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Zadro JR, O'Keeffe M, Ferreira GE. Is It Time to Reframe How Health Care Professionals Label Musculoskeletal Conditions? Phys Ther 2024; 104:pzae018. [PMID: 38365434 DOI: 10.1093/ptj/pzae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/27/2023] [Accepted: 12/20/2023] [Indexed: 02/18/2024]
Affiliation(s)
- Joshua R Zadro
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Mary O'Keeffe
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Giovanni E Ferreira
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
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Berlin A, Ramotar M, Santiago AT, Liu Z, Li J, Wolinsky H, Wallis CJD, Chua MLK, Paner GP, van der Kwast T, Cooperberg MR, Vickers AJ, Urbach DR, Eggener SE. The influence of the "cancer" label on perceptions and management decisions for low-grade prostate cancer. J Natl Cancer Inst 2023; 115:1364-1373. [PMID: 37285311 PMCID: PMC10637044 DOI: 10.1093/jnci/djad108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/01/2023] [Accepted: 06/05/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND Grade Group 1 (GG1) prostate cancer should be managed with active surveillance (AS). Global uptake of AS remains disappointingly slow and heterogeneous. Removal of cancer labels has been proposed to reduce GG1 overtreatment. We sought to determine the impact of GG1 disease terminology on individual's perceptions and decision making. METHODS Discrete choice experiments were conducted on 3 cohorts: healthy men, canonical partners (partners), and patients with GG1 (patients). Participants reported preferences in a series of vignettes with 2 scenarios each, permuting key opinion leader-endorsed descriptors: biopsy (adenocarcinoma, acinar neoplasm, prostatic acinar neoplasm of low malignant potential [PAN-LMP], prostatic acinar neoplasm of uncertain malignant potential), disease (cancer, neoplasm, tumor, growth), management decision (treatment, AS), and recurrence risk (6%, 3%, 1%, <1%). Influence on scenario selection were estimated by conditional logit models and marginal rates of substitution. Two additional validation vignettes with scenarios portraying identical descriptors except the management options were embedded into the discrete choice experiments. RESULTS Across cohorts (194 healthy men, 159 partners, and 159 patients), noncancer labels PAN-LMP or prostatic acinar neoplasm of uncertain malignant potential and neoplasm, tumor, or growth were favored over adenocarcinoma and cancer (P < .01), respectively. Switching adenocarcinoma and cancer labels to PAN-LMP and growth, respectively, increased AS choice by up to 17%: healthy men (15%, 95% confidence interval [CI] = 10% to 20%, from 76% to 91%, P < .001), partners (17%, 95% CI = 12% to 24%, from 65% to 82%, P < .001), and patients (7%, 95% CI = 4% to 12%, from 75% to 82%, P = .063). The main limitation is the theoretical nature of questions perhaps leading to less realistic choices. CONCLUSIONS "Cancer" labels negatively affect perceptions and decision making regarding GG1. Relabeling (ie, avoiding word "cancer") increases proclivity for AS and would likely improve public health.
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Affiliation(s)
- Alejandro Berlin
- Department of Radiation Oncology, University of Toronto; Radiation Medicine Program, Princess Margaret Cancer Centre; TECHNA Institute, University Health Network, Toronto, ON, Canada
| | - Matthew Ramotar
- Department of Radiation Oncology, University of Toronto; Radiation Medicine Program, Princess Margaret Cancer Centre; TECHNA Institute, University Health Network, Toronto, ON, Canada
| | - Anna T Santiago
- Department of Biostatistics, Princess Margaret Cancer Centre; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Zhihui Liu
- Department of Biostatistics, Princess Margaret Cancer Centre; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Joyce Li
- The University of Western Ontario, London, ON, Canada
| | - Howard Wolinsky
- AnCan Active Surveillance Virtual Support Group; The Active Surveillor Newsletter, Chicago, IL, USA
| | - Christopher J D Wallis
- Division of Urology, Department of Surgery, University of Toronto, Mount Sinai Hospital, and University Hospital Network, Toronto, ON, Canada
| | - Melvin L K Chua
- Divisions of Radiation Oncology and Medical Sciences, National Cancer Centre Singapore; Oncology Academic Programme, Duke-NUS Medical School, Singapore
| | - Gladell P Paner
- Departments of Pathology and Surgery, University of Chicago. Chicago, IL, USA
| | | | - Matthew R Cooperberg
- Departments of Urology and Epidemiology and Biostatistics, University of California San Francisco Comprehensive Cancer Center, San Francisco, CA, USA
| | - Andrew J Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David R Urbach
- Institute for Clinical Evaluative Sciences (ICES), Department of Surgery, University of Toronto; Perioperative Services, Women’s College Hospital and Research Institute, Toronto, ON, Canada
| | - Scott E Eggener
- Section of Urology, Department of Surgery, The University of Chicago Comprehensive Cancer Center, Chicago, IL, USA
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Ma T, Semsarian CR, Barratt A, Parker L, Pathmanathan N, Nickel B, Bell KJL. Should low-risk DCIS lose the cancer label? An evidence review. Breast Cancer Res Treat 2023; 199:415-433. [PMID: 37074481 PMCID: PMC10175360 DOI: 10.1007/s10549-023-06934-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/30/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Population mammographic screening for breast cancer has led to large increases in the diagnosis and treatment of ductal carcinoma in situ (DCIS). Active surveillance has been proposed as a management strategy for low-risk DCIS to mitigate against potential overdiagnosis and overtreatment. However, clinicians and patients remain reluctant to choose active surveillance, even within a trial setting. Re-calibration of the diagnostic threshold for low-risk DCIS and/or use of a label that does not include the word 'cancer' might encourage the uptake of active surveillance and other conservative treatment options. We aimed to identify and collate relevant epidemiological evidence to inform further discussion on these ideas. METHODS We searched PubMed and EMBASE databases for low-risk DCIS studies in four categories: (1) natural history; (2) subclinical cancer found at autopsy; (3) diagnostic reproducibility (two or more pathologist interpretations at a single time point); and (4) diagnostic drift (two or more pathologist interpretations at different time points). Where we identified a pre-existing systematic review, the search was restricted to studies published after the inclusion period of the review. Two authors screened records, extracted data, and performed risk of bias assessment. We undertook a narrative synthesis of the included evidence within each category. RESULTS Natural History (n = 11): one systematic review and nine primary studies were included, but only five provided evidence on the prognosis of women with low-risk DCIS. These studies reported that women with low-risk DCIS had comparable outcomes whether or not they had surgery. The risk of invasive breast cancer in patients with low-risk DCIS ranged from 6.5% (7.5 years) to 10.8% (10 years). The risk of dying from breast cancer in patients with low-risk DCIS ranged from 1.2 to 2.2% (10 years). Subclinical cancer at autopsy (n = 1): one systematic review of 13 studies estimated the mean prevalence of subclinical in situ breast cancer to be 8.9%. Diagnostic reproducibility (n = 13): two systematic reviews and 11 primary studies found at most moderate agreement in differentiating low-grade DCIS from other diagnoses. Diagnostic drift: no studies found. CONCLUSION Epidemiological evidence supports consideration of relabelling and/or recalibrating diagnostic thresholds for low-risk DCIS. Such diagnostic changes would need agreement on the definition of low-risk DCIS and improved diagnostic reproducibility.
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Affiliation(s)
- Tara Ma
- School of Public Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Caitlin R Semsarian
- School of Public Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Alexandra Barratt
- School of Public Health, The University of Sydney, Sydney, NSW, 2006, Australia
- Wiser Healthcare, Sydney, Australia
| | - Lisa Parker
- Sydney School of Pharmacy, Charles Perkins Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Radiation Oncology, Royal North Shore Hospital, Sydney, Australia
| | - Nirmala Pathmanathan
- Western Sydney Local Health District, Sydney, Australia
- Westmead Breast Cancer Institute, Westmead Hospital, Sydney, Australia
| | - Brooke Nickel
- School of Public Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Katy J L Bell
- School of Public Health, The University of Sydney, Sydney, NSW, 2006, Australia.
