Understanding Patient Preferences Regarding the Important Determinants of Breast Cancer Treatment: A Narrative Scoping Review

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.

Simulation modeling of breast cancer endocrine therapy duration by patient and tumor characteristics

Background

Extending endocrine therapy from 5 to 10 years is recommended for women with invasive estrogen receptor (ER)‐positive breast cancers. We evaluated the benefits and harms of the five additional years of therapy.

Methods

An established Cancer Intervention and Surveillance Network (CISNET) model used a lifetime horizon with national and clinical trial data on treatment efficacy and adverse events and other‐cause mortality among multiple birth cohorts of U.S. women ages 25–79 newly diagnosed with ER+, non‐metastatic breast cancer. We assumed 100% use of therapy. Outcomes included life years (LYs), quality‐adjusted life years (QALYs), and breast cancer mortality. Results were discounted at 3%. Sensitivity analyses tested a 15‐year time horizon and alternative assumptions.

Results

Extending tamoxifen therapy duration among women ages 25–49 reduced the lifetime probability of breast cancer death from 11.9% to 9.3% (absolute difference 2.6%). This translates to a gain of 0.77 LYs (281 days)/woman (undiscounted). Adverse events reduce this gain to 0.44 QALYs and after discounting, gains are 0.20 QALYs (73 days)/woman. Extended aromatase inhibitor therapy in women 50–79 had small absolute benefits and gains were offset by adverse events (loss of 0.06 discounted QALYs). There were greater gains with extended endocrine therapy for women with node‐positive versus negative cancers, but only women ages 25–49 and 50–59 had a net QALY gain. All gains were reduced with less than 100% treatment completion.

Conclusion

The extension of endocrine therapy from 5 to 10 years modestly improved lifetime breast cancer outcomes, but in some women, treatment‐related adverse events may outweigh benefits.

Patient Preferences: Results of a German Adaptive Choice-Based Conjoint Analysis (Market Research Study Sponsored by Eli Lilly and Company) in Patients on Palliative Treatment for Advanced Breast Cancer

INTRODUCTION

Integration of patient preferences into shared decision making improves disease-related outcomes, but such data from patients with advanced breast cancer (aBC) are limited. The objective of this study was to demonstrate the relative importance of overall survival (OS) and progression-free survival (PFS) in relation to quality of life (QoL) and therapy-associated side effects from the perspective of patients with aBC.

METHODS

Postmenopausal patients with hormone receptor-positive, human epidermal growth factor receptor 2-negative aBC receiving first- or second-line treatment were recruited throughout Germany. Patient-relevant attributes for aBC therapy assessment were collected using a stepwise multimodal approach. A conjoint matrix was developed, resulting in 2 attributes for therapy goals (OS and PFS), 4 for QoL, and 6 for side effects. An online quantitative survey was then performed using adaptive choice-based conjoint (ACBC) methodology.

RESULTS

The quantitative survey included 104 patients: 67 (64.4%) receiving first-line treatment and 37 (35.6%) receiving second-line treatment. The QoL attribute "physical agility and mobility" received the highest utility score (19.4 of 100%), reflecting the greatest importance to patients, followed by treatment goals (OS [15.2%] and PFS [14.4%]). Therapy-related side effects were less important, with nausea/vomiting being the most important (9.3%), followed by infection (6.4%) and hair loss (5.0%). The McFadden pseudo R2 (0.805), the root likelihood (0.864), and the χ2 test (2,809.041; p < 0.0001) indicated a very good fit of the statistical model.

CONCLUSION

Using ACBC analysis, it appears that QoL, OS, and PFS are most important to postmenopausal patients with aBC in relation to cancer treatment. Side effects seem to be less important if OS or PFS are prolonged and the QoL is maintained. Thus, QoL, OS, and PFS should be considered equally when making treatment decisions in aBC.

Simulation of Chemotherapy Effects in Older Breast Cancer Patients With High Recurrence Scores

BACKGROUND

Tumor genomic expression profile data are used to guide chemotherapy choice, but there are gaps in evidence for women aged 65 years and older. We estimate chemotherapy effects by age and comorbidity level among women with early-stage, hormone receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative breast cancers and Oncotype DX scores of 26 or higher.

METHODS

A discrete-time stochastic state transition simulation model synthesized data from population studies and clinical trials to estimate outcomes over a 25-year horizon for subgroups based on age (65-69, 70-74, 75-79, and 80-89 years) and comorbidity levels (no or low, moderate, severe). Outcomes were discounted at 3%, and included quality-adjusted life-years (QALYs), life-years, and breast cancer and other-cause mortality with chemoendocrine vs endocrine therapy. Sensitivity analysis tested the effect of varying uncertain parameters.

RESULTS

Women aged 65-69 years with no or low comorbidity gained 0.16 QALYs with chemo-endocrine and reduced breast cancer mortality from 34.8% to 29.7%, for an absolute difference of 5.1%; this benefit was associated with a 12.8% rate of grade 3-4 toxicity. Women aged 65-69 years with no or low or moderate comorbidity levels, and women aged 70-74 years with no or low comorbidity had small chemotherapy benefits. All women aged 75 years and older experienced net losses in QALYs with chemo-endocrine therapy. The results were robust in sensitivity analyses. Chemotherapy had greater benefits as treatment effectiveness increased, but toxicity reduced the QALYs gained.

