Understanding surgery choices for breast cancer: how might the Theory of Planned Behaviour and the Common Sense Model contribute to decision support interventions?

Improving shared decision making in virtual breast cancer surgery consultations

With the COVID19 pandemic, use of telehealth has expanded rapidly in subspecialties with limited prior telehealth experience. While telehealth offers many opportunities to improve patient convenience, access, and comfort, the virtual platform poses unique challenges for shared decision making. In this review article, we describe what occurs within a standard in-person breast surgery consult and propose a model for an ideal virtual breast surgery consult, including strategies to foster patient engagement and shared decision making. Our model incorporates pre-visit preparation, deliberate pauses, and targeted engagement as ways to encourage patients to integrate information and actively participate in treatment decisions. Intentional strategies such as these must be adopted to improve shared decision making on the virtual platform.

How patient acceptability affects access to breast reconstruction: a qualitative study

OBJECTIVES

There has been limited research on the acceptability of breast reconstruction (BR) to breast cancer patients. We performed interviews to explore breast cancer patients' acceptability of BR.

DESIGN

Qualitative study.

SETTING

Recruitment from six Ontario hospitals across the province (Toronto, Ottawa, Hamilton, London, Thunder Bay and Windsor) as well as key breast cancer organisations between November 2017 and June 2018.

PARTICIPANTS

Women of any age with a diagnosis of breast cancer planning to undergo or having undergone a mastectomy with or without BR.

INTERVENTION

Sixty-minute semi-structured interviews were analysed using qualitative descriptive methodology that draws on inductive thematic analysis.

OUTCOME

In the telephone interviews, participants discussed their experience with breast cancer and accessing BR, focusing on the acceptability of BR as a surgical option post-mastectomy.

RESULTS

Of the 28 participants, 11 had undergone BR at the time of the interview, 5 at the time of mastectomy and 6 at a later date. Four inter-related themes were identified that reflected women's evolving ideas about BR as they progressed through different stages of their disease and treatment. The themes we developed were: (1) cancer survival before BR, (2) the influence of physicians on BR acceptability, (3) patient's shift to BR acceptance and (4) women's need to justify BR. For many women, access to BR surgery became more salient over time, thus adding a temporal element to the existing access framework.

CONCLUSION

In our study, women's access to BR was negatively influenced by the poor acceptability of this surgical procedure. The acceptability of BR was a complex process taking place over time, from the moment of breast cancer diagnosis to BR consideration. BR access may be improved through enhancing patient acceptability of BR. We suggest adapting the current access to care frameworks by further developing the concept of acceptability.

Patient, physician, and caregiver perspectives on ovarian cancer treatment decision making: lessons from a qualitative pilot study

Background

Ovarian cancer is the deadliest gynecologic malignancy and the fifth leading cause of cancer death among women living in the USA. Treatment for ovarian cancer that follows the guidelines published by the National Comprehensive Cancer Network is associated with a 33% decrease in disease-specific mortality, yet fewer than 40% of women with ovarian cancer receive guideline-adherent treatment. Little is known about the process by which women with ovarian cancer, their unpaid caregivers, and physicians make decisions about ovarian cancer treatment. We are planning to conduct a population-based study examining the ovarian cancer treatment decision-making process from the perspective of women with ovarian cancer, their caregivers, and physicians using a qualitative approach. Prior to embarking on a large-scale study, we determined it would be beneficial to pilot test our unpaid caregiver recruitment protocol and identify preliminary topics for the main study's interview guide.

Methods

We conducted a cross-sectional descriptive study using a qualitative approach. Data were collected via unstructured, individual interviews. Data were analyzed using modified grounded theory methods.