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Kim H, Wang H, Demanelis K, Clump DA, Vargo JA, Keller A, Diego M, Gorantla V, Smith KJ, Rosenzweig MQ. Factors associated with ductal carcinoma in situ (DCIS) treatment patterns and patient-reported outcomes across a large integrated health network. Breast Cancer Res Treat 2023; 197:683-692. [PMID: 36526807 PMCID: PMC9883362 DOI: 10.1007/s10549-022-06831-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE To examine associations between ductal carcinoma in situ (DCIS) patients' characteristics, treating locations and DCIS treatments received and to pilot assessing quality-of-life (QoL) values among DCIS patients with diverse backgrounds. METHODS We performed a retrospective tumor registry review of all patients diagnosed and treated with DCIS from 2018 to 2019 in the UPMC-integrated network throughout central and western Pennsylvania. Demographics, clinical information, and administered treatments were compiled from tumor registry records. We categorized contextual factors such as different hospital setting (academic vs. community), socioeconomic status based on the neighborhood deprivation index (NDI) as well as age and race. QoL survey was administered to DCIS patients with diverse backgrounds via QoL questionnaire breast cancer module 23 and qualitative assessment questions. RESULTS A total of 912 patients were reviewed. There were no treatment differences noted for age, race, or NDI. Mastectomy rate was higher in academic sites than community sites (29 vs. 20.4%; p = 0.0045), while hormone therapy (HT) utilization rate was higher in community sites (74 vs. 62%; p = 0.0012). QoL survey response rate was 32%. Only HT side effects negatively affected in QoL scores and there was no significant difference in QoL domains and decision-making process between races, age, NDI, treatment groups, and treatment locations. CONCLUSION Our integrated health network did not show chronically noted disparities arising from social determinates of health for DCIS treatments by implementing clinical pathways and system-wide peer review. Also, we demonstrated feasibility in collecting QoL for DCIS women with diverse backgrounds and different socioeconomic statuses.
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Affiliation(s)
- Hayeon Kim
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA, USA.
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Magee Women's Hospital, 300 Halket Street, Pittsburgh, PA, 15213, USA.
| | - Hong Wang
- Department of Biostatistics, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Kathryn Demanelis
- Department of Biostatistics, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - David A Clump
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - John A Vargo
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Andrew Keller
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Mia Diego
- Department of Breast Surgery, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Vikram Gorantla
- Department of Medical Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Kenneth J Smith
- Clinical and Translational Science and Center for Research On Health Care, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Margaret Q Rosenzweig
- Department of Nursing, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Wieringa G, Dale M, Eccles FJR. Adjusting to living with Parkinson's disease; a meta-ethnography of qualitative research. Disabil Rehabil 2022; 44:6949-6968. [PMID: 34592863 DOI: 10.1080/09638288.2021.1981467] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE Parkinson's disease (PD) is a condition which causes significant difficulties in physical, cognitive and psychological domains. It is a progressive condition which people have to live with for a long time; consequently, there is a need to understand what contributes to individual adjustment. This review aimed to answer the question "how do individuals adjust to PD?" METHOD A systematic search of three databases (MEDLINE, CINAHL and PsycINFO) was carried out of papers documenting the adjustment process when living with PD and the findings were synthesised using a meta-ethnographic approach. RESULTS After exclusion based on eligibility criteria, 21 articles were included and were assessed for quality prior to analysing the data. Three main themes are proposed relating to the process of adjustment: "maintaining a coherent sense of self", "feeling in control" and "holding a positive mindset". Although many of the studies described challenges of living with PD, the results are dominated by the determination of individuals to self-manage their condition and maintain positive wellbeing. CONCLUSION The results highlight the need to empower patients to self-manage their illness, mitigating the effects of Parkinson's disease and supporting future wellbeing.IMPLICATIONS FOR REHABILITATIONIndividual identity disruption impacts on the self-value and sense of self coherence in individuals living with Parkinson's disease.Healthcare professionals should appreciate the complexity of the adjustment process which is related to the ability to maintain a coherent sense of self, to feel in control and to hold a positive mindset.Healthcare professionals should ensure information and knowledge related to self-management is tailored to an individual's understanding and experience of the disease.
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Affiliation(s)
- Gina Wieringa
- Faculty of Health and Medicine, Division of Health Research, Furness College, Lancaster University, Lancaster, UK
| | - Maria Dale
- Leicestershire Partnership NHS Trust, Mill Lodge, Leicestershire, UK
| | - Fiona J R Eccles
- Faculty of Health and Medicine, Division of Health Research, Furness College, Lancaster University, Lancaster, UK
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Barlet MH, Barks MC, Ubel PA, Davis JK, Pollak KI, Kaye EC, Weinfurt KP, Lemmon ME. Characterizing the Language Used to Discuss Death in Family Meetings for Critically Ill Infants. JAMA Netw Open 2022; 5:e2233722. [PMID: 36197666 PMCID: PMC9535532 DOI: 10.1001/jamanetworkopen.2022.33722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/09/2022] [Indexed: 12/03/2022] Open
Abstract
Importance Communication during conversations about death is critical; however, little is known about the language clinicians and families use to discuss death. Objective To characterize (1) the way death is discussed in family meetings between parents of critically ill infants and the clinical team and (2) how discussion of death differs between clinicians and family members. Design, Setting, and Participants This longitudinal qualitative study took place at a single academic hospital in the southeast US. Patients were enrolled from September 2018 to September 2020, and infants were followed up longitudinally throughout their hospitalization. Participants included families of infants with neurologic conditions who were hospitalized in the intensive care unit and had a planned family meeting to discuss neurologic prognosis or starting, not starting, or discontinuing life-sustaining treatment. Family meetings were recorded, transcribed, and deidentified before being screened for discussion of death. Main Outcomes and Measures The main outcome was the language used to reference death during family meetings between parents and clinicians. Conventional content analysis was used to analyze data. Results A total of 68 family meetings involving 36 parents of 24 infants were screened; 33 family meetings (49%) involving 20 parents (56%) and 13 infants (54%) included discussion of death. Most parents involved in discussion of death identified as the infant's mother (13 [65%]) and as Black (12 [60%]). Death was referenced 406 times throughout the family meetings (275 times by clinicians and 131 times by family members); the words die, death, dying, or stillborn were used 5% of the time by clinicians (13 of 275 references) and 15% of the time by family members (19 of 131 references). Four types of euphemisms used in place of die, death, dying, or stillborn were identified: (1) survival framing (eg, not live), (2) colloquialisms (eg, pass away), (3) medical jargon, including obscure technical terms (eg, code event) or talking around death with physiologic terms (eg, irrecoverable heart rate drop), and (4) pronouns without an antecedent (eg, it). The most common type of euphemism used by clinicians was medical jargon (118 of 275 references [43%]). The most common type of euphemism used by family members was colloquialism (44 of 131 references [34%]). Conclusions and Relevance In this qualitative study, the words die, death, dying, or stillborn were rarely used to refer to death in family meetings with clinicians. Families most often used colloquialisms to reference death, and clinicians most often used medical jargon. Future work should evaluate the effects of euphemisms on mutual understanding, shared decision-making, and clinician-family relationships.
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Affiliation(s)
| | - Mary C. Barks
- Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Peter A. Ubel
- Duke University School of Medicine, Durham, North Carolina
- Fuqua School of Business, Duke University, Durham, North Carolina
- Sanford School of Public Policy, Duke University, Durham, North Carolina
| | - J. Kelly Davis
- Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Kathryn I. Pollak
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Erica C. Kaye
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Kevin P. Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Monica E. Lemmon
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
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Eggener SE, Berlin A, Vickers AJ, Paner GP, Wolinsky H, Cooperberg MR. Low-Grade Prostate Cancer: Time to Stop Calling It Cancer. J Clin Oncol 2022; 40:3110-3114. [DOI: 10.1200/jco.22.00123] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Andrew J. Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY
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Rosenberg SM, Gierisch JM, Revette AC, Lowenstein CL, Frank ES, Collyar DE, Lynch T, Thompson AM, Partridge AH, Hwang ES. "Is it cancer or not?" A qualitative exploration of survivor concerns surrounding the diagnosis and treatment of ductal carcinoma in situ. Cancer 2022; 128:1676-1683. [PMID: 35191017 PMCID: PMC9274613 DOI: 10.1002/cncr.34126] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/15/2021] [Accepted: 10/20/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Of the nearly 50,000 women in the United States who undergo treatment for ductal carcinoma in situ (DCIS) annually, many may not benefit from treatment. To better understand the impact of a DCIS diagnosis, patients self-identified as having had DCIS were engaged regarding their experience. METHODS In July 2014, a web-based survey was administered through the Susan Love Army of Women breast cancer listserv. The survey included open-ended questions designed to assess patients' perspectives about DCIS diagnosis and treatment. Deductive and inductive codes were applied to the responses; common themes were summarized. RESULTS Among the 1832 women included in the analytic sample, the median age at diagnosis was 60 years. Four primary themes were identified: 1) uncertainty surrounding a DCIS diagnosis, 2) uncertainty about DCIS treatment, 3) concern about treatment side effects, and 4) concern about recurrence and/or developing invasive breast cancer. When diagnosed, participants were often uncertain about whether they had cancer or not and whether they should be considered a "survivor." Uncertainty about treatment manifested as questioning the appropriateness of the amount of treatment received. Participants expressed concern about the "cancer spreading" or becoming invasive and that they were not necessarily "doing enough" to prevent recurrence. CONCLUSIONS In a large, national sample, participants with a history of DCIS reported confusion and concern about the diagnosis and treatment, which caused worry and significant uncertainty. Developing strategies to improve patient and provider communications regarding the nature of DCIS and acknowledging gaps in the current knowledge of management options should be a priority.