CONCLUSION

Among women aged 65-89 years whose tumors indicate a high recurrence risk, only those aged 65-74 years with no or low or moderate comorbidity have small benefits from adding chemotherapy to endocrine therapy. Genomic expression profile testing (and chemotherapy use) should be reserved for women aged younger than 75 years without severe comorbidity.

Patient, Oncologist, and Payer Preferences for Adjuvant Endocrine Therapy and CDK4/6 Inhibitor Regimens in Early-Stage Breast Cancer: A Discrete Choice Experiment

PURPOSE

Several adjuvant phase III trials are evaluating cyclin-dependent kinase 4/6 inhibitors (CDK4/6is) in combination with endocrine therapy (ET) in hormonal receptor positive (HR+)/human epidermal growth factor receptor 2 negative (HER2-) early-stage breast cancer (eBC). This study examines preferences for this combination regimen and ET alone among patients, oncologists, and payers in the United States.

METHODS

A web-based questionnaire, including a discrete choice experiment (DCE), was administered to patients, practicing oncologists, and payers. In the DCE, respondents selected between hypothetical treatment profiles with attributes associated with ET monotherapy and CDK4/6i + ET regimens. Each treatment alternative was defined by the following attributes: 5-year invasive disease-free survival (iDFS), nausea, diarrhea, neutropenia, alopecia, dosing schedule, and electrocardiogram (ECG) monitoring. Payers had the additional attribute of annual per-patient treatment cost. Hierarchical Bayesian models were used to estimate relative preference weights for each attribute-level and relative attribute importance.

RESULTS

For patients (n=300) and oncologists (n=200), iDFS was most important (2 to 3 times more important than the next most important attribute), followed by neutropenia and diarrhea risks for patients and oncologists, respectively. Patients and oncologists required an improvement in iDFS of 8.0 and 5.6 percentage-points, respectively, to accept an increase in diarrhea risk from 11% to 81%. Payers (n=60) viewed annual per-patient cost as most important for treatment access decision-making, closely followed by iDFS. Payers required an improvement in iDFS of 21.8 percentage-points to accept an increase in cost from $5,100 to $149,400. Across all stakeholder groups, dosing schedule, alopecia risk, and ECG monitoring were perceived as least important.

CONCLUSION

Patients, oncologists, and payers expect a large absolute risk reduction in efficacy to offset the potential risks and costs of adding a CDK4/6i to current standard of care. An open discussion between all stakeholders is necessary to ensure that decision-making, whether at patient- or system-level, is informed by preferences for novel treatments, like CDK4/6is.

Potentially Modifiable Factors Associated with Adherence to Adjuvant Endocrine Therapy among Breast Cancer Survivors: A Systematic Review

Adjuvant endocrine therapy (AET) reduces risk of breast cancer recurrence. However, suboptimal adherence and persistence to AET remain important clinical issues. Understanding factors associated with adherence may help inform efforts to improve use of AET as prescribed. The present systematic review examined potentially modifiable factors associated with adherence to AET in accordance with PRISMA guidelines (PROSPERO registration ID: CRD42019124200). All studies were included, whether factors were significantly associated with adherence or results were null. This review also accounted for the frequency with which a potentially modifiable factor was examined and whether univariate or multivariate models were used. This review also examined whether methodological or sample characteristics were associated with the likelihood of a factor being associated with AET adherence. A total of 68 articles were included. Potentially modifiable factors were grouped into six categories: side effects, attitudes toward AET, psychological factors, healthcare provider-related factors, sociocultural factors, and general/quality of life factors. Side effects were less likely to be associated with adherence in studies with retrospective or cross-sectional than prospective designs. Self-efficacy (psychological factor) and positive decisional balance (attitude toward AET) were the only potentially modifiable factors examined ≥10 times and associated with adherence or persistence ≥75% of the time in both univariate and multivariate models. Self-efficacy and decisional balance (i.e., weight of pros vs. cons) were the potentially modifiable factors most consistently associated with adherence, and hence may be worth focusing on as targets for interventions to improve AET adherence among breast cancer survivors.

Patient Preferences for Breast Cancer Treatment Interventions: A Systematic Review of Discrete Choice Experiments

INTRODUCTION

Understanding how patients value different characteristics of an intervention and make trade-offs in a therapy choice context with potential benefit and possible harm may result in decisions for which a better reflected value is delivered. This systematic review summarizes patient preferences for breast cancer treatments elicited by discrete choice experiments (DCE).

METHODOLOGY

The electronic databases MEDLINE (PubMed), Scopus, PsycINFO, CINAHL, LILACS, and Web of Science were last searched on May 9, 2019 without restrictions regarding language and time of publication. Original studies reporting patient preferences related to breast cancer treatment (surgery, radiotherapy, endocrine therapy, chemotherapy or palliative care) elicited by DCE were eligible. A narrative synthesis of the relative importance and trade-offs of the treatment attributes of each study was reported.

