 5 years differed by < 1% between predicted and observed values. (3) Cluster-randomised clinical trial of decision support tools: 46 UK breast units were randomised (intervention, n = 21; usual care, n = 25), recruiting 1339 women (intervention, n = 670; usual care, n = 669). There was no significant difference in global quality of life at 6 months post baseline (difference –0.20, 95% confidence interval –2.7 to 2.3; p = 0.90). In women offered a choice of endocrine therapy alone or surgery plus adjuvant endocrine therapy, knowledge about treatments was greater in the intervention arm than the usual care arm (94% vs. 74%; p = 0.003). Treatment choice was altered, with higher rates of endocrine therapy alone than of surgery in the intervention arm. Similarly, chemotherapy rates were lower in the intervention arm (endocrine therapy alone rate: intervention sites 21% vs. usual-care sites 15%, difference 5.5%, 95% confidence interval 1.1% to 10.0%; p = 0.02; adjuvant chemotherapy rate: intervention sites 10% vs. usual-care site 15%, difference 4.5%, 95% confidence interval 0.0% to 8.0%; p = 0.013). Survival was similar in both arms. (4) Health economic analysis: a probabilistic economic model was developed using registry and cohort study data. For most health and fitness strata, surgery plus adjuvant endocrine therapy had lower costs and returned more quality-adjusted life-years than endocrine therapy alone. However, for some women aged > 90 years, surgery plus adjuvant endocrine therapy was no longer cost-effective and generated fewer quality-adjusted life-years than endocrine therapy alone. The incremental benefit of surgery plus adjuvant endocrine therapy reduced with age and comorbidities. (5) Variation in practice: analysis of rates of surgery plus adjuvant endocrine therapy or endocrine therapy alone between the 56 breast units in the cohort study demonstrated significant variation in rates of endocrine therapy alone that persisted after adjustment for age, fitness and stage. Clinician preference was an important determinant of treatment choice.
Conclusions
This study demonstrates that, for older women with oestrogen-receptor-positive breast cancer, there is a cohort of women with a life expectancy of < 4 years for whom surgery plus adjuvant endocrine therapy may offer little benefit and simply have a negative impact on quality of life. The Age Gap decision tool may help make this shared decision. Similarly, although adjuvant chemotherapy offers little benefit and has a negative impact on quality of life for the majority of older women with oestrogen-receptor-positive breast cancer, for women with oestrogen-receptor-negative breast cancer, adjuvant chemotherapy is beneficial. The negative impacts of adjuvant chemotherapy on quality of life, although significant, are transient. This implies that, for the majority of fitter women aged ≥ 70 years, standard care should be offered.
Limitations
As with any observational study, despite detailed propensity score matching, residual bias cannot be excluded. Follow-up was at median 52 months for the cohort analysis. Longer-term follow-up will be required to validate these findings owing to the slow time course of oestrogen-receptor-positive breast cancer.
Future work
The online algorithm is now available (URL: https://agegap.shef.ac.uk/; accessed May 2022). There are plans to validate the tool and incorprate quality-of-life and 10-year survival outcomes.
Trial registration
This trial is registered as ISRCTN46099296.
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 6. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Lynda Wyld
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
- Jasmine Breast Centre, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | | | - Karen Collins
- Faculty of Health and Wellbeing, Department of Allied Health Professions, Collegiate Cresent Campus, Sheffield Hallam University, Sheffield, UK
| | - Sue Ward
- Department of Health and Social Care Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Geoff Holmes
- Department of Health and Social Care Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Jenna Morgan
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
- Jasmine Breast Centre, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Mike Bradburn
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Stephen Walters
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Maria Burton
- Faculty of Health and Wellbeing, Department of Allied Health Professions, Collegiate Cresent Campus, Sheffield Hallam University, Sheffield, UK
| | - Kate Lifford
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Adrian Edwards
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Kate Brain
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Esther Herbert
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester, Cardiovascular Research Centre, Glenfield General Hospital, Leicester, UK
| | - Charlene Martin
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
- Jasmine Breast Centre, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Tim Chater
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Kirsty Pemberton
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Anne Shrestha
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
- Jasmine Breast Centre, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | | | - Paul Richards
- Department of Health and Social Care Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Alan Brennan
- Department of Health and Social Care Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Annaliza Todd
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
- Jasmine Breast Centre, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | | | - Riccardo Audisio
- Sahlgrenska Universitetssjukhuset, University of Gothenburg, Göteborg, Sweden
| | | | | | | | | | | | - Margot Gosney
- School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
| | | | | | - Julietta Patnick
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Tracy Green
- Yorkshire and Humber Research Network Consumer Research Panel, Sheffield, UK
| | - Deirdre Revill
- Yorkshire and Humber Research Network Consumer Research Panel, Sheffield, UK
| | - Jacqui Gath
- Yorkshire and Humber Research Network Consumer Research Panel, Sheffield, UK
| | | | - Chris Holcombe
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Matt Winter
- Breast Unit, Weston Park Hospital, Sheffield, UK
| | - Jay Naik
- Breast Unit, Pinderfields Hospital, Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
| | - Rishi Parmeshwar
- Breast Unit, Royal Lancaster Infirmary, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, UK
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10
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Noteboom EA, May AM, van der Wall E, de Wit NJ, Helsper CW. Patients' preferred and perceived level of involvement in decision making for cancer treatment: A systematic review. Psychooncology 2021; 30:1663-1679. [PMID: 34146446 PMCID: PMC8518833 DOI: 10.1002/pon.5750] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 05/28/2021] [Accepted: 06/11/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Patient involvement in decision making is conditional for personalised treatment decisions. We aim to provide an up-to-date overview of patients' preferred and perceived level of involvement in decision making for cancer treatment. METHODS A systematic search was performed in PubMed, EMBASE, PsycINFO and CINAHL for articles published between January 2009 and January 2020. Search terms were 'decision making', 'patient participation', 'oncology', 'perception' and 'treatment'. Inclusion criteria were: written in English, peer-reviewed, reporting patients' preferred and perceived level of involvement, including adult cancer patients and concerning decision making for cancer treatment. The percentages of patients preferring and perceiving an active, shared or passive decision role and the (dis)concordance are presented. Quality assessment was performed with a modified version of the New-Castle Ottawa Scale. RESULTS 31 studies were included. The median percentage of patients preferring an active, shared or passive role in decision making was respectively 25%, 46%, and 27%. The median percentage of patients perceiving an active, shared or passive role was respectively 27%, 39%, and 34%. The median concordance in preferred and perceived role of all studies was 70%. Disconcordance was highest for a shared role; 42%. CONCLUSIONS Patients' preferences for involvement in cancer treatment decision vary widely. A significant number of patients perceived a decisional role other than preferred. Improvements in patient involvement have been observed in the last decade. However, there is still room for improvement and physicians should explore patients' preferences for involvement in decision making in order to truly deliver personalised cancer care.