Results

We interviewed six women with ovarian cancer, four unpaid caregivers, and three physicians. The recruitment protocol successfully recruited patient participants but did not allow for direct recruitment of unpaid caregivers, which presented logistical difficulties. The interview guide was adequate to elicit participants' discussion of the major topics of interest; however, the opening statement needed modification to account for physician participants' specialties. Patient and caregiver participants identified three major categories of concepts describing the process of ovarian cancer treatment decision making: (a) choosing a provider, (b) choosing a facility, and (c) choosing a treatment. All three groups of participants addressed the influence of geographic location on treatment decisions, while physicians described encounters with patients declining recommended treatment.

Conclusions

This pilot study met our objectives of testing unpaid caregiver recruitment procedures and identifying topics to include in the interview guide for a planned grounded theory study. Although the thematic results of this study are preliminary, the categories of concepts described by participants provide a framework for the exploration of patient, unpaid caregiver, and physician perspectives of ovarian cancer treatment decision making.

Implementing strategies in consumer and community engagement in health care: results of a large-scale, scoping meta-review

BACKGROUND

There is growing recognition of the importance of the active involvement of consumers and community members in health care. Despite the long history of consumer and community engagement (CCE) research and practice, there is no consensus on the best strategies for CCE. In this paper, we identify various dimensions of CCE-related strategies and offer a practical model to assist policy-makers, practitioners and researchers.

METHODS

We undertook a large-scale, scoping meta-review and searched six databases using a list of nine medical subject headings (MeSH) and a comprehensive list of 47 phrases. We identified and examined a total of 90 relevant systematic reviews.

RESULTS

Identified reviews show that although there is a significant body of research on CCE, the development of the field is hindered by a lack of evidence relating to specific elements of CCE. They also indicate a diverse and growing enterprise, drawing on a wide range of disciplinary, political and philosophical perspectives and a mix of definitions, targets, approaches, strategies and mechanisms. CCE interventions and strategies aim to involve consumers, community members and the public in general, as well as specific sub-groups, including children and people from culturally and linguistically diverse backgrounds. Strategies for CCE vary in terms of their aim and type of proposed activity, as do the methods and tools which have been developed to support them. Methods and tools include shared decision making, use of decision aids, consumer representation, application of electronic and internet-based facilities, and peer support. The success of CCE is dependent on both the approach taken and contextual factors, including structural facilitators such as governmental support, as well as barriers such as costs, organisational culture and population-specific limitations.

CONCLUSIONS

The diversity of the field indicates the need to measure each component of CCE. This meta-review provides the basis for development of a new eight stage model of consumer and community engagement. This model emphasises the importance of clarity and focus, as well as an extensive evaluation of contextual factors within specific settings, before the implementation of CCE strategies, enabling those involved in CCE to determine potential facilitators and barriers to the process.

Patient age is related to decision-making, treatment selection, and perceived quality of life in breast cancer survivors

BACKGROUND

Patients with breast cancer must choose among a variety of treatment options when first diagnosed. Patient age, independent of extent of disease, is also related to quality of life. This study examined the impact of patient age on treatment selected, factors influencing this selection, and perceived quality of life.

METHODS

A 62-question survey evaluating breast cancer treatment and quality of life was mailed to breast cancer survivors. Responses were stratified by age (<50, 50-65, >65 years) and extent of disease.

RESULTS

Of the 1,131 surveys mailed, 402 were included for analysis. There were 104, 179, and 119 women aged <50, 50-65, and >65 years, respectively. The median patient age was 58 years, and the average interval from diagnosis to survey participation was 31.5 months.

CONCLUSIONS

Young women were more likely to have undergone aggressive therapies and had better physical functioning than old women. Old patients reported good quality of life and body image. Clinicians should consider patient age when discussing breast cancer treatment options.

Option Grids to facilitate shared decision making for patients with Osteoarthritis of the knee: protocol for a single site, efficacy trial

BACKGROUND

Despite policy interest, an ethical imperative, and evidence of the benefits of patient decision support tools, the adoption of shared decision making (SDM) in day-to-day clinical practice remains slow and is inhibited by barriers that include culture and attitudes; resources and time pressures. Patient decision support tools often require high levels of health and computer literacy. Option Grids are one-page evidence-based summaries of the available condition-specific treatment options, listing patients' frequently asked questions. They are designed to be sufficiently brief and accessible enough to support a better dialogue between patients and clinicians during routine consultations. This paper describes a study to assess whether an Option Grid for osteoarthritis of the knee (OA of the knee) facilitates SDM, and explores the use of Option Grids by patients disadvantaged by language or poor health literacy.