RESULTS

Five studies conducted in Japan, Thailand, USA and the Netherlands with 146-298 participants evaluated preferences regarding chemotherapy regimens for advanced/metastatic disease, and breast reconstruction after mastectomy. The attributes with major relative effects on preferences were greater survival, better aesthetic result of the surgery, and lower side effects and complication rates. Patients would trade a better aesthetic result to minimize complication rates, and, in advanced disease, the willingness to pay was greater for gains in survival and to avoid some severe adverse events.

CONCLUSION

Despite the relative lack of evidence in this specific context, our review shows that breast cancer patients naturally value greater benefit and, in scenarios of advanced and metastatic disease, are willing to face risks of some side effects for gains in survival.

Factors influencing adherence to adjuvant endocrine therapy in breast cancer-treated women: using real-world data to inform a switch from acute to chronic disease management

PURPOSE

Adjuvant endocrine therapy (AET) for ≥ 5 years is generally recommended for women with hormone receptor-positive breast cancer to reduce cancer recurrence/mortality; however, adherence can be suboptimal. We tested determinants of AET adherence using patient characteristics, treatment pathways, AET initiation timing, and multiple healthcare facility use. An underlying objective was to explore how oncological pathways mirror chronic disease management to monitor adherence and target improvement interventions using administrative datasets.

METHODS

Using patient-linked administrative health data from the Italian Lombardy Region, we identified 33.291 surviving patients starting AET in 2010-2016, with two (22.939 patients) or five years (8400 patients) follow-up, using a ≥ 80% prescription refill approach to measure adherence and logistic regression to test determinants of adherence.

RESULTS

AET crude adherence falls significantly during follow-up, from 94% at 1 Year to 58% at 5 Years. At 5 Years, patients who were older (>70), prescribed tamoxifen-only (OR 0.69; 95% CI 0.57-0.83; p = 0.0001) vs. aromatase inhibitors-only or therapy switches, treated for depression (OR 0.68; 95% CI 0.60-0.78; p < 0.0001), with surgery performed in high-volume hospitals (OR 0.85; 95% CI 0.75-0.97; p = 0.0116) showed lower adherence. Loyalty, or continued care in the surgical hospital (OR 1.73; 95% CI 1.51-2.00; p < 0.0001), undergoing chemotherapy before AET (OR 2.65; 95% CI 2.02-3.48; p < 0.0001), and earlier AET initiation, positively influenced adherence.

CONCLUSIONS

Chronic disease monitoring using administrative data can help oncologists focus efforts to ensure AET adherence. Results suggest addressing mental health, age, disease severity patient perceptions, timely AET initiation and therapy switches, and encouraging continued follow-up in the same hospital or better care coordination with outside follow-up specialists.

Clinical Benefit in the Treatment of Patients with Early Breast Cancer

Adjuvant treatment for early breast cancer involves multiple modalities with distinct toxicities and varying relative contributions to the improvement of long-term outcomes. In many situations the expected benefits of treatment may be modest and thus debated, and even in higher risk scenarios, when treatment is clearly indicated, several options are available with varying schedules and toxicities. Regulatory and professional society guidelines defining clinical benefit are available to guide decision-making, but do not capture clinical meaningfulness. There is wide variation among patients regarding the expected improvement in outcomes sufficient to make adjuvant chemotherapy or endocrine therapy worthwhile. While many consider small improvements in outcomes meaningful, some need greater benefit, and a small minority prefer to avoid adjuvant therapies at any rate. Shared decision making has a central role in bridging between clinical evidence, multiple treatment alternatives and patient preferences in the adjuvant treatment of early breast cancer. It is associated with increased patient involvement and responsibility, satisfaction, quality of life and in some instances increase the likelihood of accepting adjuvant treatment. A current understanding of evidence and clinical guidelines, combined with the skills to elicit and appreciate individual patient preferences, is necessary to determine an optimal treatment approach for every individual with breast cancer.

Final results from IMPROVE: a randomized, controlled, open-label, two-arm, cross-over phase IV study to determine patients' preference for everolimus in combination with exemestane or capecitabine in combination with bevacizumab in advanced HR-positive, HER2-negative breast cancer

Background

The objective of the IMPROVE study was patients’ preference for either endocrine-based therapy or combined chemo- and anti-angiogenic therapy in advanced HR-positive/HER2-negative breast cancer.

Methods

In this randomized, cross-over phase IV study, 77 patients were recruited in 26 sites in Germany. Patients were randomized 1:1 to receive either capecitabine plus bevacizumab (Cap+Bev) as first-line therapy followed by cross-over to everolimus plus exemestane (Eve+Exe) as second-line therapy (Arm A) or the reverse sequence (Arm B). The primary endpoint was patients’ preference for either regimen, assessed by the Patient Preference Questionnaire 12 weeks after cross-over. Key secondary endpoints included progression-free survival (PFS), overall survival (OS), safety, and quality of life (QoL).

Results

61.5% of patients preferred Cap+Bev (p = 0.1653), whereas 15.4% preferred Eve+Exe and 23.1% were indecisive. Physicians showed a similar tendency towards Cap+Bev (58.1%) as the preferred regimen versus Eve+Exe (32.3%). Median first-line PFS was longer for Cap+Bev than for Eve+Exe (11.1 months versus 3.5 months). Median second-line PFS was similar between Cap+Bev and Eve+Exe (3.6 months versus 3.7 months). Median OS was comparable between Arm A (28.8 months) and Arm B (24.7 months). 73.0% and 52.6% (first−/second-line, Cap+Bev) and 54.1% and 52.9% (first−/second-line, Eve+Exe) of patients experienced grade 3/4 TEAEs. No treatment-related deaths occurred. QoL and treatment satisfaction were not significantly different between arms or treatment lines.

