Treatment decision-making in the medical encounter: comparing the attitudes of French surgeons and their patients in breast cancer care

Patient experience and satisfaction with shared decision-making: A cross-sectional study among outpatients

OBJECTIVES

This study aimed to investigate how doctor-patient communication, trust in doctors impacted patients' experience and satisfaction in shared decision-making (SDM).

METHODS

This study is based on the data from a cross-sectional survey (n = 12,401) conducted in 27 public specialist outpatient clinics in Hong Kong.

RESULTS

The multivariable regression models revealed that doctors' better communication skills were associated with lower decision-making involvement (odd ratio, 0.75 [95 % CI, 0.88-0.94], P < .001) but higher satisfaction with involvement (odd ratio, 6.88 [95 % CI, 5.99-7.93], P < .001). Similarly, longer consultation durations were associated with reduced involvement in decision-making (odd ratio, 0.71 [95 % CI, 0.66-0.73], P < .001) but increased satisfaction with involvement (odd ratio, 1.91 [95 % CI, 1.80-2.04], P < .001). Trust in doctors significantly mediated these associations, except for the association between consultation duration and patients' satisfaction with decision-making involvement.

CONCLUSION

Doctors' better communication skills and longer consultations might not necessarily increase patient involvement in SDM but correlated with increased satisfaction with involvement. Trust in doctors emerged as a mediator for participation and satisfaction in decision-making.

PRACTICE IMPLICATIONS

Clinics should consider patients' preferences and capabilities when tailoring communication strategies about decision-making and optimizing patient satisfaction.

An Autoethnographic Exploration of My Breast Cancer Journey: Egg Freezing, Childfreeness, and "Going Flat"

In this essay, I discuss my personal experience with breast cancer, exploring three intertwined choices: declining medical egg freezing, choosing not to bear children, and opting out of breast reconstruction after a double mastectomy. Through autoethnography, I narrate how being an immigrant Latina cisgender lesbian in Europe influenced my decision-making processes. Challenging common assumptions about the invariably negative emotional impact on survivors of bilateral mastectomy and infertility, I emphasize the importance for me of minimizing additional pain by eliminating "unnecessary" medical interventions. Likewise, I address concerns about body changes, bodily integrity, and the impact of a positive genetic mutation on my family. My aim is to shed light on knowledge production gaps by sharing my journey from a minority perspective.

Shared Decision-making in Breast Cancer Reconstructive Surgery: Experience in a Leading Hospital

Background

The paradigm of healthcare has evolved toward patient-centered approaches, where shared decision-making (SDM) plays a pivotal role. This study aimed to explore the implementation of SDM during breast cancer reconstruction consultations and assess its impact on patient satisfaction and the decision-making process as a whole.

Methods

A total of 102 female patients undergoing breast reconstruction were included in a multidisciplinary breast pathology unit. A streamlined SDM model involving choice introduction, option description, and preference exploration was implemented. A validated Spanish version of the nine-item Shared Decision Making Questionnaire was used alongside a complementary questionnaire. Data analysis was carried out using electronic data capture software.

Results

The nine-item Shared Decision Making Questionnaire results indicate strong agreement in presenting various options and explaining their advantages and disadvantages. Patients were less confident about their participation in decision-making. The Complementary Shared Decision Making Questionnaire highlighted high satisfaction with interview times and language clarity but areas for improvement in consultation space and therapeutic choice participation.

Conclusions

Integrating SDM into breast reconstruction consultations empowers patients in the decision-making process and enhances satisfaction. Decision aids prove effective in this context, facilitating patients' comprehension and reducing decisional conflict. There are areas for improvement within the SDM strategy, and they are detectable through scales. Although challenges in information transmission and patient involvement persist, adopting an SDM model has potential benefits that warrant further investigation.

[Facilitators and barriers to shared decision-making in France in 2021: National survey in cancer]

INTRODUCTION

Shared-decision making (SDM) combines clinical expertise of the healthcare professional with patient's knowledge, values and preferences. This survey explores from a patient perspective, the implementation, facilitators and barriers of SDM in oncology in France in 2021.