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Affiliation(s)
- Eveline A. Noteboom
- Department: Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Anne M. May
- Department: Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Elsken van der Wall
- Department: Medical OncologyUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Niek J. de Wit
- Department: Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Charles W. Helsper
- Department: Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
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11
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Morgan JL, Shrestha A, Reed MWR, Herbert E, Bradburn M, Walters SJ, Martin C, Collins K, Ward S, Holmes G, Burton M, Lifford K, Edwards A, Ring A, Robinson T, Chater T, Pemberton K, Brennan A, Cheung KL, Todd A, Audisio R, Wright J, Simcock R, Thomson AM, Gosney M, Hatton M, Green T, Revill D, Gath J, Horgan K, Holcombe C, Winter MC, Naik J, Parmeschwar R, Wyld L. Bridging the age gap in breast cancer: impact of omission of breast cancer surgery in older women with oestrogen receptor-positive early breast cancer on quality-of-life outcomes. Br J Surg 2021; 108:315-325. [PMID: 33760065 PMCID: PMC10364859 DOI: 10.1093/bjs/znaa125] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 11/15/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Primary endocrine therapy may be an alternative treatment for less fit women with oestrogen receptor (ER)-positive breast cancer. This study compared quality-of-life (QoL) outcomes in older women treated with surgery or primary endocrine therapy. METHODS This was a multicentre, prospective, observational cohort study of surgery or primary endocrine therapy in women aged over 70 years with operable breast cancer. QoL was assessed using European Organisation for Research and Treatment of cancer QoL questionnaires QLQ-C30, -BR23, and -ELD14, and the EuroQol Five Dimensions 5L score at baseline, 6 weeks, and 6, 12, 18, and 24 months. Propensity score matching was used to adjust for baseline variation in health, fitness, and tumour stage. RESULTS The study recruited 3416 women (median age 77 (range 69-102) years) from 56 breast units. Of these, 2979 (87.2 per cent) had ER-positive breast cancer; 2354 women had surgery and 500 received primary endocrine therapy (125 were excluded from analysis due to inadequate data or non-standard therapy). Median follow-up was 52 months. The primary endocrine therapy group was older and less fit. Baseline QoL differed between the groups; the mean(s.d.) QLQ-C30 global health status score was 66.2(21.1) in patients who received primary endocrine therapy versus 77.1(17.8) among those who had surgery plus endocrine therapy. In the unmatched analysis, changes in QoL between 6 weeks and baseline were noted in several domains, but by 24 months most scores had returned to baseline levels. In the matched analysis, major surgery (mastectomy or axillary clearance) had a more pronounced adverse impact than primary endocrine therapy in several domains. CONCLUSION Adverse effects on QoL are seen in the first few months after surgery, but by 24 months these have largely resolved. Women considering surgery should be informed of these effects.
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Affiliation(s)
- J L Morgan
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
| | - A Shrestha
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
| | - M W R Reed
- Brighton and Sussex Medical School, Brighton, UK
| | - E Herbert
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - M Bradburn
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - S J Walters
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - C Martin
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
| | - K Collins
- Faculty of Health and Wellbeing, Department of Allied Health Professions, Sheffield Hallam University, Sheffield, UK
| | - S Ward
- Department of Health Economics and Decision Science, School for Health and Related Research, ScHARR, University of Sheffield, Sheffield, UK
| | - G Holmes
- Department of Health Economics and Decision Science, School for Health and Related Research, ScHARR, University of Sheffield, Sheffield, UK
| | - M Burton
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - K Lifford
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - A Edwards
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - A Ring
- Department of Medical Oncology, Royal Marsden Hospital, London, UK
| | - T Robinson
- Department of Cardiovascular Sciences and National Institute for Health Research Biomedical Research Centre, University of Leicester, Cardiovascular Research Centre, Glenfield General Hospital, Leicester, UK
| | - T Chater
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - K Pemberton
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - A Brennan
- Department of Health Economics and Decision Science, School for Health and Related Research, ScHARR, University of Sheffield, Sheffield, UK
| | - K L Cheung
- School of Medicine, University of Nottingham, Royal Derby Hospital, Derby, UK
| | - A Todd
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
| | - R Audisio
- Department of Surgery, University of Gothenberg, Sahlgrenska Universitetssjukhuset, Gothenberg, Sweden
| | - J Wright
- Brighton and Sussex Medical School, Brighton, UK
| | - R Simcock
- Brighton and Sussex Medical School, Brighton, UK
| | - A M Thomson
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - M Gosney
- School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
| | - M Hatton
- Sheffield Teaching Hospitals NHS Foundation Trust, Weston Park Hospital, Sheffield, UK
| | - T Green
- North Trent Cancer Research Network Consumer Research Panel, Sheffield, UK
| | - D Revill
- North Trent Cancer Research Network Consumer Research Panel, Sheffield, UK
| | - J Gath
- North Trent Cancer Research Network Consumer Research Panel, Sheffield, UK
| | - K Horgan
- Department of Breast Surgery, Bexley Cancer Centre, St James's University Hospital, Leeds, UK
| | - C Holcombe
- Department of Breast Surgery, Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | - M C Winter
- Sheffield Teaching Hospitals NHS Foundation Trust, Weston Park Hospital, Sheffield, UK
| | - J Naik
- Department of General Surgery, Pinderfields Hospital, Mid Yorkshire NHS Foundation Trust, Wakefield, UK
| | - R Parmeschwar
- Department of Breast Surgery, University Hospitals of Morecambe Bay, Lancaster, UK
| | - L Wyld
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
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12
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Wyld L, Reed MWR, Collins K, Burton M, Lifford K, Edwards A, Ward S, Holmes G, Morgan J, Bradburn M, Walters SJ, Ring A, Robinson TG, Martin C, Chater T, Pemberton K, Shrestha A, Nettleship A, Murray C, Brown M, Richards P, Cheung KL, Todd A, Harder H, Brain K, Audisio RA, Wright J, Simcock R, Armitage F, Bursnall M, Green T, Revell D, Gath J, Horgan K, Holcombe C, Winter M, Naik J, Parmeshwar R, Gosney M, Hatton M, Thompson AM. Bridging the age gap in breast cancer: cluster randomized trial of two decision support interventions for older women with operable breast cancer on quality of life, survival, decision quality, and treatment choices. Br J Surg 2021; 108:499-510. [PMID: 33760077 PMCID: PMC10364907 DOI: 10.1093/bjs/znab005] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 10/04/2020] [Accepted: 12/28/2020] [Indexed: 11/14/2022]
Abstract