Conclusions

Patients tended to favor Cap+Bev over Eve+Exe, which was in line with physicians’ preference. Cap+Bev showed superior first-line PFS, while QoL was similar in both arms. No new safety signals were reported.

Trial registration

EudraCT No: 2013–005329-22. Registered on 19 August 20

Adherence to Adjuvant Endocrine Therapy in Women With Breast Cancer: A Prospective Observational Study in Japanese Women

INTRODUCTION

Nonadherence to adjuvant endocrine therapy has been poorly studied in Asian patients with breast cancer. We therefore assessed adherence to endocrine therapy among women with breast cancer in Japan.

PATIENTS AND METHODS

We conducted a prospective observational study among Japanese women with hormone receptor-positive breast cancer. Patients brought their pill packets to visits for 1 year and answered a questionnaire. We also examined prescription records during the study period. Adherence to endocrine therapy was defined as patients who had taken > 80% of the pills according to the packets during the study. Clinicopathologic features and questionnaires were compared between adherent and nonadherent patients.

RESULTS

A total of 234 patients completed the trial, of whom 85% demonstrated adherence based on pill packets, and 98% demonstrated adherence based on prescription records. Mastectomy, higher stage, nodal metastasis and adjuvant chemotherapy were correlated with adherence based on pill packets. Adjuvant chemotherapy was an independent factor associated with adherence. According to the questionnaire, adherent patients were more likely to consult a nurse when they had trouble with their medication. These patients also emphasized the efficacy rather than the side effects of the medication. Nonadherent patients were aware that they were being nonadherent.

CONCLUSION

The results of this study revealed that 85% of patients were adherent to endocrine therapy, but physicians were unaware of the nonadherent patients. Raised awareness of nonadherence and information sharing between patients and medical teams might increase adherence to endocrine therapy.

Understanding patients' preferences for surgical management of urethral stricture disease

OBJECTIVES

To understand how prioritization of treatment attributes and treatment choice varies by patient characteristics, we sought to specifically determine how demographic variables affect patient treatment preference.

PATIENTS AND METHODS

Male patients with urethral stricture disease participated in a choice-based conjoint (CBC) analysis exercise evaluating six treatment attributes associated with internal urethrotomy and urethroplasty. Demographic and past symptom data were collected. Stratified analysis of demographic variables, including age, education, income, was conducted using a mixed effect logistic regression model to evaluate the coefficient size and confidence intervals between the treatments attribute preferences of each strata.

RESULTS

169 patients completed the CBC exercise and were included in our analysis. Overall success of the procedure is the most important treatment attribute to patients and this persists across strata. Older patients (≥65) express preferences for better success rates and fewer future procedures, whereas younger patients prefer a less invasive approach and are more willing to accept additional procedures if needed. Patients with lower levels of education preferred open reconstruction and had a stronger preference against multiple future procedures, whereas those with higher levels of education preferred endoscopic treatment and had a less strong preference against multiple future procedures. Low-income individuals express statistically significant stronger negative preferences against high copay costs compared to high-income individuals.

CONCLUSION

These results can help to inform physicians' counseling about surgical management of urethral stricture disease to better align patient preferences with treatment selection and encourage shared decision making.

Grip Strength in Women Being Treated for Breast Cancer and Receiving Adjuvant Endocrine Therapy: Systematic Review

BACKGROUND

Adjuvant endocrine therapy in breast cancer has increased survival rates; however, it is not without musculoskeletal side effects.

PURPOSE

The purpose of this review was to systematically and critically appraise the available scientific evidence concerning the effect of adjuvant endocrine treatment on grip strength in women being treated for breast cancer.

DATA SOURCES AND STUDY SELECTION

The National Library of Medicine (MEDLINE-PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), Excerpta Medical Database by Elsevier (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Physiotherapy Evidence Database (PEDro) were searched from inception to February 2017 for appropriate papers that could answer the focused question. The searches were independently screened by 2 reviewers. The data from 7 papers that met the eligibility criteria were processed for further analysis.

DATA EXTRACTION AND SYNTHESIS

The collective data and the statistical analysis of all included studies were summarized and presented in a descriptive manner. If not provided, based on data from the individual included studies, a mean percent change in grip strength was calculated. The included studies evaluating aromatase inhibitors had inconclusive outcomes, and studies with a follow-up of 6 or 12 months showed a percent reduction in grip strength varying from 0.1% to 9.7%. None of the included studies showed a significant decrease in grip strength in tamoxifen users, with a percent reduction in grip strength varying from 1.4% to 2.2%.

LIMITATIONS

The 7 studies included cohort studies lacking a control group.

CONCLUSIONS

There is inconclusive evidence for a small decrease in grip strength in women treated for breast cancer who are also receiving aromatase inhibitors. In those that use tamoxifen, grip strength did not change significantly.

Can demographic, clinical and treatment-related factors available at hormonal therapy initiation predict non-persistence in women with stage I-III breast cancer?

