Conflicts in decision-making for breast cancer surgery

How Ineffective Interprofessional Collaboration Affects Delivery of Breast Reconstruction to Breast Cancer Patients: A Qualitative Study

BACKGROUND

Despite the benefits of breast reconstruction (BR), health care professionals do not consistently integrate it as an option in the treatment of breast cancer patients. Interprofessional collaboration (IPC) amongst professionals may facilitate the elaboration of comprehensive oncological treatment plans. As the application of IPC in the delivery of BR has not yet been studied, we undertook a qualitative study to explore the perceptions of physicians and administrators on IPC in breast cancer care and how these impact BR delivery.

METHODS

Interviews were conducted with 30 participants (22 physicians and 8 administrators). Physician interviews focused on their personal beliefs and values regarding BR, while administrator interviews explored their institutional treatment regimens as well as the availability of a BR program. Our thematic analysis was informed by the Canadian Interprofessional Health Collaborative (CIHC) competency framework.

RESULTS

IPC challenges were thought by participants to affect the delivery of BR. At the physician level, a lack of role clarity as well as the absence of an explicitly established leader negatively influence collaboration in BR delivery. In addition, varying views on the usefulness of BR and on the role of plastic surgeons in breast oncological teams discourage positive collaboration, rendering the delivery of BR more difficult.

CONCLUSIONS

The delivery of BR is overall impaired due to a lack of effective IPC. IPC could be improved through clarifying physician roles, establishing clear leadership, and aligning viewpoints on quality oncological care in collaborative teams; ultimately, this may promote equitable BR delivery for breast cancer patients.

Surgeons’ Recommendation is the Factor in Determining the Breast Cancer Surgery Procedures: an Experience from Rural Hospital in Thailand

Introduction:

The majority of breast cancer patients in rural hospital in developing countries still warrant for total mastectomy. Surgeon advice regard surgical procedure is one of the most important factors in decision making. Our study aims to compare the rate of breast-conserving surgery (BCS), mastectomy (MT) and mastectomy with immediate breast reconstruction (MTIBR) between the surgeons who offer only MT (group A) and who offer BCS MT and MTIBR (group B).

Method:

A retrospective cohort study was conducted at Ratchaburi hospital, Thailand from January 2010 to April 2014. We categorized patients into 2 groups (group A and B). Univariated analysis was selected to determine the factors that associated with the breast surgery procedures.

Results:

From January 2010 to April 2014, we recruited 310 breast cancer patients, 221 patients (71.2%) were treated by surgeons in group A, 89 patients (28.7%) by surgeons in group B. The choice of breast surgery is significantly different between 2 groups (P<0.001). In group A, 213 (96.3%) patient had MT and only 3 (1.3%) BCS and 5 (2.2%) MTIBR. Whilst in group B, 58 (65.1%) patient had MT and 11 (12.3%) BCS and 20(22.4%) MTIBR. Choice of breast surgery in patients with stage 1,2,3 are significantly different between 2 groups (P=0.004, <0.001, 0.025 respectively). Age is the only factor that significantly affects the choice of surgery in the group B but not in group A.

Conclusion:

Surgeon’s competency and comprehensive preoperative consultation by offering BCS, MT and MTIBR can affect the choice of surgical procedure for breast cancer patient.

Breast cancer survivor's perspectives on the role different providers play in follow-up care

IMPORTANCE

Significant variation in the number and types of oncologists that provide breast cancer follow-up exists. However, there is limited understanding regarding breast cancer survivors' preferences for who provides their follow-up. Our objective was to explore breast cancer survivors' perspectives on the goals of breast cancer follow-up, the preferred role for primary care providers, and the perceived roles of different types of oncologists during follow-up.

METHODS

A convenience sample of stage 0-III breast cancer survivors was identified and in-depth one-on-one interviews conducted. Data were analyzed using inductive content analysis.

RESULTS

Survivors cited a strong preference for oncology-based follow-up within the first 5 years after diagnosis, driven by their need for reassurance that cancer had not recurred. Survivors also thought that their primary care provider needed to be involved. Survivors assumed that oncology follow-up was directed by a standard protocol that included streamlining the follow-up team. Survivors recognized that patients with more complex cancers or challenging treatment courses may require more intensive follow-up and deviate from the standard protocol. Most survivors were comfortable deferring decisions regarding who participated in follow-up to the oncology team.