BACKGROUND Rates of surgery and adjuvant therapy for breast cancer vary widely between breast units. This may contribute to differences in survival. This cluster RCT evaluated the impact of decision support interventions (DESIs) for older women with breast cancer, to ascertain whether DESIs influenced quality of life, survival, decision quality, and treatment choice. METHODS A multicentre cluster RCT compared the use of two DESIs against usual care in treatment decision-making in older women (aged at least ≥70 years) with breast cancer. Each DESI comprised an online algorithm, booklet, and brief decision aid to inform choices between surgery plus adjuvant endocrine therapy versus primary endocrine therapy, and adjuvant chemotherapy versus no chemotherapy. The primary outcome was quality of life. Secondary outcomes included decision quality measures, survival, and treatment choice. RESULTS A total of 46 breast units were randomized (21 intervention, 25 usual care), recruiting 1339 women (670 intervention, 669 usual care). There was no significant difference in global quality of life at 6 months after the baseline assessment on intention-to-treat analysis (difference -0.20, 95 per cent confidence interval (C.I.) -2.69 to 2.29; P = 0.900). In women offered a choice of primary endocrine therapy versus surgery plus endocrine therapy, knowledge about treatments was greater in the intervention arm (94 versus 74 per cent; P = 0.003). Treatment choice was altered, with a primary endocrine therapy rate among women with oestrogen receptor-positive disease of 21.0 per cent in the intervention versus 15.4 per cent in usual-care sites (difference 5.5 (95 per cent C.I. 1.1 to 10.0) per cent; P = 0.029). The chemotherapy rate was 10.3 per cent at intervention versus 14.8 per cent at usual-care sites (difference -4.5 (C.I. -8.0 to 0) per cent; P = 0.013). Survival was similar in both arms. CONCLUSION The use of DESIs in older women increases knowledge of breast cancer treatment options, facilitates shared decision-making, and alters treatment selection. Trial registration numbers: EudraCT 2015-004220-61 (https://eudract.ema.europa.eu/), ISRCTN46099296 (http://www.controlled-trials.com).
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Affiliation(s)
- L Wyld
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
| | - M W R Reed
- Brighton and Sussex Medical School, Falmer, Brighton, UK
| | - K Collins
- College of Health, Wellbeing and Life Sciences, Department of Allied Health Professions, Sheffield Hallam University, Sheffield, UK
| | - M Burton
- College of Health, Wellbeing and Life Sciences, Department of Allied Health Professions, Sheffield Hallam University, Sheffield, UK
| | - K Lifford
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - A Edwards
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - S Ward
- Department of Health Economics and Decision Science, School for Health and Related Research, ScHARR, University of Sheffield, Sheffield, UK
| | - G Holmes
- Department of Health Economics and Decision Science, School for Health and Related Research, ScHARR, University of Sheffield, Sheffield, UK
| | - J Morgan
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
| | - M Bradburn
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - S J Walters
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - A Ring
- Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - T G Robinson
- Department of Cardiovascular Sciences and NIHR Biomedical Research Centre, University of Leicester, Cardiovascular Research Centre, Glenfield General Hospital, Leicester, UK
| | - C Martin
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
| | - T Chater
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - K Pemberton
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - A Shrestha
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
| | - A Nettleship
- EpiGenesys, University of Sheffield, Sheffield, UK
| | - C Murray
- EpiGenesys, University of Sheffield, Sheffield, UK
| | - M Brown
- EpiGenesys, University of Sheffield, Sheffield, UK
| | - P Richards
- Department of Health Economics and Decision Science, School for Health and Related Research, ScHARR, University of Sheffield, Sheffield, UK
| | - K L Cheung
- University of Nottingham, Royal Derby Hospital, Derby, UK
| | - A Todd
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
| | - H Harder
- Brighton and Sussex Medical School, Falmer, Brighton, UK
| | - K Brain
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - R A Audisio
- University of Gothenberg, Sahlgrenska Universitetssjukhuset, Gothenberg, Sweden
| | - J Wright
- Brighton and Sussex Medical School, Falmer, Brighton, UK
| | - R Simcock
- Brighton and Sussex Medical School, Falmer, Brighton, UK
| | | | - M Bursnall
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - T Green
- Yorkshire and Humber Consumer Research Panel (yhcrp.org.uk), Leeds, UK
| | - D Revell
- Yorkshire and Humber Consumer Research Panel (yhcrp.org.uk), Leeds, UK
| | - J Gath
- Yorkshire and Humber Consumer Research Panel (yhcrp.org.uk), Leeds, UK
| | - K Horgan
- Department of Breast Surgery, Bexley Cancer Centre, St James's University Hospital, Leeds, UK
| | - C Holcombe
- Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | - M Winter
- Weston Park Hospital, Sheffield, UK
| | - J Naik
- Pinderfields Hospital, Mid Yorkshire NHS Foundation Trust, Wakefield, UK
| | - R Parmeshwar
- University Hospitals of Morecambe Bay, Lancaster, UK
| | - M Gosney
- Royal Berkshire NHS Foundation Trust, Reading, UK
| | - M Hatton
- Weston Park Hospital, Sheffield, UK
| | - A M Thompson
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
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13
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Age specific recruitment and retention to a large multicentre observational breast cancer trial in older women: The Age Gap Trial. J Geriatr Oncol 2020; 12:714-723. [PMID: 33127384 PMCID: PMC8205116 DOI: 10.1016/j.jgo.2020.10.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 09/07/2020] [Accepted: 10/21/2020] [Indexed: 12/02/2022]
Abstract
Introduction Recruitment and retention are two of the most important factors in successfully running clinical trials. Many trials encounter problems with both, causing delays or preventing study progress. These issues are greater in older adults and patients with cancer. Materials and methods We assessed recruitment and retention in a large, multicentre, observational breast cancer study in older female patients (>70 years, N = 3440). Data collected by the Age Gap study were used to assess rates of, and reasons for, patients not being recruited or retained. Statistical analysis assessed the impact of age as a predictor of recruitment and retention. Results Between February 2013 and June 2018, 6876 patients were screened and 3456 were consented across 56 United Kingdom (UK) breast units. Reasons for non-recruitment included ineligibility, clinician issues, staffing resource issues, patients' lack of interest or time and trial burden. In comparison with the age demographics of patients with breast cancer in the UK, women aged 70–75 years were over-represented compared to older age groups. Logistic regression demonstrated that older age significantly reduced the odds of consent (OR = 0.96, CI: 0.938–0.982; p < 0.001). Multivariate analysis showed that age (p < 0.001), markers of poor functional ability (Eastern Cooperative Oncology Group Performance Status (p = 0.011)) and instrumental activities of daily living (p = 0.026) were significant predictors of withdrawal. Discussion This study has demonstrated that selection and attrition bias for age are apparent despite a range of ‘age friendly’ study design measures. Exploration of the underlying reasons for this and development of measures to address this should be the focus of further research.