PURPOSE

To investigate whether demographic, clinical and treatment-related risk factors known at treatment initiation can be used to reliably predict future hormonal therapy non-persistence in women with breast cancer, and to inform intervention development.

METHODS

Women with stage I-III breast cancer diagnosed 2000-2012 and prescribed hormonal therapy were identified from the National Cancer Registry Ireland (NCRI) and linked to pharmacy claims data from Ireland's Primary Care Reimbursement Services (PCRS). Non-persistence was defined as a treatment gap of ≥180 days within 5 years of initiation. Seventeen demographic, clinical and treatment-related risk factors, identified from a systematic review, were abstracted from the NCRI-PCRS dataset. Multivariate binomial models were used to estimate relative risks (RR) and risk differences (RD) for associations between risk factors and non-persistence. Calibration and discriminative performance of the models were assessed. The analysis was repeated for early non-persistence (<1 year of initiation).

RESULTS

Within 5 years of treatment initiation 680 women (19.9%) were non-persistent. Women aged <50 years (adjusted RR 1.41, 95% CI 1.16-1.70) and those prescribed antidepressants (RR 1.22, 95% CI 1.04-1.45) had increased risk of non-persistence. Married women (RR 0.82 95% CI 0.71-0.94) and those with prior medication use (RR 0.62 95% CI 0.51-0.75) had reduced risk of non-persistence. The area under the receiver-operating characteristic (ROC) curve for non-persistence was 0.61. Findings were similar for early non-persistence.

CONCLUSION

The risk prediction model did not discriminate well between women at higher and lower risk of non-persistence at treatment initiation. Future studies should consider other factors, such as psychological characteristics and experience of side-effects.

Use of Conjoint Analysis to Determine Patient Preferences for Surgical Treatment of Urethral Stricture Disease

INTRODUCTION

Understanding patient preferences for characteristics of treatments facilitates patient participation and doctor-patient communication and enhances patient-centered care. Patient participation is especially important for urethral stricture disease, which has no definitive treatment guidelines favoring either endoscopic incision or open reconstruction, making patient preference an important factor in treatment choice. However, to date, there have been no studies assessing factors that patients value when choosing a treatment option.

METHODS

We employ choice-based conjoint analysis to assess patient preferences in the trade-offs of treatment attributes for urethral stricture disease. Male patients undergoing treatment or follow-up examination for urethral stricture disease were recruited through a University Medical Practice. We included 169 patients in the analysis. Six attributes of both risk and benefit were examined: treatment type, success rate, number of future procedures, post-treatment catheter duration, recovery time, and copayment amount.

RESULTS

The treatment success rate was by far the most important attribute. Relative to a 25% success rate (OR = 1) an 85% success rate (OR = 26.72, p<.01) increased patient preference by approximately 27 times. Furthermore, patients are willing to pay a $10,000 copayment to double the success rate from 25% to 50%. Patients demonstrated a strong aversion to time with a urinary catheter. Catheter duration for 1 week or less (OR = .67, p<.01) reduced patient preference by about 1.5 times when compared to requiring no catheter. We also found that patients place low importance on both how invasive the treatment seems and low copayment amounts but are willing to pay $10,000 copayment for an open reconstruction surgery compared with an endoscopic incision procedure.

CONCLUSION

The findings highlight the importance of shared and detailed physician/patient discussions of all the risk and benefits of each treatment choice and suggest that conjoint analysis may be helpful as a decision aid to guide discussions with individual patients deciding on a treatment.

Evaluating a Decision Aid for Improving Decision Making in Patients with Early-stage Breast Cancer

BACKGROUND

Early-stage breast cancer patients face a series of complex treatment decisions, with the first typically being choice of locoregional treatment. There is a need for tools to support patients in this decision-making process.

METHODS

We developed an innovative, online locoregional treatment tool based on International Patient Decision Aids Standards criteria. We evaluated its impact on patient knowledge about treatment and appraisal of decision making in a pilot study using a clinical sample of newly diagnosed, breast cancer patients who were randomized to view the decision aid website first or complete a survey prior to viewing the decision aid. Differences in knowledge and decision appraisal between the two groups were compared using t-tests and chi-square tests. Computer-generated preferences for treatment were compared with patients' stated preferences using chi-square tests.

RESULTS

One hundred and one newly diagnosed patients were randomized to view the website first or take a survey first. Women who viewed the website first had slightly higher, though not significantly, knowledge about surgery (p = 0.29) and reconstruction (p = 0.10) than the survey-first group. Those who viewed the website first also appraised their decision process significantly more favorably than did those who took the survey first (p < 0.05 for most decision outcomes). There was very good concordance between computer-suggested and stated treatment preferences.

CONCLUSION

This pilot study suggests that an interactive decision tool shows promise for supporting early-stage breast cancer patients with complicated treatment decision making.

What Matters to Women When Making Decisions About Breast Cancer Chemoprevention?

PURPOSE

Despite the effectiveness of chemoprevention (tamoxifen and raloxifene) in preventing breast cancer among women at high risk for the disease, uptake is low. The objective of this study was to determine the tradeoff preferences for various attributes associated with chemoprevention among women not currently taking the drugs.