METHODS/DESIGN

This will be a stepped wedge exploratory trial involving 72 patients with OA of the knee referred from primary medical care to a specialist musculoskeletal service in Oldham. Six physiotherapists will sequentially join the trial and consult with six patients using usual care procedures. After a period of brief training in using the Option Grid, the same six physiotherapists will consult with six further patients using an Option Grid in the consultation. The primary outcome will be efficacy of the Option Grid in facilitating SDM as measured by observational scores using the OPTION scale. Comparisons will be made between patients who have received the Option Grid and those who received usual care. A Decision Quality Measure (DQM) will assess quality of decision making. The health literacy of patients will be measured using the REALM-R instrument. Consultations will be observed and audio-recorded. Interviews will be conducted with the physiotherapists, patients and any interpreters present to explore their views of using the Option Grid.

DISCUSSION

Option Grids offer a potential solution to the barriers to implementing traditional decision aids into routine clinical practice. The study will assess whether Option Grids can facilitate SDM in day-to-day clinical practice and explore their use with patients disadvantaged by language or poor health literacy.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN94871417.

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

OBJECTIVES

To explore attitudes of French surgeons and their patients towards treatment decision-making (TDM) in the medical encounter.

METHODS

Surgeons involved in early stage breast cancer and their patients treated in a French cancer care network received a cross-sectional survey questionnaire containing examples of four different approaches to TDM: paternalistic, "some sharing", informed TDM and, shared TDM.

RESULTS

Surgeons' interaction styles were clearly distributed among paternalistic, shared and mixed. The paternalistic approach seemed to be associated with private rather than public practice and with less professional experience. Patients reported a rather low level of participation in TDM, varying by socio-demographic characteristics. One third of patients were dissatisfied with the way their treatment decision had been made.

CONCLUSION

Most surgeons reported adopting the "some sharing" approach. However, one patient out of three reported that they would have liked to participate more in the TDM process.

PRACTICE IMPLICATIONS

Surgeons need to ask patients what their preferences for involvement in TDM are and then think about ways to accommodate both their own and patients' preferences regarding the TDM process to be used in each encounter. In addition, decision aids could be offered to surgeons to help them discuss treatment options with their patients.

Factors influencing the surgery intentions and choices of women with early breast cancer: the predictive utility of an extended theory of planned behaviour

Background

Women diagnosed with early breast cancer (stage I or II) can be offered the choice between mastectomy or breast conservation surgery with radiotherapy due to equivalence in survival rates. A wide variation in the surgical management of breast cancer and a lack of theoretically guided research on this issue highlight the need for further research into the factors influencing women’s choices. An extended Theory of Planned Behaviour (TPB) could provide a basis to understand and predict women’s surgery choices. The aims of this study were to understand and predict the surgery intentions and choices of women newly diagnosed with early breast cancer, examining the predictive utility of an extended TPB.

Methods

Sixty-two women recruited from three UK breast clinics participated in the study; 48 women, newly diagnosed with early breast cancer, completed online questionnaires both before their surgery and after accessing an online decision support intervention (BresDex). Questionnaires assessed views about breast cancer and the available treatment options using items designed to measure constructs of an extended TPB (i.e., attitudes, subjective norms, perceived behavioural control, and anticipated regret), and women’s intentions to choose mastectomy or BCS. Objective data were collected on women’s choice of surgery via the clinical breast teams. Multiple and logistic regression analyses examined predictors of surgery intentions and subsequent choice of surgery.