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14
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Shinkunas LA, Klipowicz CJ, Carlisle EM. Shared decision making in surgery: a scoping review of patient and surgeon preferences. BMC Med Inform Decis Mak 2020; 20:190. [PMID: 32787950 PMCID: PMC7424662 DOI: 10.1186/s12911-020-01211-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 08/03/2020] [Indexed: 11/25/2022] Open
Abstract
Background Many suggest that shared decision-making (SDM) is the most effective approach to clinical counseling. It is unclear if this applies to surgical decision-making-especially regarding urgent, highly-morbid operations. In this scoping review, we identify articles that address patient and surgeon preferences toward SDM in surgery. Methods We used the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews (PRISMA-ScR) to develop our protocol. Medline, EMBASE, and Cochrane databases were searched from inception through 11.2017. Title/abstract review identified peer-reviewed, empirical articles that addressed patient/surgeon preferences toward SDM in surgery. Identified articles underwent full review by two independent investigators. We addressed the following questions: (1) What is known from existing empirical evidence about patients’ and/or surgeons’ surgical decision-making preferences? (2) Why might patients and/or surgeons prefer SDM? (3) Does acuity of intervention impact surgical decision-making preferences? Outcome measures included study methods, surgical specialty, diagnosis, study location/setting, type/number of subjects, acuity of intervention, surgeon/patient decision-making preferences, and factors associated with favoring SDM. Data was analyzed in Microsoft Excel. Results 20,359 articles were identified with 4988 duplicates, yielding 15,371 articles for title/abstract review. 74 articles were included in final analysis. 68% of articles discussed oncologic decision-making. 46% of these focused on breast cancer. 92% of articles included patients, 22% included surgeons. 75% of articles found surgeons favored SDM, 25% demonstrated surgeons favored surgeon guidance. 54% of articles demonstrated patients favored SDM, 35% showed patients favored surgeon guidance, 11% showed patients preferred independent decision-making. The most common factors for patients favoring SDM included female gender, higher education, and younger age. For surgeons, the most common factors for favoring SDM included limited evidence for a given treatment plan, multiple treatment options, and impact on patient lifestyle. No articles evaluated decision-making preferences in an emergent setting. Conclusions There has been limited evaluation of patient and surgeon preferences toward SDM in surgical decision-making. Generally, patients and surgeons expressed preference toward SDM. None of the articles evaluated decision-making preferences in an emergent setting, so assessment of the impact of acuity on decision-making preferences is limited. Extension of research to complex, emergent clinical settings is needed.
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Affiliation(s)
- Laura A Shinkunas
- Program in Bioethics and Humanities, University of Iowa Carver College of Medicine, Iowa City, USA
| | | | - Erica M Carlisle
- Program in Bioethics and Humanities, University of Iowa Carver College of Medicine, Iowa City, USA. .,Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, USA.
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15
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Ward SE, Holmes GR, Morgan JL, Broggio JW, Collins K, Richards PD, Reed MWR, Wyld L. Bridging the Age Gap: a prognostic model that predicts survival and aids in primary treatment decisions for older women with oestrogen receptor-positive early breast cancer. Br J Surg 2020; 107:1625-1632. [PMID: 32602959 DOI: 10.1002/bjs.11748] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/28/2020] [Accepted: 05/03/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND A prognostic model was developed and validated using cancer registry data. This underpins an online decision support tool, informing primary treatment choice for women aged 70 years or older with hormone receptor-positive early breast cancer. METHODS Data from women diagnosed between 2002 and 2010 in the English Northern and Yorkshire and West Midlands regions were used to develop the model. Primary treatment options of surgery with adjuvant endocrine therapy or primary endocrine therapy were compared. Models predicting the hazard of breast cancer-specific mortality and hazard of other-cause mortality were combined to derive survival probabilities. The model was validated externally using data from the Eastern Cancer Registration and Information Centre. RESULTS The model was developed using data from 23 842 women, and validated externally on a data set from 14 526 patients. The overall model calibration was good. At 2 and 5 years, predicted mortality from breast cancer and other causes differed from the observed rate by less than 1 per cent. At 5 years, there were slight overpredictions in breast cancer mortality (2629 predicted versus 2556 observed deaths; P = 0·142) and mortality from all causes (6399 versus 6320 respectively; P = 0·583). The discrepancy varied between subgroups. Model discrimination was 0·75 or above for all mortality measures. CONCLUSION A prognostic model for older women with oestrogen receptor-positive early breast cancer was developed and validated in the present study. This forms a basis for an online decision support tool (https://agegap.shef.ac.uk/).