METHODS

We used rating-based conjoint analysis to evaluate the relative importance of a number of attributes associated with chemoprevention, including risk of side effects, drug effectiveness, time needed to take the drugs, and availability of a blood test to see if the drugs were working in an Internet sample of women. We generated mean importance values and part-worth utilities for all attribute levels associated with taking chemoprevention. We then used multivariable linear regression to examine attribute importance scores controlling for participant age, race, Hispanic ethnicity, educational level, and a family history of breast cancer.

RESULTS

Overall interest in taking chemoprevention was low among the 1094 women included in the analytic sample, even for the scenario in which participants would receive the greatest benefit and fewest risks associated with taking the drugs. Time needed to take the pill for it to work and 5-year risk of breast cancer were the most important attributes driving tradeoff preferences between the chemoprevention scenarios.

CONCLUSIONS

Interest in taking chemoprevention among this sample of women at average risk was low. Addressing women's concerns about the time needed to take chemoprevention for it to work may help clinicians improve uptake of the drugs among those likely to benefit.

Patient-centered Treatment Decisions for Urethral Stricture: Conjoint Analysis Improves Surgical Decision-making

OBJECTIVE

To determine whether the use of a choice-based conjoint analysis (CA) exercise decreased patients' decisional conflict about treatment preferences for surgical management of urethral stricture disease. Understanding patient preferences for treatment decisions assists in shared decision-making and emphasizes patient-centered outcomes. CA offers a method to understand what risks patients are willing to take for what gains.

METHODS

The CA methodology was used by providing participants with case-based choices to elucidate the relative importance that individuals place on various treatment aspects. Patients' decisional conflict regarding surgery for urethral stricture was assessed before and after the CA exercise to assess the impact the exercise had on their decisional conflict.

RESULTS

Completion of the CA exercise resulted in a significant decrease in decisional conflict (P < .001). The majority (59.5%) of participants with decisional conflict before the CA exercise experienced a decrease in decisional conflict afterwards, with only a minority (16.5%) experiencing new decisional conflict after the exercise. Participants felt the choice-based CA exercise was helpful in deciding what was important in making treatment decisions (70%) and in expressing their priorities and treatment preferences (82%). The number needed to counsel to achieve a decrease in decisional conflict was 1.69 and to achieve no decisional conflict was 3.65.

CONCLUSION

Choice-based CA improves patients' ability to express their treatment preferences and decreases decisional conflict. CA may be a new tool that physicians and patients can use to aid in shared decision-making with a focus on patient-centered outcomes.

Treatment Preferences for Routine Lymphadenectomy Versus No Lymphadenectomy in Early-Stage Endometrial Cancer

BACKGROUND

Debate on the value of lymphadenectomy continues in endometrial cancer. The aim of this study was to investigate patient and clinician preferences for routine lymphadenectomy versus no lymphadenectomy in the surgical management of endometrial cancer.

METHODS

A discrete choice experiment and trade-off question were designed and distributed to 103 endometrial cancer patients and 90 gynecologic oncologists. Participant preferences were quantified with regression analysis using scenarios based on three attributes: 5-year progression-free survival and the rates of acute and chronic complication. A trade-off technique varying the risk of recurrence for no lymphadenectomy was used to quantify any additional risk of recurrence that these participants would accept to receive no lymphadenectomy instead of routine lymphadenectomy.

RESULTS

On the basis of discrete choice experiment, the recurrence rate and lymphedema risk had a statistically significant impact on respondents' preference. The trade-off question showed that the median additional accepted risk of having no lymphadenectomy was 2.8% for gynecologic oncologists (0.5-14%) and 3.0% for patients (0.5-10%), but this difference was not significant (p = 0.620). Patients who were younger or had a higher education level or no history of delivery or shorter duration since diagnosis were prepared to accept higher additional risks of having no lymphadenectomy.

CONCLUSIONS

Our results show that the majority of endometrial cancer patients and clinicians will accept a small amount of recurrence risk to reduce the incidence of lymphedema. Regarding preference heterogeneity among patients, our results show that it is important for surgeons to take a patient-tailored approach when discussing surgical management.

Understanding Patients' Preferences for Referrals to Specialists for an Asymptomatic Condition

BACKGROUND

A specialty referral is a common but complex decision that often requires a primary care provider to balance his or her own interests with those of the patient.

OBJECTIVE

To examine the factors that influence a patient's choice of a specialist for consultation for an asymptomatic condition and better understand the tradeoffs that patients are and are not willing to make in this decision.

DESIGN

Stratified cross-sectional convenience sample of subjects selected to parallel US population demographics.

PARTICIPANTS

Members of an Internet survey panel who reported seeing a physician in the past year whose responses met objective quality metrics for attention.

MAIN MEASURES

Respondents completed an adaptive conjoint analysis survey comparing specialists regarding eight attributes. The reliability of assessments and the predictive validity of models were measured using holdout samples. The relative importance (RI) of different attributes was computed using paired t tests. The implications of utility values were studied using market simulation methods.