PATIENTS AND METHODS

From August to October 2021, the digital platform Cancer contribution conducted an online survey relayed by 11 patient associations.

RESULTS

Out of 916 responses, 727 were analyzed: 394 from patients with hematological malignancies [HM], 185 with breast cancer [BC], 93 with other solid tumors [ST] and 55 with multiple cancers [MC]. Among the participants, 47.2 % reported that they participated in a decision about their health management, with a significant variation according to the pathology (BC 43.8 %, HM 41.1 %, ST 57 %, MC 60 %, P=0.01), and regardless of age and gender. Two-thirds felt comfortable with the shared decision-making process, in relation with the time allocated and the information provided, regardless of the pathology. In addition, emotions, uncertainty and lack of information are the main reasons quoted by patients to explain their lack of ease in making a decision related to their health.

CONCLUSIONS

In this survey, less than half of the patients declared that they have been enrolled in a SDM approach, this rate varying according to the type of solid tumor or hematological malignancy. This study shows that to improve the implementation of SDM in routine clinical practice in cancer, sufficient time and use of decision aids are needed.

How are patient-related characteristics associated with shared decision-making about treatment? A scoping review of quantitative studies

OBJECTIVES

To identify what patient-related characteristics have been reported to be associated with the occurrence of shared decision-making (SDM) about treatment.

DESIGN

Scoping review.

ELIGIBILITY CRITERIA

Peer-reviewed articles in English or Dutch reporting on associations between patient-related characteristics and the occurrence of SDM for actual treatment decisions.

INFORMATION SOURCES

COCHRANE Library, Embase, MEDLINE, PsycInfo, PubMed and Web of Science were systematically searched for articles published until 25 March 2019.

RESULTS

The search yielded 5289 hits of which 53 were retained. Multiple categories of patient characteristics were identified: (1) sociodemographic characteristics (eg, gender), (2) general health and clinical characteristics (eg, symptom severity), (3) psychological characteristics and coping with illness (eg, self-efficacy) and (4) SDM style or preference. Many characteristics showed no association or unclear relationships with SDM occurrence. For example, for female gender positive, negative and, most frequently, non-significant associations were seen.

CONCLUSIONS

A large variety of patient-related characteristics have been studied, but for many the association with SDM occurrence remains unclear. The results will caution often-made assumptions about associations and provide an important step to target effective interventions to foster SDM with all patients.

Study protocol comparing the ethical, psychological and socio-economic impact of personalised breast cancer screening to that of standard screening in the "My Personal Breast Screening" (MyPeBS) randomised clinical trial

Background

The MyPeBS study is an ongoing randomised controlled trial testing whether a risk-stratified breast cancer screening strategy is non-inferior, or eventually superior, to standard age-based screening at reducing incidence of stage 2 or more cancers. This large European Commission-funded initiative aims to include 85,000 women aged 40 to 70 years, without prior breast cancer and not previously identified at high risk in six countries (Belgium, France, Italy, Israel, Spain, UK). A specific work package within MyPeBS examines psychological, socio-economic and ethical aspects of this new screening strategy. It compares women’s reported data and outcomes in both trial arms on the following issues: general anxiety, cancer-related worry, understanding of breast cancer screening strategy and information-seeking behaviour, socio-demographic and economic characteristics, quality of life, risk perception, intention to change health-related behaviours, satisfaction with the trial.

Methods

At inclusion, 3-months, 1-year and 4-years, each woman participating in MyPeBS is asked to fill online questionnaires. Descriptive statistics, bivariate analyses, subgroup comparisons and analysis of variations over time will be performed with appropriate tests to assess differences between arms. Multivariate regression models will allow modelling of different patient reported data and outcomes such as comprehension of the information provided, general anxiety or cancer worry, and information seeking behaviour. In addition, a qualitative study (48 semi-structured interviews conducted in France and in the UK with women randomised in the risk-stratified arm), will help further understand participants’ acceptability and comprehension of the trial, and their experience of risk assessment.