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Affiliation(s)
- S E Ward
- Department of Health Economics and Decision Science, School for Health and Related Research, Sheffield
| | - G R Holmes
- Department of Health Economics and Decision Science, School for Health and Related Research, Sheffield
| | - J L Morgan
- Department of Oncology and Metabolism, Medical School, University of Sheffield, Sheffield
| | - J W Broggio
- National Cancer Registration and Analysis Service, Public Heath England, Birmingham, UK.,Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - K Collins
- Centre for Health and Social Care Research, Sheffield Hallam University, Sheffield
| | - P D Richards
- Department of Health Economics and Decision Science, School for Health and Related Research, Sheffield
| | - M W R Reed
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - L Wyld
- Department of Oncology and Metabolism, Medical School, University of Sheffield, Sheffield
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16
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Karakatsanis A, Markopoulos C. The challenge of avoiding over- and under-treatment in older women with ductal cancer in situ: A scoping review of existing knowledge gaps and a meta-analysis of real-world practice patterns. J Geriatr Oncol 2020; 11:917-925. [PMID: 32146094 DOI: 10.1016/j.jgo.2020.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 01/25/2020] [Accepted: 02/18/2020] [Indexed: 01/03/2023]
Abstract
Ductal cancer in situ (DCIS) is mainly a screen-detected disease and although the risk for breast cancer is age-dependent, most screening programs do not include women over the age of 75 years. Older women are usually excluded from clinical trials and treatment practices are largely based on observational studies or extrapolation of trial results from younger patients, leading to either over- or under-treatment of this population. We systematically reviewed available electronic databases for DCIS treatment patterns and outcomes in older patients 15 years. Inclusion criteria allowed for randomised controlled trials, cohort studies, case-control and cross-sectional studies, as well as meta-analyses, systematic reviews and position papers. Results showed that, although elderly are not necessarily frail, they are generally treated as such by physicians, aiming to de-escalate therapeutic interventions. After adjusting for frailty, age seems to be a significant factor for less surgery; however, older women with DCIS are more probable to receive surgery than their counterparts with early invasive cancer. DCIS biology and subtypes are independent risk factors for local recurrence or progression to invasive carcinoma, if DCIS is under-treated. The end-benefit of surgery, radio- and endocrine-therapy depend on additional parameters, such as life expectancy, co-morbidities and competing risks of death. Screen-detected DCIS in older women is a challenging clinical problem, mainly due to the lack of high-level data. Therapeutic strategies should be tailored to life expectancy and performance status, DCIS features and patient preference, aiming at combining optimal oncological outcomes with maintenance of quality of life.
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Affiliation(s)
- Andreas Karakatsanis
- Section for Endocrine and Breast Surgery, Department for Surgical Sciences, Uppsala University, Uppsala, Sweden.
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17
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Lee C, Jafari M, Brownbridge R, Phillips C, Vanstone JR. The viral prescription pad - a mixed methods study to determine the need for and utility of an educational tool for antimicrobial stewardship in primary health care. BMC FAMILY PRACTICE 2020; 21:42. [PMID: 32087685 PMCID: PMC7035666 DOI: 10.1186/s12875-020-01114-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 02/18/2020] [Indexed: 12/17/2022]
Abstract
Background In order to combat rising rates of antimicrobial resistant infections, it is vital that antimicrobial stewardship become embedded in primary health care (PHC). Despite the high use of antimicrobials in PHC settings, there is a lack of data regarding the integration of antimicrobial stewardship programs (ASP) in non-hospital settings. Our research aimed to determine which antimicrobial stewardship interventions are optimal to introduce into PHC clinics beginning to engage with an ASP, as well as how to optimize those interventions. This work became focused specifically around management of viral upper respiratory tract infections (URTIs), as these infections are one of the main sources of inappropriate antibiotic use. Methods This mixed methods study of sequential explanatory design was developed through three research projects over 3 years in Regina, Saskatchewan, Canada. First, a survey of PHC providers was performed to determine their perceived needs from a PHC-based ASP. From this work, a “viral prescription pad” was developed to provide a tool to help PHC providers engage in patient education regarding appropriate antimicrobial use, specifically for URTIs. Next, interviews were performed with family physicians to discuss their perceived utility of this tool. Finally, we performed a public survey to determine preferences for the medium by which information is received regarding symptom management for viral URTIs. Results The majority of PHC providers responding to the initial survey indicated they were improperly equipped with tools to aid in promoting conversations with patients and providing education about the appropriate use of antimicrobials. Following dissemination of the viral prescription pad and semi-structured interviews with family physicians, the viral prescription pad was deemed to be a useful educational tool. However, about half of the physicians interviewed indicated they did not actually provide a viral prescription to patients when providing advice on symptom management for viral URTIs. When asked about their preferences, 76% of respondents to the public survey indicated they would prefer to receive written or a combination of verbal and written information in this circumstance. Conclusions PHC providers indicated a need for educational tools to promote conversations with patients and provide education about the appropriate use of antimicrobials. Viral prescription pads were regarded by family physicians and patients as useful tools in facilitating discussion on the appropriate use of antimicrobials. PHC providers should exercise caution in opting out of providing written forms of information, as many respondents to the general public survey indicated their preference in receiving both verbal and written information.
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Affiliation(s)
- Christine Lee
- College of Pharmacy and Nutrition, University of Saskatchewan, 104 Clinic Place, Saskatoon, SK, S7N 2Z4, Canada
| | - Maryam Jafari
- Dr. T. Bhanu Prasad Medical Professional Corporation, 3401B Pasqua St., Regina, SK, S4S 7K9, Canada
| | - Regan Brownbridge
- College of Medicine, University of Saskatchewan, 107 Wiggins Rd., Saskatoon, SK, S7N 5E5, Canada
| | - Casey Phillips
- Antimicrobial Stewardship Program, Saskatchewan Health Authority - Regina Area, 4B35, 1440 - 14th Ave., Regina, SK, S4P 0W5, Canada
| | - Jason R Vanstone
- Stewardship and Clinical Appropriateness, Saskatchewan Health Authority - Regina Area, 4B35, 1440 - 14th Ave., Regina, SK, S4P 0W5, Canada.