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Affiliation(s)
- Shoshana M Rosenberg
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jennifer M Gierisch
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina.,Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina
| | - Anna C Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Carol L Lowenstein
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Elizabeth S Frank
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Thomas Lynch
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Alastair M Thompson
- Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Ann H Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - E Shelley Hwang
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Muscat DM, Morris GM, Bell K, Cvejic E, Smith J, Jansen J, Thomas R, Bonner C, Doust J, McCaffery K. Benefits and Harms of Hypertension and High-Normal Labels: A Randomized Experiment. Circ Cardiovasc Qual Outcomes 2021; 14:e007160. [PMID: 33813855 DOI: 10.1161/circoutcomes.120.007160] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Recent US guidelines lowered the threshold for diagnosing hypertension while other international guidelines use alternative/no labels for the same group (blood pressure [BP], <140/90 mm Hg). We investigated potential benefits and harms of hypertension and high-normal BP labels, compared with control, among people at lower risk of cardiovascular disease. METHODS We conducted a randomized experiment using a national sample of Australians (n=1318) 40 to 50 years of age recruited from an online panel. Participants were randomized to 1 of 3 hypothetical scenarios where a general practitioner told them they had a BP reading of 135/85 mm Hg, using either hypertension/high-normal BP/control (general BP description) labels. Participants were then randomized to receive an additional absolute risk description or nothing. Primary outcomes were willingness to change diet and worry. Secondary outcomes included exercise/medication intentions, risk perceptions, and other psychosocial outcomes. RESULTS There was no difference in willingness to change diet across label groups (P=0.22). The hypertension label (mean difference [MD], 0.74 [95% CI, 0.41-1.06]; P<0.001) and high-normal BP label (MD, 0.45 [95% CI, 0.12-0.78]; P=0.008) had increased worry about cardiovascular disease risk compared with control. There was no evidence that either label increased willingness to exercise (P=0.80). However, the hypertension (MD, 0.20 [95% CI, 0.04-0.36]; P=0.014), but not high-normal label (MD, 0.06 [95% CI, -0.10 to 0.21]; P=0.49), increased willingness to accept BP-lowering medication compared with control. Psychosocial differences including lower control, higher risk perceptions, and more negative affect were found for the hypertension and high-normal labels compared with control. Providing absolute risk information decreased willingness to change diet (MD, 0.25 [95% CI, 0.10-0.41]; P=0.001) and increase exercise (MD, 0.28 [95% CI, 0.11-0.45]; P=0.001) in the hypertension group. CONCLUSIONS Neither hypertension nor high-normal labels motivated participants to change their diet or exercise more than control, but both labels had adverse psychosocial outcomes. Labeling people with systolic BP of 130 to 140 mm Hg, who are otherwise at low risk of cardiovascular disease, may cause harms that outweigh benefit. Registration: URL: http://www.anzctr.org.au/; Unique identifier: ACTRN12618001700224.
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Affiliation(s)
- Danielle Marie Muscat
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health (D.M.M., E.C., J.S., J.J., C.B., K.M.), The University of Sydney, New South Wales, Australia.,Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health (D.M.M., J.S., J.J., C.B., K.M.), The University of Sydney, New South Wales, Australia
| | - Georgina May Morris
- Faculty of Medicine and Health, Sydney School of Public Health (G.M.M., K.B., E.C.), The University of Sydney, New South Wales, Australia
| | - Katy Bell
- Faculty of Medicine and Health, Sydney School of Public Health (G.M.M., K.B., E.C.), The University of Sydney, New South Wales, Australia
| | - Erin Cvejic
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health (D.M.M., E.C., J.S., J.J., C.B., K.M.), The University of Sydney, New South Wales, Australia.,Faculty of Medicine and Health, Sydney School of Public Health (G.M.M., K.B., E.C.), The University of Sydney, New South Wales, Australia
| | - Jenna Smith
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health (D.M.M., E.C., J.S., J.J., C.B., K.M.), The University of Sydney, New South Wales, Australia.,Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health (D.M.M., J.S., J.J., C.B., K.M.), The University of Sydney, New South Wales, Australia
| | - Jesse Jansen
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health (D.M.M., E.C., J.S., J.J., C.B., K.M.), The University of Sydney, New South Wales, Australia.,Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health (D.M.M., J.S., J.J., C.B., K.M.), The University of Sydney, New South Wales, Australia
| | - Rae Thomas
- Faculty of Health Sciences and Medicine, Centre for Research in Evidence-Based Practice, Bond University, Queensland, Australia (R.T., J.D.)
| | - Carissa Bonner
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health (D.M.M., E.C., J.S., J.J., C.B., K.M.), The University of Sydney, New South Wales, Australia.,Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health (D.M.M., J.S., J.J., C.B., K.M.), The University of Sydney, New South Wales, Australia
| | - Jenny Doust
- Faculty of Health Sciences and Medicine, Centre for Research in Evidence-Based Practice, Bond University, Queensland, Australia (R.T., J.D.)
| | - Kirsten McCaffery
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health (D.M.M., E.C., J.S., J.J., C.B., K.M.), The University of Sydney, New South Wales, Australia.,Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health (D.M.M., J.S., J.J., C.B., K.M.), The University of Sydney, New South Wales, Australia
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10
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Labbate CV, Paner GP, Eggener SE. Should Grade Group 1 (GG1) be called cancer? World J Urol 2021; 40:15-19. [PMID: 33432506 DOI: 10.1007/s00345-020-03583-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 12/24/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION ISUP Grade Group 1 prostate cancer is the lowest histologic grade of prostate cancer with a clinically indolent course. Removal of the term 'cancer' has been proposed and has historical precedent both in urothelial and thyroid carcinoma. METHODS Evidence-based review identifying arguments for and against Grade Group 1 being referred to as cancer. RESULTS Grade Group 1 has histologic evidence of tissue microinvasion and 0.3-3% rate of extraprostatic extension. Genomic evaluation suggests overlap of a minority of Grade Group 1 cancers with those of Grade Group 2. Conversely, Grade Group 1 tumors appear to have distinct genetic and genomic profiles from Grade Group 3 or higher tumors. Grade Group 1 has no documented ability for regional or distant metastasis and long-term follow up after treatment or active surveillance is safe with excellent oncologic outcomes. DISCUSSION Grade Group 1 prostate cancer, while showing evidence of neoplasia on histology has a remarkably indolent natural history more akin to non-neoplastic precursor lesions. Consideration should be given to renaming Grade Group 1 prostate cancer, which has the potential to minimize overtreatment, treatment-related side effects, patient anxiety, and financial burden on the healthcare system.
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Affiliation(s)
- Craig V Labbate
- Section of Urology, Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Gladell P Paner
- Department of Pathology, University of Chicago Medicine, Chicago, IL, USA
| | - Scott E Eggener
- Section of Urology, Department of Surgery, University of Chicago Medicine, Chicago, IL, USA.
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11
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Love RR, Baum M, Love SM, Straus AM. Clinical practice to address tamoxifen nonadherence. Breast Cancer Res Treat 2020; 184:675-682. [PMID: 32926316 DOI: 10.1007/s10549-020-05912-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 09/01/2020] [Indexed: 10/23/2022]
Abstract
The primary and secondary benefits of tamoxifen as adjuvant therapy in women with hormone-receptor-positive breast cancer are substantial: a 1% decrease in the risk of death each year for 10 years with each additional year of treatment during the first 5 years. Considerable data, however, indicate that these benefits are lost to many patients because of treatment nonadherence. Nonadherence is examined within the framework of the Common-Sense Model of Self-Regulation to describe patients' models of disease and treatment that organize their thinking and behavior, and the crucial role of the practitioner in addressing and altering these models. Common patient education and social communications about patients' hormone-receptor-positive breast cancer and tamoxifen treatment promote an acute disease paradigm in which cancer occurs within specific locations and is either present or absent. We recommend that clinicians communicate the concepts of hormone-receptor-positive breast cancer as follows: i. a non-dichotomous systemic disorder entailing a treatment goal of homeostasis and disease quiescence and ii. a disorder undetectable by currently available tests in subclinical states. Equally important, the clinician can provide a comprehensive picture of the well-documented secondary effects of tamoxifen, noting in particular the beneficial effects. Specific action plans, grounded in individual patient understanding, can be developed and reinforced, in an ongoing process that validates and integrates patient values and goals as they change over time.