Discussion

Beyond the scientific and medical objectives of this clinical study, it is critical to acknowledge the consequences of such a paradigm shift for women. Indeed, introducing a risk-based screening relying on individual biological differences also implies addressing non-biological differences (e.g. social status or health literacy) from an ethical perspective, to ensure equal access to healthcare. The results of the present study will facilitate making recommendations on implementation at the end of the trial to accompany any potential change in screening strategy.

Trial registration

Study sponsor: UNICANCER. My personalised breast screening (MyPeBS). Clinicaltrials.gov (2018) available at: https://clinicaltrials.gov/ct2/show/NCT03672331

Contact: Cécile VISSAC SABATIER, PhD, + 33 (0)1 73 79 77 58 ext + 330,142,114,293, contact@mypebs.eu.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09484-6.

Patients' preferred and perceived level of involvement in decision making for cancer treatment: A systematic review

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.

Shared decision making in Australian physiotherapy practice: A survey of knowledge, attitudes, and self-reported use

Objective

To assess Australian physiotherapists’ knowledge about, attitudes towards, and self-reported use of shared decision making, as well as perceived barriers to its implementation in practice.

Methods

Physiotherapists registered for a national Australian physiotherapy conference were invited via email and the conference app to complete a self-administered online questionnaire about shared decision making, including: a) knowledge, b) attitude to and reported approach in practice, c) behaviours used, d) barriers, e) previous training and future training interest. Responses were analysed descriptively and open-ended questions synthesised narratively.

Results

372 physiotherapists (71% female, mean age 45 years, mean experience 23 years) completed the survey. Respondents had a good level of knowledge on most questions, with correct responses ranging from 39.5% to 98.5% of participants, and a generally positive attitude towards shared decision making, believing it useful to most practice areas. Sixty percent indicated they make decisions with their patients and there was general agreement between how decisions should be made and how they are actually made. The behaviour with the lowest reported occurrence was explaining the relevant research evidence about the benefits and harms of the options. The main perceived barriers were patient knowledge and confidence, consequent fewer physiotherapy sessions, and time constraints. Most (79%) were keen to learn more about shared decision making.

Conclusions

Shared decision making is of growing importance to all health professions and rarely studied in physical therapy. This sample of Australian physiotherapists had a generally positive attitude to shared decision making and learning more about it. Opportunities for providing such skills training at the undergraduate level and in continuing professional development should be explored. This training should ensure that the communicating evidence component of shared decision making is addressed as well as debunking myths about perceived barriers to its implementation.

Implementing a breast cancer patient decision aid: Process evaluation using medical files and the patients' perspective

Objective

Although patient decision aids (PtDAs) have been shown to improve shared decision‐making, integration into clinical care pathways remains limited. This study investigated, among other outcomes, the uptake of the PtDA by professionals and the uptake as perceived by patients.

Methods

We performed a process evaluation among four breast cancer care teams that had been exposed to a multifaceted implementation strategy. Data were gathered by auditing patient files using a standardised data extraction sheet and conducting telephone interviews with patients using a structured interview guide. We analysed the data by using descriptive statistics.

Results

We found that the implementation strategies, including advice on how and when to present the PtDA to the patient, were followed for 14% of the included patients (N = 84); 92% of the patients reported to have received a login code for the web‐based PtDA, while 67% logged in and used the PtDA at home. An important factor influencing the use was the clinician promoting it when delivering the PtDA (OR 9.95 95% CI 3.03–37.72).

Discussion

The implementation strategies were followed in 14% of the patients, and a high delivery of the PtDA was achieved. Redesigning the care pathway and providing personal instruction on using PtDAs seem crucial.

Decision role preferences for return of results from genome sequencing amongst young breast cancer patients

OBJECTIVE

To better understand decision role preferences in women diagnosed with breast cancer at a young age for return of results of genome sequencing in research and clinical settings.

METHODS

Participants were surveyed about communication and decision-making preferences related to genome sequencing results and factors that may affect these preferences. The primary outcome was decision role preference (Control Preference Scale) for selecting what results to receive within medical care or within a research study.

RESULTS

For results returned as part of medical care, most patients preferred a collaborative (N = 481, 45%) or active (N = 488, 45%) role with only 107 (10%) choosing a passive role. When making the decision as part of a research study, most patients preferred an active role (N = 617, 57%), 350 (33%) choosing a collaborative role, and110 (10%) choosing a passive role.