Results

The extended TPB accounted for 69.9% of the variance in intentions (p <.001); attitudes and subjective norms were significant predictors. Including additional variables revealed anticipated regret to be a more important predictor than subjective norms. Surgery intentions significantly predicted surgery choices (p <.01).

Conclusions

These findings demonstrate the utility of an extended TPB in predicting and understanding women’s surgery intentions and choices for early breast cancer. Understanding these factors should help to identify key components of interventions to support women while considering their surgery options.

Patient autonomy in multiple sclerosis--possible goals and assessment strategies

Patient autonomy has been increasingly acknowledged as prerequisite for successful medical decision making in Western countries. In medical decisions with a need to involve a health professional, patient autonomy becomes apparent in the extent of patients' participation in the communication as described in the concept of shared decision making. Patient autonomy can be derived from different perspectives or goals and the focus of evaluation approaches may vary accordingly. Multiple sclerosis (MS) is a paradigmatic disease to study patient autonomy mainly because MS patients are highly disease competent and due to ambiguous evidence on many aspects of disease-related medical decision making. This review gives an overview on measurement issues in studying decision making in MS, categorized according to prerequisites, process measures and outcomes of patient autonomy. As relevant prerequisites role preferences, risk attribution, risk tolerance, and risk knowledge are discussed. Regarding processes, we distinguish intra-psychic and interpersonal aspects. Intra-psychic processes are elucidated using the theory of planned behavior, which guided development of a 30-item scale to capture decisions about immunotherapy. Moreover, a theory of uncertainty management has been created resulting in the development of a corresponding measurement concept. Interpersonal processes evolving between physician and patient can be thoroughly analyzed from different perspectives by use of the newly developed comprehensive MAPPIN'SDM inventory. Concerning outcomes, besides health related outcomes, we discuss match of preferred roles during the decision encounters (preference match), decisional conflict as well as an application of the multidimensional measure of informed choice to decisions of MS patients. These approaches provide an overview on patient-inherent and interpersonal factors and processes modulating medical decision making and health behavior in MS and beyond.

Applying the theory of planned behaviour to multiple sclerosis patients' decisions on disease modifying therapy--questionnaire concept and validation

BACKGROUND

Patients making important medical decisions need to evaluate complex information in the light of their own beliefs, attitudes and priorities. The process can be considered in terms of the theory of planned behaviour. Decision support technologies aim at helping patients making informed treatment choices. Instruments assessing informed choices need to include risk knowledge, attitude (towards therapy) and actual uptake. However, mechanisms by which decision support achieves its goals are poorly understood.Our aim was therefore to develop and validate an instrument modeling the process of multiple sclerosis (MS) patients' decision making about whether to undergo disease modifying (immuno-)therapies (DMT).

METHODS

We constructed a 30-item patient administered questionnaire to access the elaboration of decisions about DMT in MS according to the theory of planned behaviour. MS-patients' belief composites regarding immunotherapy were classified according to the domains "attitude", "subjective social norm" and "control beliefs" and within each domain to either "expectations" or "values" yielding 6 sub-domains. A randomized controlled trial (n = 192) evaluating an evidence based educational intervention tested the instrument's predictive power regarding intention to use immunotherapy and its sensitivity to the intervention.

RESULTS

The psychometric properties of the questionnaire were satisfactory (mean item difficulty 62, mean SD 0.9, range 0-3). Responses explain up to 68% of the variability in the intention to use DMT was explained by up to 68% in the total sample. Four weeks after an educational intervention, predictive power was higher in the intervention (IG) compared to the control group (CG) (intention estimate: CG 56% / IG 69%, p = .179; three domains CG 56% / IG 74%, p = .047; six sub-domains CG 64% / IG 78%, p = .073). The IG held more critical beliefs towards immunotherapy (p = .002) and were less willing to comply with social norm (p = .012).

CONCLUSIONS

The questionnaire seems to provide a valid way of explaining patients' inherent decision processes and to be sensitive towards varying levels of elaboration. Similar tools based on the theory of planned behaviour could be applied to other decision making scenarios.