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Affiliation(s)
- Richard R Love
- Department of Computer Science, Marquette University, Milwaukee, WI, USA.
| | | | - Susan M Love
- Dr. Susan Love Research Foundation, Encino, CA, USA
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12
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Morgan DJ, Scherer LD, Korenstein D. Improving Physician Communication About Treatment Decisions: Reconsideration of "Risks vs Benefits". JAMA 2020; 324:937-938. [PMID: 32150219 DOI: 10.1001/jama.2020.0354] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine & Hospital Epidemiology, Baltimore
- Veterans Affairs Maryland Health Care System, Baltimore
| | - Laura D Scherer
- Adult and Child Consortium of Health Outcomes Research and Delivery Science (ACCORDS), Division of Cardiology, University of Colorado School of Medicine, Aurora
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Denver, Denver, Colorado
| | - Deborah Korenstein
- Center for Health Policy and Outcomes, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York
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13
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Charvin M, Launoy G, Berchi C. The effect of information on prostate cancer screening decision process: a discrete choice experiment. BMC Health Serv Res 2020; 20:467. [PMID: 32456702 PMCID: PMC7249621 DOI: 10.1186/s12913-020-05327-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 05/14/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Prostate cancer screening is controversial because of uncertainty about its benefits and risks. The aim of this survey was to reveal preferences of men concerning prostate cancer screening and to test the effect of an informative video on these preferences. METHODS A stated preferences questionnaire was sent by e-mail to men aged 50-75 with no history of prostate cancer. Half of them were randomly assigned to view an informative video. A discrete choice model was established to reveal men's preferences for six prostate cancer screening characteristics: mortality by prostate cancer, number of false positive and false negative results, number of overdiagnosis, out-of-pocket costs and recommended frequency. RESULTS A population-based sample composed by 1024 men filled in the entire questionnaire. Each attribute gave the expected sign except for overdiagnosis. The video seemed to increase the intention to abstain from prostate cancer screening. CONCLUSIONS The participants attached greater importance to a decrease in the number of false negatives and a reduction in prostate cancer mortality than to other risks such as the number of false positives and overdiagnosis. Further research is needed to help men make an informed choice regarding screening.
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Affiliation(s)
- M Charvin
- Normandie Univ, UniCaen, Inserm, Anticipe, 14000, Caen, France.
| | - G Launoy
- Normandie Univ, UniCaen, Inserm, Anticipe, 14000, Caen, France
- University Hospital of Caen, Caen, France
| | - C Berchi
- Normandie Univ, UniCaen, Inserm, Anticipe, 14000, Caen, France
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14
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Nyhof BB, Wright FC, Look Hong NJ, Groot G, Helyer L, Meiers P, Quan ML, Baxter NN, Urquhart R, Warburton R, Gagliardi AR. Identifying opportunities to support patient-centred care for ductal carcinoma in situ: qualitative interviews with clinicians. BMC Cancer 2020; 20:364. [PMID: 32354355 PMCID: PMC7191683 DOI: 10.1186/s12885-020-06821-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 04/02/2020] [Indexed: 11/29/2022] Open
Abstract
Background Women with ductal carcinoma in situ (DCIS) report poor patient-clinician communication, and long-lasting confusion and anxiety about their treatment and prognosis. Research shows that patient-centred care (PCC) improves patient experience and outcomes. Little is known about the clinician experience of delivering PCC for DCIS. This study characterized communication challenges faced by clinicians, and interventions they need to improve PCC for DCIS. Methods Purposive and snowball sampling were used to recruit Canadian clinicians by specialty, gender, years of experience, setting, and geographic location. Qualitative interviews were conducted by telephone. Data were analyzed using constant comparison. Findings were mapped to a cancer-specific, comprehensive PCC framework to identify opportunities for improvement. Results Clinicians described approaches they used to address the PCC domains of fostering a healing relationship, exchanging information, and addressing emotions, but do not appear to be addressing the domains of managing uncertainty, involving women in making decisions, or enabling self-management. However, many clinicians described challenges or variable practices for all PCC domains but fostering a healing relationship. Clinicians vary in describing DCIS as cancer based on personal beliefs. When exchanging information, most find it difficult to justify treatment while assuring women of a good prognosis, and feel frustrated when women remain confused despite their efforts to explain it. While they recognize confusion and anxiety among women, clinicians said that patient navigators, social workers, support groups and high-quality information specific to DCIS are lacking. Despite these challenges, clinicians said they did not need or want communication interventions. Conclusions Findings represent currently unmet opportunities by which to help clinicians enhance PCC for DCIS, and underscore the need for supplemental information and supportive care specific to DCIS. Future research is needed to develop and test communication interventions that improve PCC for DCIS. If effective and widely implemented, this may contribute to improved care experiences and outcomes for women diagnosed with and treated for DCIS.
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Affiliation(s)
- Bryanna B Nyhof
- Toronto General Hospital Research Institute, University Health Network, 200 Elizabeth Street, Toronto, Ontario, M5G2C4, Canada.
| | | | | | - Gary Groot
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Pamela Meiers
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Nancy N Baxter
- St Michael's Hospital Department of Surgery and Li Ka Shing Knowledge Institute, Department of Surgery and the Institute for Health Policy Management and Evaluation, Toronto, Canada.,University of Toronto, Toronto, Canada
| | | | | | - Anna R Gagliardi
- Toronto General Hospital Research Institute, University Health Network, 200 Elizabeth Street, Toronto, Ontario, M5G2C4, Canada
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15
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Dixon PR, Tomlinson G, Pasternak JD, Mete O, Bell CM, Sawka AM, Goldstein DP, Urbach DR. The Role of Disease Label in Patient Perceptions and Treatment Decisions in the Setting of Low-Risk Malignant Neoplasms. JAMA Oncol 2020; 5:817-823. [PMID: 30896738 DOI: 10.1001/jamaoncol.2019.0054] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance The cancer disease label may lead to overtreatment of low-risk malignant neoplasms owing to a patient's emotional response or misunderstanding of prognosis. Decision making should be driven by risks and benefits of treatment and prognosis rather than disease label. Objective To determine whether disease label plays a role in patient decision making in the setting of low-risk malignant neoplasms and to determine how the magnitude of the disease-label effect compares with preferences for treatment and prognosis. Design, Setting, and Participants A discrete choice experiment conducted using an online survey of 1314 US residents in which participants indicated their preferences between a series of 2 hypothetical vignettes describing the incidental discovery of a small thyroid lesion. Vignettes varied on 3 attributes: disease label (cancer, tumor, or nodule); treatment (active surveillance or hemithyroidectomy); and risk of progression or recurrence (0%, 1%, 2%, or 5%). The independent associations of each attribute with likelihood of vignette selection was estimated with a Bayesian mixed logit model. Main Outcomes and Measures The preference weight of the cancer disease label was compared with preference weights for other attributes. Results In 1068 predominantly healthy respondents (605 women and 463 men) with a median age of 35 years (range, 18-78 years), the cancer disease label played a considerable role in respondent decision making independent of treatment offered and risk of progression or recurrence. Participants accepted a 4-percentage-point increase in risk of progression or recurrence (from 1% to 5%) to avoid labeling their disease as cancer in favor of nodule (marginal rate of substitution [MRS], 1.0; 95% credible interval [CrI], 0.9-1.1). Preference for the nodule label instead of cancer was similar in magnitude to the preference for active surveillance over surgery (MRS, 1.0; 95% CrI, 0.9-1.1). Conclusions and Relevance Disease label plays a role in patient preference independent of treatment risks or prognosis. Raising the threshold for biopsy or removing the word cancer from the disease label may mitigate patient preference for aggressive treatment of low-risk lesions. Health care professionals should emphasize treatment risks and benefits and natural disease history when supporting treatment decisions for potentially innocuous epithelial malignant neoplasms.