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18
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Baker DM, Lee MJ, Folan AM, Blackwell S, Robinson K, Wootton R, Sebastian S, Brown SR, Jones GL, Lobo AJ. Development and evaluation of a patient decision aid for patients considering ongoing medical or surgical treatment options for ulcerative colitis using a mixed-methods approach: protocol for DISCUSS study. BMJ Open 2020; 10:e031845. [PMID: 31941765 PMCID: PMC7045112 DOI: 10.1136/bmjopen-2019-031845] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Approximately 20%-30% of patients with ulcerative colitis (UC) require surgery, the majority of these being elective due to chronic symptoms refractory to medical treatment. The decision for surgery is difficult and dependent on patient preferences. Current resources for patients considering surgery have been found not to meet minimum international standards. The overall aim of the 'DISCUSS' study is to develop and evaluate a new patient decision aid (PtDA) for patients considering surgery for UC created in line with international minimum standards. METHODS AND ANALYSIS This is a prospective mixed-methods study of adults (18+ years) who are considering surgical intervention for UC across two regional centres in Yorkshire, UK. This study is in three stages. In stage 1 we will develop the PtDA and its content via systematic reviews and a patient questionnaire. In stage 2 we will assess the face validity of the PtDA using mixed-methods on key stakeholders using both semistructured interviews and questionnaires, following which the PtDA will be refined. In stage 3 we will assess the acceptability of using the PtDA in clinical practice. This will use a mixed-methods approach on clinicians and patients who are considering undergoing elective surgery. Questionnaires including the Preparation for Decision-Making Scale, a measure of anxiety and decisional conflict will be analysed at two timepoints using paired sample t-tests and CIs. Interviews with patients and clinicians will be analysed using thematic analysis. ETHICS AND DISSEMINATION Research ethics approval from North East-Tyne & Wear South Research Ethics Committee (Ref: 19/NE/0073) and Health Research Authority approval (Ref: 257044) have been granted. Results will be published in open access peer-reviewed journals, presented in conferences and distributed through the Crohn's and Colitis UK charity. External endorsement will be sought from the International Patient Decision Aid Standards Collaboration inventory of PtDAs. PROSPERO REGISTRATION NUMBER CRD42018115513, CRD42019126186, CRD42019125193.
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Affiliation(s)
| | - Matthew James Lee
- Department of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Anne-Mairead Folan
- Department of Psychology, Leeds Beckett University, Leeds, West Yorkshire, UK
| | | | - Kerry Robinson
- Inflammatory Bowel Disease Nurse Specialist, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rebecca Wootton
- Stoma Care Specialist Nurse, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Shaji Sebastian
- Department of Gastroenterology, Hull and East Yorkshire Hospitals NHS Trust, Hull, Kingston upon Hull, UK
| | - Steven R Brown
- Department of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Georgina Louise Jones
- Deparment of Psychology, Leeds Beckett University Faculty of Health and Social Sciences, Leeds, UK
| | - Alan J Lobo
- Gastroenterology Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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19
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Jo HS, Park K, Jung SM. A scoping review of consumer needs for cancer information. PATIENT EDUCATION AND COUNSELING 2019; 102:1237-1250. [PMID: 30772114 DOI: 10.1016/j.pec.2019.02.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 01/30/2019] [Accepted: 02/05/2019] [Indexed: 05/08/2023]
Abstract
OBJECTIVE This study was a scoping review of research on cancer-related health information seeking and needs of patients, survivor, non-patients, and caregivers. METHODS This study used the COSI model to search for articles published from 2007 to 2017. RESULTS In total, 117 articles with titles and abstracts including the following terms were selected: cancer, health, information, seeking. Non-patients obtained information from the Internet, doctors, and media, whereas patients obtained information from doctors, the Internet, and media. Information needs were the highest for treatment, prognosis, and psychosocial support. Patients had the highest need for information on prognosis and treatment, whereas non-patients had the highest need for general cancer information, prevention, and cancer examination. Caregivers sought information about treatment, psychosocial support, and prevention. CONCLUSION This study revealed an increase in the number of research articles identifying cancer patients' information needs. Cancer patients rely on health professionals for information; thus, relevant materials are needed. Furthermore, not only medical but also psychosocial support information is needed. PRACTICE IMPLICATIONS There is a need for cancer information from health professionals, and thus for patient-centered training materials. Furthermore, a survey system to evaluate consumers' cancer information needs should be developed.
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Affiliation(s)
- Heui Sug Jo
- Department of Health Policy and Management, Kangwon National University College of Medicine, Chuncheon, South Korea
| | - Keeho Park
- Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, South Korea
| | - Su Mi Jung
- Department of Health Policy and Management, Kangwon National University College of Medicine, Chuncheon, South Korea.
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20
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Karuturi MS, Lei X, Shen Y, Giordano SH, Swanick CW, Smith BD. Long-term decision regret surrounding systemic therapy in older breast cancer survivors: A population-based survey study. J Geriatr Oncol 2019; 10:973-979. [PMID: 30940493 DOI: 10.1016/j.jgo.2019.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 12/01/2018] [Accepted: 03/20/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Little is known regarding regret experienced by older breast cancer survivors surrounding the choice for adjuvant systemic therapy, which limits providers' ability to optimally engage in the shared decision-making process. To address this, we evaluated endocrine therapy and chemotherapy decisional regret in a population-based cohort of older breast cancer survivors. MATERIALS AND METHODS Nationally comprehensive Medicare claims identified women age ≥67 living in the US with non-metastatic breast cancer diagnosed in 2009 and still alive in 2015. The Decision Regret Scale, a validated index that assesses regret regarding treatment decisions on a scale of 0 (no regret) to 100, was used to measure regret for endocrine therapy and chemotherapy approximately 6 years after diagnosis and was adjusted for sampling weight. Multivariable logistic regression adjusted for patient, demographic, and treatment characteristics identified predictors of endocrine therapy and chemotherapy decision regret. RESULTS Of the 480 respondents, 299 patients (61.1%) reported receiving endocrine therapy and 133 (27%) chemotherapy. The overall weighted decision-regret score was 17.2 (95%CI 13.6-20.8) for endocrine therapy and 17.7 (95%CI 12.1-23.3) for chemotherapy. Risk factors for higher endocrine therapy regret included white race (referent non-white race; estimate 12.8, 95%CI 3.0-22.7; P = 0.01) and post-graduate educational attainment (referent college education; 11.6, 95%CI 1.9-21.3; P = 0.02). The only risk factor for chemotherapy regret, albeit marginal, was age ≥75 (referent age 67-74; 12.0, 95%CI -0.1-24.2; P = 0.05) CONCLUSION: Overall, decision regret levels regarding systemic therapy in older breast cancer survivors are reassuringly low. However, further studies are needed to explore drivers of regret in certain vulnerable subgroups of patients.