CONCLUSION

Most women in this study preferred to share in decision making. Participants had somewhat different role preferences for clinical and research contexts, with greater preference for active roles in the research context.

PRACTICE IMPLICATIONS

We advocate for practice guidelines that incorporate discussion of decision role as an integral part of patient centered care and shared decision-making and recognize that more work is needed to inform guidelines.

Systematic review of shared decision-making in surgery

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

[Why and how to promote decision-making autonomy of cancer patients?]

Involvement of patients in decision-making about their health has been promoted nationally and internationally since several years. Despite this, patient (and their relatives) participation remains insufficient and one of the objectives of the current French national cancer policy (Plan cancer 2014-2019) is to give everyone the possibility to play an active role in the management of their care. This overview focuses on decision-making autonomy of cancer patients through two main questions: why and how to promote it? After a brief review of the decision-making models described in the literature in the past decades insisting on the major role of the decisional context and the dynamic character of this context, this article presents a selection of published works which aimed to respond to those 2 questions.

Information behaviour and decision-making in patients during their cancer journey

Purpose

This paper aims to investigate the effect of cancer patients’ information behaviour on their decision-making at the diagnosis and treatment stages of their cancer journey. Patients’ information sources and their decision-making approaches were analyzed.

Design/methodology/approach

Semi-structured interviews were conducted with 15 participants.

Findings

The cancer patients sought information from various sources in choosing a hospital, physician, treatment method, diet and alternative therapy. Physicians were the primary information source. The patients’ approaches to treatment decision-making were diverse. An informed approach was adopted by nine patients, a paternalistic approach by four and a shared decision-making approach by only two.

Practical implications

In practice, the findings may assist hospitals and medical professionals in fostering pertinent interactions with patients.

Originality/value

The findings can enhance researcher understanding regarding the effect of cancer patients’ information behaviour on their decision-making.

The decision-making process for breast reconstruction after cancer surgery: Representations of heterosexual couples in long-standing relationships

OBJECTIVES

Most people deal with intrusive life events such as cancer and the care trajectory together with their intimate partners. To our knowledge, no research has studied the involvement of the partner in the decision-making process regarding breast reconstruction (BR) after cancer. This study aimed to gain a better understanding of the couples' decision-making process for BR in the cancer context and particularly to investigate the partners' involvement in this process.

METHOD

Eighteen participants (nine women who underwent a mastectomy following a first breast cancer and their intimate partners) took part in this study. We conducted semidirective interviews, and a general inductive approach was chosen to capture the representations of the couples.

RESULTS

The women in the sample were aged between 33 and 66 years (M = 54, SD = 7.5) and their partner between 40 and 76 years (M = 59, SD = 11.6). The duration of their intimate relationship was on average 18 years (SD = 10.4; minimum = 4; maximum = 33). The analysis revealed 11 major themes. The two most salient ones were 'external influence' and 'implication of the partner'. The exploration of the subthemes revealed that the decision-making process is often reported as an interrelated experience by the couples and as a dyadic stressor. The partner's role is depicted as consultative and mostly supportive.

CONCLUSION

These results provide new insights on the involvement of the partner in decision-making. Thus, it now seems crucial to develop a prospective study, which will help understand the progression of the decision-making process over time. Statement of contribution What is already known on this subject? Most people deal with intrusive life events such as cancer and the care trajectory together with their intimate partners. Shared decision-making between patients and physicians is now the 'gold standard' in Western Europe and the United States. However, in the context of breast reconstruction (BR) after cancer, factors guiding the decision-making process for BR, especially the potential involvement of the partner, are not very well understood. What does this study add? Provides a qualitative insight on the specific nature of heterosexual couples' representations regarding the decision-making process for breast reconstruction after cancer. Reveals that the decision-making process is often reported as an interrelated experience by the couples and as a dyadic stressor. Underlines the consultative function of partners with women engaged in breast reconstruction.

Physician attitudes toward shared decision making: A systematic review

OBJECTIVE

Although evidence suggests that shared decision-making (SDM) can improve patient outcomes, uptake to date has been sparse. The purpose of this review was to determine the reported opinions of physicians regarding the use of SDM in clinical practice and to identify strategies to promote uptake.