CONCLUSIONS

Most patients think a streamlined approach to oncology-based breast cancer follow-up already occurs, driven by a standard protocol. The use of a standard protocol to provide guidance for which types of oncology providers should participate in breast cancer follow-up will streamline care and represents a significant opportunity to reduce unnecessary variation. This approach is especially critical given patients' strong preferences for oncology-based follow-up.

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.

The adherence paradox: guideline deviations contribute to the increased 5-year survival of breast cancer patients

BACKGROUND

In German breast cancer care, the S1-guidelines of the 1990s were substituted by national S3-guidelines in 2003. The application of guidelines became mandatory for certified breast cancer centers. The aim of the study was to assess guideline adherence according to time intervals and its impact on survival.

METHODS

Women with primary breast cancer treated in three rural hospitals of one German geographical district were included. A cohort study design encompassed women from 1996-97 (N = 389) and from 2003-04 (N = 488). Quality indicators were defined along inpatient therapy sequences for each time interval and distinguished as guideline-adherent and guideline-divergent medical decisions. Based on all of the quality indicators, a binary overall adherence index was defined and served as a group indicator in multivariate Cox-regression models. A corrected group analysis estimated adjusted 5-year survival curves.

RESULTS

From a total of 877 patients, 743 (85 %) and 504 (58 %) were included to assess 104 developed quality indicators and the resuming binary overall adherence index. The latter significantly increased from 13-15 % (1996-97) up to 33-35 % (2003-04). Within each time interval, no significant survival differences of guideline-adherent and -divergent treated patients were detected. Across time intervals and within the group of guideline-adherent treated patients only, survival increased but did not significantly differ between time intervals. Across time intervals and within the group of guideline-divergent treated patients only, survival increased and significantly differed between time intervals.

CONCLUSIONS

Infrastructural efforts contributed to the increase of process quality of the examined certified breast cancer center. Paradoxically, a systematic impact on 5-year survival has been observed for patients treated divergently from the guideline recommendations. This is an indicator for the appropriate application of guidelines. A maximization of guideline-based decisions instead of the ubiquitous demand of guideline adherence maximization is advocated.

Decision making about surgery for early-stage breast cancer

BACKGROUND

Practice variation in breast cancer surgery has raised concerns about the quality of treatment decisions. We sought to evaluate the quality of decisions about surgery for early-stage breast cancer by measuring patient knowledge, concordance between goals and treatments, and involvement in decisions.

STUDY DESIGN

A mailed survey of stage I/II breast cancer survivors was conducted at 4 sites. The Decision Quality Instrument measured knowledge, goals, and involvement in decisions. A multivariable logistic regression model of treatment was developed. The model-predicted probability of mastectomy was compared with treatment received for each patient. Concordance was defined as having mastectomy and predicted probability >0.5 or partial mastectomy and predicted probability <0.5. Frequency of discussion about partial mastectomy was compared with discussion about mastectomy using chi-square tests.

RESULTS

Four hundred and forty patients participated (59% response rate). Mean overall knowledge was 52.7%; 45.9% knew that local recurrence risk is higher after breast conservation and 55.7% knew that survival is equivalent for the 2 options. Most participants (89.0%) had treatment concordant with their goals. Participants preferring mastectomy had lower concordance (80.5%) than those preferring partial mastectomy (92.6%; p = 0.001). Participants reported more frequent discussion of partial mastectomy and its advantages than of mastectomy, and 48.6% reported being asked their preference.

CONCLUSIONS

Breast cancer survivors had major knowledge deficits, and those preferring mastectomy were less likely to have treatment concordant with goals. Patients perceived that discussions focused on partial mastectomy, and many were not asked their preference. Improvements in the quality of decisions about breast cancer surgery are needed.

Challenges and economics of private breast cancer surgery practice

The role of the breast cancer surgeon has changed from one with performance of one operation, to a position in which the surgeon is the patient's initial contact, leader of a multidisciplinary team, the clinical leader who ensures that the patient receives the most appropriate breast cancer treatment and then also receives follow up and surveillance services. Breast conservation rates, patient satisfaction rates, clear margins, use of oncoplastic surgical techniques, appropriate referral to other consultants, clinical trial referral, and survival rates are all higher when patients are cared for by breast-focused surgeons. This new role requires greater time both before and after surgery to provide the proper planning and care for these patients. Women with breast cancer should have access to these dedicated breast-focused surgeons. Recognition of this expanding responsibility and reimbursement for this time and expertise is needed so that women with breast cancer can be offered the highest quality of care.