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Affiliation(s)
- Meghan Sri Karuturi
- Department of Breast Medical Oncology, The University of Texas, MD Anderson Cancer Center, United States of America.
| | - Xiudong Lei
- Department of Health Services, The University of Texas, MD Anderson Cancer Center, United States of America
| | - Yu Shen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, United States of America
| | - Sharon H Giordano
- Department of Breast Medical Oncology, The University of Texas, MD Anderson Cancer Center, United States of America; Department of Health Services, The University of Texas, MD Anderson Cancer Center, United States of America
| | - Cameron W Swanick
- Department of Radiation Oncology, Orlando Health UF Health Cancer Center, United States of America
| | - Benjamin D Smith
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, United States of America
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21
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Clarke Hillyer G, Basch CH, Guerro S, Sackstein P, Basch CE. YouTube videos as a source of information about mastectomy. Breast J 2019; 25:349-350. [PMID: 30734408 DOI: 10.1111/tbj.13222] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 12/23/2017] [Accepted: 01/03/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Grace Clarke Hillyer
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Corey H Basch
- Department of Public Health, William Paterson University, Wayne, NJ
| | - Sharon Guerro
- Department of Public Health, William Paterson University, Wayne, NJ
| | - Paul Sackstein
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Charles E Basch
- Health and Behavior Studies, Teachers College, Columbia University, New York, New York
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Lifford KJ, Edwards A, Burton M, Harder H, Armitage F, Morgan JL, Caldon L, Balachandran K, Ring A, Collins K, Reed M, Wyld L, Brain K. Efficient development and usability testing of decision support interventions for older women with breast cancer. Patient Prefer Adherence 2019; 13:131-143. [PMID: 30679905 PMCID: PMC6338238 DOI: 10.2147/ppa.s178347] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Around one-third of breast cancers diagnosed every year in the UK are in women aged ≥70 years. However, there are currently no decision support interventions (DESIs) for older women who have a choice between primary endocrine therapy and surgery followed by adjuvant endocrine therapy (surgery+endocrine therapy), or who can choose whether or not to have chemotherapy following surgery. There is also little evidence-based guidance specifically on the management of these older patients. A large UK cohort study is currently underway to address this lack of evidence and to develop two DESIs to facilitate shared decision-making with older women about breast cancer treatments. Here, we present the development and initial testing of these two DESIs. METHODS An initial prototype DESI was developed for the choice of primary endocrine therapy or surgery+endocrine therapy. Semi-structured interviews with healthy volunteers and patients explored DESI acceptability, usability, and utility. A framework approach was used for analysis. A second DESI for the choice of having chemotherapy or not was subsequently developed based on more focused development and testing. RESULTS Participants (n=22, aged 75-94 years, 64% healthy volunteers, 36% patients) found the primary endocrine therapy /surgery+endocrine therapy DESI acceptable, and contributed to improved wording and illustrations to address misunderstandings. The chemotherapy DESI (tested with 14 participants, aged 70-87 years, 57% healthy volunteers, 43% patients) was mostly understandable, however, suggestions for rewording sections were made. Most participants considered the DESIs helpful, but highlighted the importance of complementary discussions with clinicians. CONCLUSION It was possible to use a template DESI to efficiently create a second prototype for a different treatment option (chemotherapy). Both DESIs were acceptable and considered helpful to support/augment consultations. Development of acceptable additional DESIs for similar target populations using simplified methods may be an efficient way to develop future DESIs. Further research is needed to test the effectiveness of the DESIs.
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Affiliation(s)
- Kate J Lifford
- Division of Population Medicine, Cardiff University, Cardiff, UK,
| | - Adrian Edwards
- Division of Population Medicine, Cardiff University, Cardiff, UK,
| | - Maria Burton
- Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK
| | - Helena Harder
- Sussex Health Outcomes Research and Education in Cancer, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Fiona Armitage
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Jenna L Morgan
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Lisa Caldon
- Department of General Surgery, The Rotherham NHS Foundation Trust, Rotherham, UK
| | | | - Alistair Ring
- Breast Unit, Royal Marsden Hospital NHS Foundation Trust, Sutton, UK
| | - Karen Collins
- Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK
| | - Malcolm Reed
- Brighton and Sussex Medical School, Brighton, UK
| | - Lynda Wyld
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Kate Brain
- Division of Population Medicine, Cardiff University, Cardiff, UK,
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23
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de Mik SML, Stubenrouch FE, Balm R, Ubbink DT. Systematic review of shared decision-making in surgery. Br J Surg 2018; 105:1721-1730. [PMID: 30357815 PMCID: PMC6282808 DOI: 10.1002/bjs.11009] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/08/2018] [Accepted: 09/05/2018] [Indexed: 12/21/2022]
Abstract
Background Multiple treatment options are generally available for most diseases. Shared decision‐making (SDM) helps patients and physicians choose the treatment option that best fits a patient's preferences. This review aimed to assess the extent to which SDM is applied during surgical consultations, and the metrics used to measure SDM and SDM‐related outcomes. Methods This was a systematic review of observational studies and clinical trials that measured SDM during consultations in which surgery was a treatment option. Embase, MEDLINE and CENTRAL were searched. Study selection, quality assessment and data extraction were conducted by two investigators independently. Results Thirty‐two articles were included. SDM was measured using nine different metrics. Thirty‐six per cent of 13 176 patients and surgeons perceived their consultation as SDM, as opposed to patient‐ or surgeon‐driven. Surgeons more often perceived the decision‐making process as SDM than patients (43·6 versus 29·3 per cent respectively). SDM levels scored objectively using the OPTION and Decision Analysis System for Oncology instruments ranged from 7 to 39 per cent. Subjective SDM levels as perceived by surgeons and patients ranged from 54 to 93 per cent. Patients experienced a higher level of SDM during consultations than surgeons (93 versus 84 per cent). Twenty‐five different SDM‐related outcomes were reported. Conclusion At present, SDM in surgery is still in its infancy, although surgeons and patients both think of it favourably. Future studies should evaluate the effect of new interventions to improve SDM during surgical consultations, and its assessment using available standardized and validated metrics. Heterogeneous data