KEY RESULTS

Five hundred and thirty subjects completed the survey and had responses that met quality criteria. The reliability of responses was high (86% agreement), and models were predictive of patients' preferences (82.6% agreement with holdout choices). The most important attribute for patients was out-of-pocket cost (RI of 19.5%, P < 0.0001 v. other factors). Among the nonfinancial factors, "collaboration and communication" with the primary care provider was the most important attribute (RI of 13.1% P < 0.001). Third in importance was whether the specialist practiced shared decision making (RI of 12.2% P < 0.001 v. other factors except delay in consultation). Cost did not dominate decision making. In market simulations, patients frequently preferred more expensive providers. For example, most patients (76.3%) were willing to pay more ($80) to see a specialist who both collaborated well with their primary care provider and practiced shared decision making. Most patients prefer to wait for a doctor who practices shared decision making: Only one-third (32.3%) of patients preferred a paternalistic doctor who was available in 2 weeks over a doctor who practiced decision making but was available in 4 weeks.

CONCLUSIONS

In the setting of a referral for an asymptomatic but serious condition, out-of-pocket costs are important to patients; however, they also value specialists who collaborate and communicate well with their primary care providers and who practice shared decision making. Patients have wide variability in preferences for specialists, and referral decisions should be individualized.

Identifying the determinants of adjuvant hormonal therapy medication taking behaviour in women with stages I-III breast cancer: A systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to identify the modifiable determinants of adjuvant hormonal therapy medication taking behaviour (MTB) in women with stage I-III breast cancer in clinical practice settings.

METHODS

We searched PubMed EMBASE, PsycINFO and CINAHL for articles investigating determinants of adjuvant hormonal therapy. Potentially modifiable determinants were identified and mapped to the 14 domains of the Theoretical Domains Framework (TDF), an integrative framework of theories of behavioural change. Meta-analysis was used to calculate pooled odds ratios for selected determinants.

RESULTS

Potentially modifiable determinants were identified in 42 studies and mapped to 9 TDF domains. In meta-analysis treatment side-effects (Domain: Beliefs about Capabilities) and follow-up care with a general practitioner (vs. oncologist) (Social Influences) were significantly negatively associated with persistence (p<0.001) and number of medications (Behaviour Regulation) was significantly positively associated with persistence (p<0.003). Studies did not examine several domains (including Beliefs about Consequences, Intentions, Goals, Social Identity, Emotion and Knowledge) which have been reported to influence MTB in other disease groups.

CONCLUSIONS

There is some evidence that the domains Beliefs about Capabilities, Behaviour Regulation and Social Influences influence hormonal therapy MTB.

PRACTICE IMPLICATIONS

Further research is needed to develop effective interventions to improve hormonal therapy MTB.

Endocrine therapy adherence: a cross-sectional study of factors affecting adherence and discontinuation of therapy

BACKGROUND/AIMS

Adjuvant endocrine therapy for at least 5 years improves oncological outcomes in oestrogen receptor-positive breast cancer. Adherence rates to prescribed endocrine therapy are low and the search for modifiable causes of this continues. The aim of this study was to assess adherence rates in an Irish cohort of breast cancer patients prescribed adjuvant endocrine therapy and to assess modifiable factors associated with suboptimal adherence.

METHODS

A cross-sectional anonymous survey was performed on 261 patients currently prescribed endocrine therapy. Data were collected regarding demographics, treatment, social and emotional factors and medication side effects. Each patient completed a medication adherence score and provided information about discontinuation of therapy and reasons for same.

RESULTS

Only 67.8 % of patients assessed demonstrated complete medication adherence on the medication adherence scale. Twenty-nine patients (10.9 %) permanently stopped taking their prescribed endocrine therapy. Suboptimal adherence was more likely in younger patients (p < 0.001), those in employment (p = 0.005), those who experienced side effects (p = 0.006), those who perceived themselves to have low levels of emotional support (p < 0.001) and those who use the internet to read about their illness (p = 0.003).

CONCLUSIONS

Endocrine therapy adherence is suboptimal in almost one-third of patients in our cohort. Appropriate assessment and management of side effects and negative emotions, combined with direction of patients to accurate internet sources of information, could help improve endocrine therapy adherence in women with early-stage breast cancer.

Women's experiences of hormonal therapy for breast cancer: exploring influences on medication-taking behaviour

PURPOSE

Five to 10 years of adjuvant hormonal therapy is recommended to prevent breast cancer recurrence. This study investigated modifiable influences on adjuvant hormonal therapy medication-taking behaviour (MTB) in women with stage I-III breast cancer.

METHODS

Semi-structured face-to-face interviews among women with stage I-III breast cancer prescribed adjuvant hormonal therapy purposively sampled by their MTB at two cancer centres. Thematic analysis was conducted based on the Framework approach, with the Theoretical Domains Framework (TDF) informing the analysis framework; the TDF is an integrative framework consisting of 14 domains of behavioural change to inform intervention design.

RESULTS

Thirty-one women participated in interviews (14 adherent/persistent; 7 non-adherent/persistent; 10 non-persistent). Three domains identified both barriers and enablers to hormonal therapy MTB across the three MTB strata: beliefs about consequences, intentions and goals and behaviour regulation, but their influence was different across the strata. Other domains influenced individual MTB strata. Key enablers for adherent/persistent women were identified within the domain beliefs about consequences (breast cancer recurrence), intentions and goals (high-priority), beliefs about capabilities (side effects) and behaviour regulation (managing medication). Barriers were identified within the domain behaviour regulation (no routine), memory, attention and decision processes (forgetting) and environmental context and resources (stressors) for non-adherent/persistent women and intentions and goals (quality of life), behaviour regulation (temporal self-regulation), reinforcement, beliefs about consequences (non-necessity) and social influences (clinical support) for non-persistent women.