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Affiliation(s)
- Peter R Dixon
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - George Tomlinson
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jesse David Pasternak
- Department of Surgery, University Health Network, Women's College Hospital, and University of Toronto, Toronto, Ontario, Canada
| | - Ozgur Mete
- Department of Laboratory Medicine and Pathobiology, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Chaim M Bell
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Anna M Sawka
- Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - David P Goldstein
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - David R Urbach
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, University Health Network, Women's College Hospital, and University of Toronto, Toronto, Ontario, Canada
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16
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Ozanne EM, Soeteman DI, Frank ES, Clarke J, Hassett MJ, Stout NK, Punglia RS. Commentary: Creating a patient-centered decision aid for ductal carcinoma in situ. Breast J 2020; 26:1498-1499. [PMID: 32034829 DOI: 10.1111/tbj.13779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/22/2020] [Accepted: 01/23/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Elissa M Ozanne
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
| | - Djøra I Soeteman
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, Boston, Massachusetts
| | - Elizabeth S Frank
- Dana-Farber/Harvard Center Breast Cancer Advocacy Group, DFCI, Boston, Massachusetts
| | - John Clarke
- Cornerstone Systems Northwest Inc, Boston, Massachusetts
| | | | - Natasha K Stout
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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17
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Nickel B, Howard K, Brito JP, Barratt A, Moynihan R, McCaffery K. Association of Preferences for Papillary Thyroid Cancer Treatment With Disease Terminology: A Discrete Choice Experiment. JAMA Otolaryngol Head Neck Surg 2019; 144:887-896. [PMID: 30140909 DOI: 10.1001/jamaoto.2018.1694] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Given recent evidence of overdiagnosis and overtreatment of small papillary thyroid cancers (PTCs) and other low-risk cancers, strategies are needed to help patients consider less invasive treatment options. Objectives To determine which factors influence treatment preferences for patients with PTC, and the trade-offs in treatment factors people are willing to accept, and to understand how terminology influences preferences and benefit-harm trade-offs. Design, Setting, and Participants Preferences in PTC treatment were evaluated using a discrete choice experiment (DCE) conducted as a web-based survey using an existing public online research panel. Participants were randomized to receive 1 of 2 frames of information based on the terminology used to describe the condition: "cancer" or "lesion." Participants chose between 3 treatment options for PTC (thyroidectomy, hemithyroidectomy, and active surveillance). Analyses were conducted using a mixed logit model. Main Outcomes and Measures The main outcome variable was treatment preference; attributes of treatment options and sociodemographic characteristics were explanatory variables. Results The DCE was completed by 2054 participants (993 [48.3%] men and 1061 [51.7%] women; mean [SD] age, 46.0 [16.5] years) with no history of thyroid cancer. Participants preferred options with less frequent follow-up, lower out-of-pocket costs, lower chances of having voice and calcium level problems, and a lower risk of developing invasive thyroid cancer and of dying of thyroid cancer. When trading benefits against harms, participants were willing to accept a higher number of extra patients experiencing adverse effects to avoid a thyroid cancer death when the condition was described as a cancer compared with a lesion. Specifically, participants for whom the condition was described as a cancer were willing to accept more patients requiring lifelong medication (mean, 273; 95% CI, 207-339 vs mean, 98; 95% CI, 66-131), experiencing calcium problems (mean, 110; 95% CI, 77-144 vs mean, 56; 95% CI, 55-58), and fatigue (mean, 958; 95% CI, 691-1224 vs mean, 469; 95% CI, 375-564). For both the cancer and lesion terminology, health literacy consistently was associated with preferences for treatment options. Those with lower health literacy had a significantly lower preference for less invasive treatment options. Conclusions and Relevance This study makes an important contribution to understanding how attributes of treatment options, terminology, and patient characteristics, in particular health literacy, influence treatment decision making for PTC. As a result of increasing evidence of the indolent nature of PTC and other low-risk cancers, strategies to deal with potential overtreatment are critically needed. Trial Registration Australian New Zealand Clinical Trials Registry: ACTRN12617000066381.
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Affiliation(s)
- Brooke Nickel
- The University of Sydney, Wiser Healthcare, Sydney, New South Wales, Australia.,The University of Sydney, Sydney School of Public Health, Sydney, New South Wales, Australia.,The University of Sydney, Sydney Health Literacy Lab, New South Wales, Australia
| | - Kirsten Howard
- The University of Sydney, Wiser Healthcare, Sydney, New South Wales, Australia.,The University of Sydney, Sydney School of Public Health, Sydney, New South Wales, Australia
| | - Juan P Brito
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Minnesota
| | - Alexandra Barratt
- The University of Sydney, Wiser Healthcare, Sydney, New South Wales, Australia.,The University of Sydney, Sydney School of Public Health, Sydney, New South Wales, Australia
| | - Ray Moynihan
- The University of Sydney, Wiser Healthcare, Sydney, New South Wales, Australia.,Centre for Research in Evidence-Based Practice, Bond University, Queensland, Australia
| | - Kirsten McCaffery
- The University of Sydney, Wiser Healthcare, Sydney, New South Wales, Australia.,The University of Sydney, Sydney School of Public Health, Sydney, New South Wales, Australia.,The University of Sydney, Sydney Health Literacy Lab, New South Wales, Australia
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18
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Nickel B, Barratt A, McGeechan K, Brito JP, Moynihan R, Howard K, McCaffery K. Effect of a Change in Papillary Thyroid Cancer Terminology on Anxiety Levels and Treatment Preferences: A Randomized Crossover Trial. JAMA Otolaryngol Head Neck Surg 2019; 144:867-874. [PMID: 30335875 DOI: 10.1001/jamaoto.2018.1272] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Given evidence of overdiagnosis and overtreatment of small papillary thyroid cancers (PTCs), strategies are needed to promote the consideration of less invasive treatment options for patients with low-risk PTC. Objective To determine the association of treatment preferences and anxiety levels for PTC with the terminology used to describe the condition. Design, Setting, and Participants This randomized crossover study involved a community sample of 550 Australian men and women 18 years or older without a history of thyroid cancer. Between March 16, 2016, and July 26, 2016, participants accessed an online study that presented 3 hypothetical but clinically realistic scenarios, each of which described PTC as papillary thyroid cancer, papillary lesion, or abnormal cells. Participants were exposed to all 3 scenarios with the different terminologies, and participants were randomized by the order (first, second, or third) in which they viewed the terminologies. Data analysis was conducted from September 1, 2016, to May 15, 2017. Main Outcomes and Measures Treatment choice (total thyroidectomy, hemithyroidectomy, or active surveillance), diagnosis anxiety, and treatment choice anxiety. Results Of the 550 participants who completed the online study and were included in the analysis, 279 (50.7%) were female and the mean (SD) age was 49.9 (15.2) years. A higher proportion of participants (108 [19.6%]) chose total thyroidectomy when papillary thyroid cancer was used to describe the condition compared with the percentage of participants who chose total thyroidectomy when papillary lesion (58 [10.5%]) or abnormal cells (60 [10.9%]) terminology was used. At first exposure, the papillary thyroid cancer terminology led 60 of 186 participants (32.3%) to choose surgery compared with 46 of 191 participants (24.1%) who chose surgery after being exposed to papillary lesion terminology first (risk ratio [RR], 0.73; 95% CI, 0.53-1.02) and 47 of 173 participants (27.2%) after being exposed to abnormal cells (RR, 0.82; 95% CI, 0.60-1.14) terminology first. After the first exposure, participants who viewed papillary thyroid cancer terminology reported significantly higher levels of anxiety (mean, 7.8 of 11 points) compared with those who viewed the papillary lesion (mean, 7.0 of 11 points; mean difference, -0.8; 95% CI, -1.3 to -0.3) or abnormal cells (mean, 7.3 of 11 points; mean difference, -0.5; 95% CI, -1.0 to 0.01). Overall, interest in active surveillance was high and higher levels of anxiety were reported by those who chose surgery, regardless of which terminology was viewed first (mean difference, 1.5; 95% CI, 1.0-1.9). Conclusions and Relevance Changing the terminology of small PTCs may be one strategy to reduce patients' anxiety levels and help them consider less invasive management options. To curtail overdiagnosis and overtreatment in PTC, other strategies may include providing balanced information about the risks and advantages of alternative treatments. Trial Registration anzctr.org.au Identifier: ACTRN12616000271404.