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Affiliation(s)
- S M L de Mik
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - F E Stubenrouch
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - R Balm
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - D T Ubbink
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Bunn F, Goodman C, Russell B, Wilson P, Manthorpe J, Rait G, Hodkinson I, Durand MA. Supporting shared decision-making for older people with multiple health and social care needs: a realist synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BackgroundHealth-care systems are increasingly moving towards more integrated approaches. Shared decision-making (SDM) is central to these models but may be complicated by the need to negotiate and communicate decisions between multiple providers, as well as patients and their family carers; this is particularly the case for older people with complex needs.ObjectivesTo provide a context-relevant understanding of how models to facilitate SDM might work for older people with multiple health and care needs and how they might be applied to integrated care models.DesignRealist synthesis following Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) publication standards.ParticipantsTwenty-four stakeholders took part in interviews.Data sourcesElectronic databases including MEDLINE (via PubMed), The Cochrane Library, Scopus, Google and Google Scholar (Google Inc., Mountain View, CA, USA). Lateral searches were also carried out. All types of evidence were included.Review methodsIterative stakeholder-driven, three-stage approach, involving (1) scoping of the literature and stakeholder interviews (n = 13) to develop initial programme theory/ies, (2) systematic searches for evidence to test and develop the theories and (3) validation of programme theory/ies with stakeholders (n = 11).ResultsWe included 88 papers, of which 29 focused on older people or people with complex needs. We identified four theories (context–mechanism–outcome configurations) that together provide an account of what needs to be in place for SDM to work for older people with complex needs: understanding and assessing patient and carer values and capacity to access and use care; organising systems to support and prioritise SDM; supporting and preparing patients and family carers to engage in SDM; and a person-centred culture of which SDM is a part. Programmes likely to be successful in promoting SDM are those that create trust between those involved, allow service users to feel that they are respected and understood, and engender confidence to engage in SDM.LimitationsThere is a lack of evidence on interventions to promote SDM in older people with complex needs or on interprofessional approaches to SDM.ConclusionsModels of SDM for older people with complex health and care needs should be conceptualised as a series of conversations that patients, and their family carers, may have with a variety of different health and care professionals. To embed SDM in practice requires a shift from a biomedical focus to a more person-centred ethos. Service providers are likely to need support, both in terms of the way services are organised and delivered and in terms of their own continuing professional development. Older people with complex needs may need support to engage in SDM. How this support is best provided needs further exploration, although face-to-face interactions and ongoing patient–professional relationships are key.Future workThere is a need for further work to establish how organisational structures can be better aligned to meet the requirements of older people with complex needs. This includes a need to define and evaluate the contribution that different members of health and care teams can make to SDM for older people with complex health and care needs.Study registrationThis study is registered as PROSPERO CRD42016039013.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Frances Bunn
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Claire Goodman
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Bridget Russell
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Patricia Wilson
- Centre for Health Service Studies, University of Kent, Canterbury, UK
| | - Jill Manthorpe
- Social Care Workforce Research Unit, King’s College London, London, UK
| | - Greta Rait
- Research Department of Primary Care and Population Health, University College London Medical School (Royal Free Campus), London, UK
| | - Isabel Hodkinson
- Tower Hamlets Clinical Commissioning Group, The Tredegar Practice, London, UK
| | - Marie-Anne Durand
- The Preference Laboratory, The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH, USA
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25
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Middleton MR, Atkins MB, Amos K, Wang PF, Kotapati S, Sabater J, Beusterien K. Societal preferences for adjuvant melanoma health states: UK and Australia. BMC Cancer 2017; 17:689. [PMID: 29041898 PMCID: PMC5646133 DOI: 10.1186/s12885-017-3673-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 10/05/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND No studies have measured preference-based utility weights for specific toxicities and outcomes associated with approved and investigational adjuvant treatments for patients with resected high-risk melanoma. METHODS A cross-sectional study was conducted in the United Kingdom and Australia to obtain utilities for 14 adjuvant melanoma health states. One-on-one interviews were conducted using standard gamble; utility weights range from 0.0, dead, to 1.0, full health. Supplemental risk questions also were asked. RESULTS Among 155 participants (52% male; mean age, 46 years) "adjuvant treatment no toxicities" (0.89) was most preferred, followed by "induction treatment" (0.88), and "no treatment" (0.86). Participants least preferred "cancer recurrence" (0.62); the utility for "cancer recurrence and 10-year survival with treatment" was 0.70. Disutilities for grade 2 toxicities ranged from -0.06 for fatigue to -0.13 for hypophysitis. The mean maximum acceptable risk of a life-threatening event ranged from 30% for a 6% increase in the chance of remaining cancer free over 3 years to 40% for an 18% increase; Australian respondents were willing to take higher risks. CONCLUSION Reproducible health utilities for adjuvant melanoma health states were obtained from the general population in two countries. These utilities can be incorporated into treatment-specific cost-effectiveness evaluations.
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Affiliation(s)
- Mark R Middleton
- University of Oxford Department of Oncology, Roosevelt Drive, Oxford, OX3 7DQ, UK
| | - Michael B Atkins
- Georgetown-Lombardi Comprehensive Cancer Ctr, 3970 Reservoir Road, NW Research Building, Room E501, Washington, DC, 20057, USA
| | - Kaitlan Amos
- Outcomes Research Strategies in Health, Washington, DC, 20008, USA
| | - Peter Feng Wang
- Bristol-Myers Squibb Co, 3401 Princeton Pike, Lawrenceville, NJ, 08648, USA
| | - Srividya Kotapati
- Bristol-Myers Squibb Co, 3401 Princeton Pike, Lawrenceville, NJ, 08648, USA
| | - Javier Sabater
- Bristol-Myers Squibb S.A. Quintanavides, 15, 28050, Madrid, Spain
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