"I Made All Decisions Myself": Breast Cancer Treatment Decision-Making by Receivers and Decliners

Declination of Treatment, Racial and Ethnic Disparity, and Overall Survival in US Patients With Breast Cancer

Importance

Declining treatment negatively affects health outcomes among patients with cancer. Limited research has investigated national trends of and factors associated with treatment declination or its association with overall survival (OS) among patients with breast cancer.

Objectives

To examine trends and racial and ethnic disparities in treatment declination and racial and ethnic OS differences stratified by treatment decision in US patients with breast cancer.

Design, Setting, and Participants

This retrospective cross-sectional study used data for patients with breast cancer from the 2004 to 2020 National Cancer Database. Four treatment modalities were assessed: chemotherapy, hormone therapy (HT), radiotherapy, and surgery. The chemotherapy cohort included patients with stage I to IV disease. The HT cohort included patients with stage I to IV hormone receptor-positive disease. The radiotherapy and surgery cohorts included patients with stage I to III disease. Data were analyzed from March to November 2023.

Exposure

Race and ethnicity and other sociodemographic and clinicopathologic characteristics.

Main Outcomes and Measures

Treatment decision, categorized as received or declined, was modeled using logistic regression. OS was modeled using Cox regression. Models were controlled for year of initial diagnosis, age, sex, health insurance, median household income, facility type, Charlson-Deyo comorbidity score, histology, American Joint Committee on Cancer stage, molecular subtype, and tumor grade.

Results

The study included 2 837 446 patients (mean [SD] age, 61.6 [13.4] years; 99.1% female), with 1.7% American Indian, Alaska Native, or other patients; 3.5% Asian or Pacific Islander patients; 11.2% Black patients; 5.6% Hispanic patients; and 78.0% White patients. Of 1 296 488 patients who were offered chemotherapy, 124 721 (9.6%) declined; 99 276 of 1 635 916 patients (6.1%) declined radiotherapy; 94 363 of 1 893 339 patients (5.0%) declined HT; and 15 846 of 2 590 963 patients (0.6%) declined surgery. Compared with White patients, American Indian, Alaska Native, or other patients (adjusted odds ratio [AOR], 1.47; 95% CI, 1.26-1.72), Asian or Pacific Islander patients (AOR, 1.29; 95% CI, 1.15-1.44), and Black patients (AOR, 2.01; 95% CI, 1.89-2.14) were more likely to decline surgery; American Indian, Alaska Native, or other patients (AOR, 1.13; 95% CI, 1.05-1.21) and Asian or Pacific Islander patients (AOR, 1.21; 95% CI, 1.16-1.27) were more likely to decline chemotherapy; and Black patients were more likely to decline radiotherapy (AOR, 1.05; 95% CI, 1.02-1.08). Asian or Pacific Islander patients (AOR, 0.81; 95% CI, 0.77-0.85), Black patients (AOR, 0.86; 95% CI, 0.83-0.89), and Hispanic patients (AOR, 0.66; 95% CI, 0.63-0.69) were less likely to decline HT. Furthermore, Black patients who declined chemotherapy had a higher mortality risk than White patients (adjusted hazard ratio [AHR], 1.07; 95% CI, 1.02-1.13), while there were no OS differences between Black and White patients who declined HT (AHR, 1.05; 95% CI, 0.97-1.13) or radiotherapy (AHR, 0.98; 95% CI, 0.92-1.04).

Conclusions and Relevance

This cross-sectional study highlights racial and ethnic disparities in treatment declination and OS, suggesting the need for equity-focused interventions, such as patient education on treatment benefits and improved patient-clinician communication and shared decision-making, to reduce disparities and improve patient survival.

Time-Related Characteristics of Medical and Psychosocial Decisions in Japanese Women with Breast Cancer: Results of a Web-Based Open-Ended Response

BACKGROUND

This study aimed to articulate chronological characteristics of decisions made by Japanese women with breast cancer (BC) since their diagnosis.

METHODS

Open-ended questions were asked using an Internet-based cross-sectional survey method. Qualitative content analysis was performed on 1,158 free descriptive responses obtained from 549 participants, which were categorized according to the content of decisions. Furthermore, 994 text data from 433 respondents to the quantitative questions were categorized according to the decisions' timing and examined in relation to medical and sociodemographic factors.

RESULTS

Whereas more than 60% of medical decisions, except chemotherapy, were made before initial treatment, approximately more than one-third of sociopsychological decisions were made only after the initial treatment. In decisions regarding medical care, only surgical decisions showed an association between timing and the participants' decision-making style. Meanwhile, in decisions regarding sociopsychological matters, socioeconomic status at the time of diagnosis, such as marital and employment status, along with the perceived importance of what was to be determined, were associated with the timing of decision-making related to employment, attitudes toward life with BC, family matters and financial affairs.

CONCLUSION

Women make various decisions depending on the amount of time since the diagnosis of BC. Generally, medical decisions are made prior to initial treatment, while these temporal characteristics are not observed for decisions relating to sociopsychological matters. Furthermore, socioeconomic status influences the timing of decision-making regarding sociopsychological matters. This finding can illustrate the manner in which to go through life with BC, and thus, help women who are unexpectedly diagnosed with BC to be more prepared.