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Affiliation(s)
- Brooke Nickel
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, Sydney, New South Wales, Australia.,Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Alexandra Barratt
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, Sydney, New South Wales, Australia
| | - Kevin McGeechan
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, Sydney, New South Wales, Australia
| | - Juan P Brito
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Ray Moynihan
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, Sydney, New South Wales, Australia.,Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Queensland, Australia
| | - Kirsten Howard
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, Sydney, New South Wales, Australia
| | - Kirsten McCaffery
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, Sydney, New South Wales, Australia.,Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
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19
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Nyhof BB, Wright FC, Look Hong NJ, Groot G, Helyer L, Meiers P, Quan ML, Baxter NN, Urquhart R, Warburton R, Gagliardi AR. Recommendations to improve patient-centred care for ductal carcinoma in situ: Qualitative focus groups with women. Health Expect 2019; 23:106-114. [PMID: 31532871 PMCID: PMC6978860 DOI: 10.1111/hex.12973] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 08/28/2019] [Accepted: 09/03/2019] [Indexed: 11/29/2022] Open
Abstract
Background Patient‐centred care (PCC) improves health‐care experiences and outcomes. Women with ductal carcinoma in situ (DCIS) and clinicians have reported communication difficulties. Little prior research has studied how to improve communication and PCC for DCIS. Objective This study explored how to achieve PCC for DCIS. Design Canadian women treated for DCIS from five provinces participated in semi‐structured focus groups based on a 6‐domain cancer‐specific PCC framework to discuss communication about DCIS. Data were analysed using constant comparative technique. Setting and Participants Thirty‐five women aged 30 to 86 participated in five focus groups at five hospitals. Results Women said their clinicians used multiple approaches for fostering a healing relationship; however, most described an absence of desired information or behaviour to exchange information, respond to emotions, manage uncertainty, make decisions and enable self‐management. Most women were confused by terminology, offered little information about the risks of progression/recurrence, uninformed about treatment benefits and risks, frustrated with lack of engagement in decision making, given little information about follow‐up plans or self‐care advice, and received no acknowledgement or offer of emotional support. Discussion and Conclusions By comparing the accounts of women with DCIS to a PCC framework, we identified limitations and inconsistencies in women's lived experience of communication about DCIS, and approaches by which clinicians can more consistently achieve PCC for DCIS. Future research should develop and evaluate informational tools to support PCC for DCIS.
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Affiliation(s)
- Bryanna B Nyhof
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | | | | | - Gary Groot
- University of Saskatchewan, Saskatoon, SK, Canada
| | | | | | | | | | | | | | - Anna R Gagliardi
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
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20
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Shehata M, Grimm L, Ballantyne N, Lourenco A, Demello LR, Kilgore MR, Rahbar H. Ductal Carcinoma in Situ: Current Concepts in Biology, Imaging, and Treatment. JOURNAL OF BREAST IMAGING 2019; 1:166-176. [PMID: 31538141 DOI: 10.1093/jbi/wbz039] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Indexed: 12/27/2022]
Abstract
Ductal carcinoma in situ (DCIS) of the breast is a group of heterogeneous epithelial proliferations confined to the milk ducts that nearly always present in asymptomatic women on breast cancer screening. A stage 0, preinvasive breast cancer, increased detection of DCIS was initially hailed as a means to prevent invasive breast cancer through surgical treatment with adjuvant radiation and/or endocrine therapies. However, controversy in the medical community has emerged in the past two decades that a fraction of DCIS represents overdiagnosis, leading to unnecessary treatments and resulting morbidity. The imaging hallmarks of DCIS include linearly or segmentally distributed calcifications on mammography or nonmass enhancement on breast MRI. Imaging features have been shown to reflect the biological heterogeneity of DCIS lesions, with recent studies indicating MRI may identify a greater fraction of higher-grade lesions than mammography does. There is strong interest in the surgical, imaging, and oncology communities to better align DCIS management with biology, which has resulted in trials of active surveillance and therapy that is less aggressive. However, risk stratification of DCIS remains imperfect, which has limited the development of precision therapy approaches matched to DCIS aggressiveness. Accordingly, there are opportunities for breast imaging radiologists to assist the oncology community by leveraging advanced imaging techniques to identify appropriate patients for the less aggressive DCIS treatments.
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Affiliation(s)
- Mariam Shehata
- University of Washington School of Medicine, Department of Radiology, Seattle, WA
| | - Lars Grimm
- Duke University Medical School, Department of Radiology, Durham, NC
| | - Nancy Ballantyne
- Duke University Medical School, Department of Radiology, Durham, NC
| | - Ana Lourenco
- Brown University Medical School, Department of Radiology, Providence, RI
| | - Linda R Demello
- Brown University Medical School, Department of Radiology, Providence, RI
| | - Mark R Kilgore
- University of Washington School of Medicine, Department of Anatomic Pathology, Seattle, WA.,Seattle Cancer Care Alliance, Seattle, WA
| | - Habib Rahbar
- University of Washington School of Medicine, Department of Radiology, Seattle, WA.,Seattle Cancer Care Alliance, Seattle, WA
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21
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Nickel B, Semsarian C, Moynihan R, Barratt A, Jordan S, McLeod D, Brito JP, McCaffery K. Public perceptions of changing the terminology for low-risk thyroid cancer: a qualitative focus group study. BMJ Open 2019; 9:e025820. [PMID: 30813118 PMCID: PMC6377531 DOI: 10.1136/bmjopen-2018-025820] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES To investigate public perceptions of overdiagnosis and overtreatment in low-risk thyroid cancer and explore opinions regarding the proposed strategy to change the terminology of low-risk cancers. DESIGN Qualitative study using focus groups that included a guided group discussion and presentation explaining thyroid cancer, overdiagnosis and overtreatment, and proposed communication strategies. Transcripts were analysed thematically. SETTING Sydney, Australia. PARTICIPANTS Forty-seven men and women of various ages from a range of socioeconomic backgrounds with no personal history of thyroid cancer. RESULTS Participants had low pre-existing general awareness of concepts of overdiagnosis and overtreatment and expressed concern regarding this new information in relation to thyroid cancer. Overall, participants understood why the strategy to change the terminology was being proposed and could see potential benefits including reducing the negative psychological impact and stigma associated with the term 'cancer'; however, many still had reservations about the strategy. The majority of the concerns were around their worry about the risk of further disease progression and that changing the terminology may create confusion and cause patients not to take the diagnosis and its associated managements seriously. Despite varied views towards the proposed strategy, there was a strong overarching desire for greater patient and public education around overdiagnosis and overtreatment in both thyroid cancer and cancer generally in order to complement any revised terminology and/or other mitigation strategies. CONCLUSIONS We found a strong and apparently widely held desire for more information surrounding the topic of overdiagnosis and overtreatment. Careful consideration of how to inform both the public and current patients about the implications of a change in terminology, including changes to patients' follow-up or treatments, would be needed if such a change were to go ahead.
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Affiliation(s)
- Brooke Nickel
- Wiser Healthcare, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Health Literacy Lab, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Caitlin Semsarian
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Ray Moynihan
- Wiser Healthcare, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Centre for Research in Evidence-Based Practice, Bond University, Herston, Queensland, Australia
| | - Alexandra Barratt
- Wiser Healthcare, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Susan Jordan
- Cancer Causes and Care, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
- School of Public Health, The University of Queensland, Herston, Queensland, Australia
| | - Donald McLeod
- Cancer Causes and Care, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
- Department of Endocrinology and Diabetes, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Juan P Brito
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Kirsten McCaffery
- Wiser Healthcare, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Health Literacy Lab, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
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Gagliardi AR, Wright FC, Look Hong NJ, Groot G, Helyer L, Meiers P, Quan ML, Urquhart R, Warburton R. National consensus recommendations on patient-centered care for ductal carcinoma in situ. Breast Cancer Res Treat 2019; 174:561-570. [PMID: 30627960 PMCID: PMC6438938 DOI: 10.1007/s10549-019-05132-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 01/05/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this research was to generate recommendations on strategies to achieve patient-centered care (PCC) for ductal carcinoma in situ (DCIS). METHODS Thirty clinicians (surgeons, medical/radiation oncologists, radiologists, nurses, navigators) who manage DCIS and 32 DCIS survivors aged 18 or older were nominated. Forty-six recommendations to support PCC for DCIS were derived from primary research, and rated in a two-round Delphi process from March to June 2018. RESULTS A total of 29 clinicians and 27 women completed Round One, and 28 clinicians and 22 women completed Round Two. The 29 recommendations retained by both women and clinicians reflected the PCC domains of fostering patient-physician relationship (5), exchanging information (5), responding to emotions (1), managing uncertainty (4), making decisions (9), and enabling patient self-management (5). An additional 13 recommendations were retained by women only: fostering patient-physician relationship (1), exchanging information (3), responding to emotions (2), making decisions (3), and enabling patient self-management (4). Some recommendations refer to processes (i.e., ask questions about lifestyle or views about risks/outcomes to understand patient preferences); others to tools (i.e., communication aid). Panelists recommended a separate consensus process to refine the language that clinicians use when describing DCIS. CONCLUSIONS This is the first study to generate guidance on how to achieve PCC for DCIS. Organizations that deliver or oversee health care can use these recommendations on PCC for DCIS to plan, evaluate, or improve services. Ongoing research is needed to develop communication tools, and establish labels and language for DCIS that optimize communication.