CONCLUSION

This study identified modifiable influences on hormonal therapy MTB. Targeting these influences in clinical practice may improve MTB and hence survival in this population.

How can we best respect patient autonomy in breast cancer treatment decisions?

Helping patients to maximize their autonomy in breast cancer decision-making is an important aspect of patient-centered care. Shared decision-making is a strategy that aims to maximize patient autonomy by integrating the values and preferences of the patient with the biomedical expertise of the physician. Application of this approach in breast cancer decision-making has not been uniform across cancer-specific interventions (e.g., surgery, chemotherapy), and in some circumstances may present challenges to evidence-based care delivery. Increasingly precise estimates of individual patients' risk of recurrence and commensurate predicted benefit from certain therapies hold significant promise in helping patients exercise autonomous decision-making for their breast cancer care, yet will also likely complicate decision-making for certain subgroups of patients.

A descriptive review on methods to prioritize outcomes in a health care context

BACKGROUND

Evidence synthesis has seen major methodological advances in reducing uncertainty and estimating the sizes of the effects. Much less is known about how to assess the relative value of different outcomes.

OBJECTIVE

To identify studies that assessed preferences for outcomes in health conditions.

METHODS

SEARCH STRATEGY

we searched MEDLINE, EMBASE, PsycINFO and the Cochrane Library in February 2014.

INCLUSION CRITERIA

eligible studies investigated preferences of patients, family members, the general population or healthcare professionals for health outcomes. The intention of this review was to include studies which focus on theoretical alternatives; studies which assessed preferences for distinct treatments were excluded.

DATA EXTRACTION

study characteristics as study objective, health condition, participants, elicitation method, and outcomes assessed in the study were extracted.

MAIN RESULTS

One hundred and twenty-four studies were identified and categorized into four groups: (1) multi criteria decision analysis (MCDA) (n = 71), (2) rating or ranking (n = 25), (3) utility eliciting (n = 5) and (4) studies comparing different methods (n = 23). The number of outcomes assessed by method group varied. The comparison of different methods or subgroups within one study often resulted in different hierarchies of outcomes.

CONCLUSIONS

A dominant method most suitable for application in evidence syntheses was not identified. As preferences of patients differ from those of other stakeholders (especially medical professionals), the choice of the group to be questioned is consequential. Further research needs to focus on validity and applicability of the identified methods.

Persistence and discontinuation of adjuvant endocrine therapy in women with breast cancer

AIMS

Although 8-73 % of breast cancer patients who receive adjuvant endocrine therapy discontinue it, discontinuation is little studied in Asian breast cancer patients.

MATERIALS AND METHODS

To determine frequency and reasons for discontinuation at a single institution, we reviewed records and database information for women with hormone receptor-positive breast cancer who were treated at the National Kyushu Cancer Center 2001-2006, defining "persistence" as continued endocrine treatment (even when physicians decided to stop because of recurrent disease or severe adverse effects), and "discontinuation" as ending therapy due to patient's wishes.

RESULTS

Among 686 patients who started adjuvant endocrine therapy, 607 patients (88 %) persisted, 79 patients (12 %) discontinued. Of the 79 patients who discontinued, 37 (46 %) did so because of side effects, 26 (33 %) stopped appointments, 11 (14 %) stopped for "no particular reason", 4 (5 %) to get pregnant, and 1 (1 %) for economic reasons. The rate of persistence was higher in patients with lymph node involvement than in those without lymph node involvement (92 vs. 87 %; P = 0.03).

CONCLUSIONS

Clinicians should discuss side effects with patients, both as part of informed consent and to prepare them to continue therapy, and should be aware that over time, patients' reasons for discontinuation change.

Adherence to endocrine therapy in breast cancer adjuvant and prevention settings

Adherence to oral endocrine therapy in adjuvant breast cancer settings is a substantial clinical problem. To provide current perspective on adherence to oral endocrine therapies, a comprehensive literature review was conducted. In adjuvant trials, endocrine therapy adherence is relatively high with greater adherence for aromatase inhibitors compared with tamoxifen. In contrast, adherence to adjuvant therapy in clinical practice is relatively poor, with only about 50% of women successfully completing 5-year therapy. Importantly, good adherence (>80% use) has been associated with lower recurrence risk. Endocrine therapy adherence in primary breast cancer prevention trials parallels that seen in adjuvant trials. Factors associated with nonadherence include low recurrence risk perception, side effects, age extremes, medication cost, suboptimal patient-physician communication, and lack of social support. Few prospective studies have evaluated interventions designed to improve adherence. Interventions currently proposed reflect inferences from clinical trial procedures in which clinical contacts are commonly greater than in usual practice settings. In conclusion, for optimal breast cancer outcome, adherence to endocrine therapy must improve. Although general recommendations likely to improve adherence can be made based on clinical trial results and preliminary prospective trial findings, research specifically targeting this issue is needed to establish effective intervention strategies.