METHODS

We conducted a systematic review, including papers published between 2007 and 2014.

RESULTS

The electronic search yielded 11,761 results. Following abstract review, 123 papers were selected for full text review, and 43 papers were included for analysis. Fourteen of the included studies considered SDM within the context of primary care, 25 in secondary care, and 4 in both.

CONCLUSIONS

Physicians express positive attitudes toward SDM in clinical practice, although the level of support varies by clinical scenario, treatment decision and patient characteristics.

PRACTICE IMPLICATIONS

Physician support for SDM is a necessary, if not sufficient, condition to facilitate meaningful SDM. In order to garner support for SDM, additional empirical evidence regarding the clinical and patient important outcomes must be established. Based on the results of this review, the authors suggest assessing the impact of SDM within the context of chronic disease management where multiple therapeutic options exist, and outcomes may be measured long-term.

A structuration framework for bridging the macro-micro divide in health-care governance

BACKGROUND

Extant studies demonstrate that macro (hierarchical) and micro (relational) governance initiatives in health-care settings continue to be developed in isolation rather than interactively. Government-driven hierarchical governance endeavours that guide health-care reforms and medical practice are disconnected from micro-level physician-patient interactions being unable to account for patient preferences in the macro-level policymaking.

METHOD/OBJECTIVE

We undertake a review of the recent literature to couch our argument for a unified governance framework for bridging the macro-micro divide in medical contexts. Adopting an interdisciplinary approach to health-care delivery, we maintain that the (strong) structuration theory provides a fruitful opportunity for narrowing the gap between hierarchical and relational governance.

DISCUSSION

Emphasizing the coexistence of institutional structures and human agency, the (strong) structuration theory elucidates how macro and micro governance devices shape each other's structure via mutually reinforcing cycles of influence. Micro-level encounters between patients and physicians give rise to social structures that constitute the constraining and enabling forces through which macro-level health-care infrastructures are altered and reproduced over time. Permitting to illustrate how patients' agency can effectively emerge from complex networks of clinical trajectories, the advanced structuration framework for macro-micro governance integration avoids the extremes of paternalism and autonomy through a balanced consideration of professional judgement and patient preferences.

CONCLUSION/IMPLICATIONS

The macro-micro integration of governance efforts is a critical issue in both high-income states, where medical institutions attempt to deploy substantial realignment efforts, and developing nations, which are lagging behind due to leadership weaknesses and lower levels of governmental investment. A key priority for regulators is the identification of relevant systems to support this holistic governance by providing clinicians with needed resources for focusing on patient advocacy and installing enabling mechanisms for incorporating patients' inputs in health-care reforms and policymaking.

Talking with parents about end-of-life decisions for their children

BACKGROUND AND OBJECTIVE

Retrospective studies show that most parents prefer to share in decisions to forgo life-sustaining treatment (LST) from their children. We do not yet know how physicians and parents communicate about these decisions and to what extent parents share in the decision-making process.

METHODS

We conducted a prospective exploratory study in 2 Dutch University Medical Centers.

RESULTS

Overall, 27 physicians participated, along with 37 parents of 19 children for whom a decision to withhold or withdraw LST was being considered. Forty-seven conversations were audio recorded, ranging from 1 to 8 meetings per patient. By means of a coding instrument we quantitatively and qualitatively analyzed physicians' and parents' communicative behaviors. On average, physicians spoke 67% of the time, parents 30%, and nurses 3%. All physicians focused primarily on providing medical information, explaining their preferred course of action, and informing parents about the decision being reached by the team. Only in 2 cases were parents asked to share in the decision-making. Despite their intense emotions, most parents made great effort to actively participate in the conversation. They did this by asking for clarifications, offering their preferences, and reacting to the decision being proposed (mostly by expressing their assent). In the few cases where parents strongly preferred LST to be continued, the physicians either gave parents more time or revised the decision.

CONCLUSIONS

We conclude that parents are able to handle a more active role than they are currently being given. Parents' greatest concern is that their child might suffer.