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Affiliation(s)
- Anna R Gagliardi
- Toronto General Hospital Research Institute, University Health Network, 200 Elizabeth Street, Toronto, M5G2C4, Canada.
| | - Frances C Wright
- Odette Cancer Research Program, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Nicole J Look Hong
- Odette Cancer Research Program, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Gary Groot
- General Surgery & Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Canada
| | - Lucy Helyer
- Department of Surgery, Dalhousie University, Nova Scotia, Canada
| | - Pamela Meiers
- Irene and Leslie Dubé Centre of Care Breast Health Centre, Saskatoon City Hospital, Saskatoon, Canada
| | - May Lynn Quan
- Calgary Breast Health Program Foothills Medical Centre, University of Calgary, Calgary, Canada
| | - Robin Urquhart
- Department of Surgery, Dalhousie University, Nova Scotia, Canada
| | - Rebecca Warburton
- Department of Surgery, University of British Columbia, Vancouver, Canada
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Buscariollo DL, Cronin AM, Borstelmann NA, Punglia RS. Impact of pre-diagnosis depressive symptoms and health-related quality of life on treatment choice for ductal carcinoma in situ and stage I breast cancer in older women. Breast Cancer Res Treat 2018; 173:709-717. [PMID: 30406869 DOI: 10.1007/s10549-018-5006-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 10/09/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE To examine whether pre-diagnosis patient-reported health-related quality of life (HRQOL) and depressive symptoms are associated with local treatment for older women with ductal carcinoma in situ (DCIS) and stage I breast cancer (BC). METHODS Using the SEER-MHOS dataset, we identified women ≥ 65 years old with DCIS or stage I BC diagnosed 1998-2011 who completed surveys ≤ 24 months before diagnosis. Depressive symptoms were measured by major depressive disorder (MDD) risk and HRQOL was measured by Physical and Mental Component Summary scores (PCS and MCS, respectively) of the SF-36/VR-12. Associations with treatment choice (breast-conserving surgery [BCS] and radiation therapy [RT], BCS alone, mastectomy) were assessed with multivariable multinomial logistic regression, controlling for patient characteristics. RESULTS We identified 425 women with DCIS and 982 with stage I BC. Overall, 20.4% endorsed depressive symptoms placing them at risk for MDD pre-diagnosis; mean MCS and PCS scores were 52.3 (SD = 10.1) and 40.5 (SD = 11.5), respectively. Among women with DCIS, those at risk for MDD were more likely to receive BCS (adjusted odds ratio [AOR] 2.04, 95% CI 1.04-4.00, p = 0.04) or mastectomy (AOR 1.88, 95% CI 0.91-3.86, p = 0.09) compared to BCS + RT. For DCIS, MCS score was not associated with treatment; higher PCS score was associated with decreased likelihood of receiving mastectomy versus BCS + RT (AOR 0.71 per 10-point increase, 95% CI 0.54-0.95, p = 0.02). For BC, none of the measures were significantly associated with treatment. CONCLUSION Older women at risk for MDD before DCIS diagnosis were less likely to receive RT after BCS, compared to BCS alone or mastectomy.
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Affiliation(s)
- Daniela L Buscariollo
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Angel M Cronin
- Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Nancy A Borstelmann
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Rinaa S Punglia
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA, 02215, USA.
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Shaffer VA, Scherer LD. Too Much Medicine: Behavioral Science Insights on Overutilization, Overdiagnosis, and Overtreatment in Health Care. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/2372732218786042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Overutilization—defined as the use of health care services for which the benefits do not outweigh the harms—has been identified as one of the leading contributors to the rising cost of health care in the United States. Although informational interventions designed to address overutilization have had a significant, but modest, impact on the rate of overutilization, they have not been sufficient to solve the problem. Also, various psychological mechanisms contribute to the desire for more medical tests and treatments. To effectively address overutilization, we need to better understand the psychological underpinnings of overuse in medicine. The article reviews recent findings from the behavioral science literature—including reliance on anecdotal evidence, test-related affect, the use of diagnostic labels, and medical maximizing tendencies—that lend insight into why patients sometimes seek, demand, or expect medical tests and treatments that are considered by experts to be low value.
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Narod SA, Sopik V. Is invasion a necessary step for metastases in breast cancer? Breast Cancer Res Treat 2018; 169:9-23. [PMID: 29353366 PMCID: PMC5882625 DOI: 10.1007/s10549-017-4644-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Accepted: 12/23/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE To review the empirical evidence to support the conventional (sequential) model of breast cancer progression, which is based on the paradigm that cancer passes through several stages, including an in situ stage prior to an invasive stage, and thereafter (in some cases) disseminates to the lymph nodes and distant organs. METHODS We review the cancer literature of the last 50 years which relates to the prevention of invasive breast cancer (through radiotherapy or surgery) and reductions in the mortality for breast cancer. RESULTS For both invasive cancers and DCIS, the literature indicates that prevention of in-breast invasive recurrences does not prevent death from breast cancer. Moreover, the presence of residual cancer cells in the breast after breast-conserving surgery does not compromise the cure rate. CONCLUSION We propose an alternate (parallel) model of breast cancer wherein there is a small pool of cancer stem cells which have metastatic potential from their inception and which disseminate synchronously through several routes-to the breast stroma, to the lymph nodes and to distant organs. Cancer cells which disseminate to the breast give rise to cells which make up the bulk of the tumour mass but these are not the source of the distant metastases.
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Affiliation(s)
- Steven A Narod
- Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, M5S 1B2, Canada.
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
- Institute of Medical Science, University of Toronto, Toronto, Canada.
| | - Victoria Sopik
- Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, M5S 1B2, Canada
- Institute of Medical Science, University of Toronto, Toronto, Canada
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26
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Schwartz PH. Progress in Defining Disease: Improved Approaches and Increased Impact. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2018; 42:485-502. [PMID: 28859465 DOI: 10.1093/jmp/jhx012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
In a series of recent papers, I have made three arguments about how to define "disease" and evaluate and apply possible definitions. First, I have argued that definitions should not be seen as traditional conceptual analyses, but instead as proposals about how to define and use the term "disease" in the future. Second, I have pointed out and attempted to address a challenge for dysfunction-requiring accounts of disease that I call the "line-drawing" problem: distinguishing between low-normal functioning and dysfunctioning. Finally, I have used a dysfunction-requiring approach to argue that some extremely prevalent conditions, such as high blood pressure, high cholesterol, and ductal carcinoma in situ, are not diseases, but instead are risk factors. Four of the papers in this issue directly engage my previous work. In this commentary, I applaud the advances these authors make, address points of disagreement, and make suggestions about where the discussion should go next.