Impact of MRI-evaluated neoadjuvant chemotherapy response on change of surgical recommendation in breast cancer

OBJECTIVE

To investigate how MRI imaging of neoadjuvant chemotherapy (NAC) tumor response affects the recommendation for optimal breast cancer surgery, both before and after NAC.

SUMMARY BACKGROUND DATA

Understanding how imaging findings are incorporated into surgeons' decision-making processes will help establish appropriate imaging guidelines for recommending breast conservation surgery (BCS) after the NAC.

METHODS

Seventy-six breast cancer patients undergoing NAC with MRI follow-up studies were analyzed. Two experienced breast surgeons reviewed all cases. An initial surgical recommendation was made based on the pre-NAC lesion presentation; a subsequent surgical recommendation was made based on the post-NAC tumor response. Finally, the pathology results were disclosed and the surgeons were asked to decide on the optimal definitive surgical procedure. MRI findings throughout the entire course of the NAC were analyzed to understand how they affected different recommendations.

RESULTS

Before the NAC, a large tumor size or extent of disease were the primary determinant factors for mastectomy. In this study, the mean tumor size was 5.3 +/- 3.4 cm (RECIST) in the mastectomy group and 3.2 +/- 1.6 cm in the lumpectomy group (P = 0.0001). After the NAC, based on consensus recommendations, 21 mastectomy candidates remained for mastectomy, with tumor size decreasing from 7.4 +/- 4.5 to 1.5 +/- 2.5 cm, and 22 mastectomy candidates were changed to lumpectomy, with tumor size decreasing from 4.2 +/- 2.1 to 0.4 +/- 0.6 cm. When the final pathology revealed pCR or minimal residual disease, the surgeons agreed that BCS is the optimal procedure. On the other hand, for a large extent of residual disease, mastectomy should be performed.

CONCLUSION

In patients who had more extensive pretreatment disease, despite an excellent response to NAC, the surgeons still tended to apply an aggressive approach and recommended mastectomy. Given that the confirmation of pCR or minimal residual disease would change surgeons' recommendations for less aggressive, conservation surgery, the maturity of MRI for NAC response prediction may provide reliable staging information to aid in the recommendation of the optimal surgical procedure.

Understanding the impact of breast reconstruction on the surgical decision-making process for breast cancer

BACKGROUND

Reconstruction is rarely incorporated into the decision-making process for surgical breast cancer treatment. We examined the importance of knowing about reconstruction to patients' surgical decision-making for breast cancer.

METHODS

We surveyed women aged < or =79 years with breast cancer (N = 1844) who were reported to the Detroit and Los Angeles Surveillance, Epidemiology, and End Results (SEER) cancer registries (response rate, 77.4%). The dependent variables were 1) patients' report of having a discussion about breast reconstruction with their general surgeon (yes/no), 2) whether or not this discussion had an impact on their willingness to be treated with a mastectomy (yes/no), and 3) whether the patient received a mastectomy (yes/no). The independent variables included age, race, education, tumor size, tumor behavior, and presence of comorbidities. Chi-square, Student t test, and logistic regression were used for analyses.

RESULTS

Only 33% of patients had a general surgeon discuss breast reconstruction with them during the surgical decision-making process for their cancer. Surgeons were significantly more likely to have this discussion with younger, more educated patients with larger tumors. Knowing about reconstructive options significantly increased patients' willingness to consider a mastectomy (OR, 2.06; P <.01). In addition, this discussion influenced surgical treatment. Patients who discussed reconstruction with their general surgeon were 4 times more likely to receive a mastectomy compared with those who did not (OR, 4.48; P < .01).

CONCLUSIONS

Most general surgeons do not discuss reconstruction with their breast cancer patients before surgical treatment. When it occurs, this discussion significantly impacts women's treatment choice, making many more likely to choose mastectomy. This highlights the importance of multidisciplinary care models to facilitate an informed surgical treatment decision-making process.