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Affiliation(s)
- Peter H Schwartz
- Indiana University School of Medicine, Indianapolis, Indiana, USA
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Nickel B, Brito JP, Moynihan R, Barratt A, Jordan S, McCaffery K. Patients' experiences of diagnosis and management of papillary thyroid microcarcinoma: a qualitative study. BMC Cancer 2018; 18:242. [PMID: 29499654 PMCID: PMC5833084 DOI: 10.1186/s12885-018-4152-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 02/20/2018] [Indexed: 12/12/2022] Open
Abstract
Background In recent years management practices in relation to low-risk papillary microcarcinoma (PMC) have been evolving with increased awareness of the potential overdiagnosis and overtreatment of PMCs, and guidelines recommendations for non-surgical management options such as active surveillance. This study aimed to develop an in-depth understanding of patients’ experiences of the communication of their PMC diagnosis, their treatment preferences and decision making. Methods Semi-structured qualitative interviews with 25 patients diagnosed pre-operatively with PMC < 1 year since their diagnosis and treatment. Interviews were conducted between September 2015 and July 2016 and were audio-recorded and transcribed verbatim. Framework analysis method was used to analyse the data. Results The diagnosis and treatment experience of PMC patients varied widely. The majority of patients were asymptomatic, and their PMC was initially detected via an imaging test requested for a reason unrelated to a thyroid disorder or symptom. Clinicians generally described PMC to patients as being a “small” or “slow-growing” cancer, and there was little evidence that clinicians had discussions about the possibility of overdiagnosis or overtreatment. Overall, surgery was the only option discussed and offered to patients. Patients preference for treatment was largely based on eliminating the possibility of the cancer spreading (thyroidectomy) or not wanting to be on thyroid replacement medication for the rest of their life (hemi-thyroidectomy). Many patients reported emotional and physical side-effects associated with their diagnosis and treatment, however patients generally indicated that active surveillance is not something they would have been interested in if it was offered to them. Conclusions Evidence continues to emerge that many patients with PMCs may be overdiagnosed, and management guidelines are recommending more conservative management options for these patients. As a result, shared decision making around treatment options is vital so that patients are fully aware of the meaning of their diagnosis and their management options including active surveillance. Importantly, interventions to reduce unnecessary diagnoses of PMC are critically needed. Electronic supplementary material The online version of this article (10.1186/s12885-018-4152-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Brooke Nickel
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, 2006, NSW, Australia.,Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, 2006, NSW, Australia
| | - Juan P Brito
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, 55905, USA
| | - Ray Moynihan
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, 2006, NSW, Australia.,Centre for Research in Evidence-Based Practice, Bond University, Robina, 4226, QLD, Australia
| | - Alexandra Barratt
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, 2006, NSW, Australia
| | - Susan Jordan
- QIMR Berghofer Medical Research Institute, Brisbane City, QLD, 4006, Australia.,School of Public Health, The University of Queensland, St Lucia, 4072, QLD, Australia
| | - Kirsten McCaffery
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, 2006, NSW, Australia. .,Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, 2006, NSW, Australia.
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Kanbayashi C, Iwata H. Current approach and future perspective for ductal carcinoma in situ of the breast. Jpn J Clin Oncol 2017; 47:671-677. [PMID: 28486668 PMCID: PMC5896693 DOI: 10.1093/jjco/hyx059] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 04/25/2017] [Indexed: 11/14/2022] Open
Abstract
Ductal carcinoma in situ (DCIS) has a good prognosis with the current treatment approach, with a 10-year breast cancer-specific survival rate of 97-98%. In ductal carcinoma in situ without micrometastasis, surgery and postoperative adjuvant therapy significantly improve local control, however it has been reported that the selection of the surgical procedure and adjuvant therapy does not influence breast cancer death. On the other hand, owing to widespread mammography screening, the frequency of early breast cancer detection has increased. In early breast cancer, increased incidence of DCIS is remarkable. However, there is not enough reduction of advanced cancer to match it. Problems with overdiagnosis are now being discussed all over the world. It has been reported that surgery for low-grade ductal carcinoma in situ does not contribute to breast cancer-specific survival. However, it is currently impossible to reliably identify a population that does not progress to invasive cancer even without treatment. Recently, a non-surgery clinical trial for low-risk ductal carcinoma in situ was started. There is a possibility of achieving individualized treatment for ductal carcinoma in situ with less treatment intervention, without compromising the good prognosis obtained with the current treatment approach. This review presents an overview of the current treatment approaches, problems with overdiagnosis and potential future management strategies for ductal carcinoma in situ of the breast.
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Affiliation(s)
| | - Hiroji Iwata
- Department of Breast Oncology, Aichi Cancer Center Hospital, Nagoya, Japan
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Copp T, McCaffery K, Azizi L, Doust J, Mol BWJ, Jansen J. Influence of the disease label 'polycystic ovary syndrome' on intention to have an ultrasound and psychosocial outcomes: a randomised online study in young women. Hum Reprod 2017; 32:876-884. [PMID: 28333180 DOI: 10.1093/humrep/dex029] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 02/03/2017] [Indexed: 12/11/2022] Open
Abstract
Study question Does the disease label 'polycystic ovary syndrome' (PCOS) have an impact on desire for medical testing and psychosocial outcomes? Summary answer When given the disease label PCOS in a hypothetical scenario, participants had higher intention to have an ultrasound, perceived the condition to be more severe and had lower self-esteem than those not given the disease label. What is known already Widening diagnostic criteria and improved imaging sensitivity have increased the number of reproductive-aged women diagnosed with PCOS from 4% to 8% to up to 21%. The uncertain clinical benefit of knowing this diagnosis needs to be weighed against the potential for poor psychological outcomes in women labelled with PCOS. Study design, size, duration This experimental online study randomised 181 young women to receive one of four hypothetical scenarios of a doctor's visit in a 2 (PCOS disease label versus no disease label) x 2 (information about unreliability of ultrasounds in clarifying diagnosis versus no information) design. Participants/materials, setting, methods Participants were university students (mean age: 19.4). After presenting the scenario, intention to have an ultrasound, negative affect, self-esteem, perceived severity of condition, credibility of the doctor and interest in a second opinion were measured. Participants were then presented with a second scenario, where the possibility of PCOS overdiagnosis was mentioned. Change in intention and perceived severity were then measured. Main results and the role of chance Participants given the PCOS label had significantly higher intention to have an ultrasound (mean = 6.62 versus mean = 5.76, P = 0.033, 95% CI(difference) = 0.069-1.599), perceived the condition to be more severe (17.17 versus 15.82, P = 0.019, 95% CI(difference) = 0.229-2.479) and had lower self-esteem (25.86 versus 27.56, P = 0.031, 95% CI(difference) = -3.187 to -0.157). After receiving overdiagnosis information, both intention and perceived severity decreased, regardless of condition (both P < 0.001). Limitations, reasons for caution This study used hypothetical scenarios; it is likely that for women facing a real diagnosis of PCOS, outcomes would be more affected than in the current study. The hypothetical design, however, allowed the symptoms and risks of PCOS to be held constant across conditions, the impact on intention and psychosocial outcomes directly attributable to the effect of the disease label. Wider implications of the findings These findings demonstrate the potential negative consequences of PCOS labelling. It is crucial we consider the impact of the label before diagnosing more women with PCOS when clinical benefit of this diagnosis is uncertain. Study funding/competing interest(s) This paper was written with support from a NHMRC grant awarded to the Screening and Test Evaluation Program. J.J. is supported by an NHMRC Early Career Fellowship. K.M. is supported by an NHMRC Career Development Fellowship. The authors declare that no competing interests exist. Trial registration number ACTRN12617000111370. Trial registration date 20/01/2017. Date of first patient's enrolment 01/06/2015.
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Affiliation(s)
- Tessa Copp
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Centre for Medical Psychology and Evidence-Based Decision-Making (CeMPED), The University of Sydney, Sydney, Australia
| | - Kirsten McCaffery
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Centre for Medical Psychology and Evidence-Based Decision-Making (CeMPED), The University of Sydney, Sydney, Australia
| | - Lamiae Azizi
- School of Mathematics and Statistics, The University of Sydney, Sydney, Australia
| | - Jenny Doust
- Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Australia
| | - Ben W J Mol
- Robinson Research Institute, School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, Australia.,The South Australian Health and Medical Research Institute, North Terrace, Adelaide, Australia
| | - Jesse Jansen
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Centre for Medical Psychology and Evidence-Based Decision-Making (CeMPED), The University of Sydney, Sydney, Australia
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Nickel B, Barratt A, Copp T, Moynihan R, McCaffery K. Words do matter: a systematic review on how different terminology for the same condition influences management preferences. BMJ Open 2017; 7:e014129. [PMID: 28698318 PMCID: PMC5541578 DOI: 10.1136/bmjopen-2016-014129] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Changing terminology for low-risk, screen-detected conditions has now been recommended by several expert groups in order to prevent overdiagnosis and reduce the associated harms of overtreatment. However, the effect of terminology on patients' preferences for management is not well understood. This review aims to synthesise existing studies on terminology and its impact on management decision making. DESIGN Systematic review. METHODS Studies were included that compared two or more terminologies to describe the same condition and measured the effect on treatment or management preferences and/or choices. Studies were identified via database searches from inception to April 2017, and from reference lists. Two authors evaluated the eligibility of studies with verification from the study team, extracted and crosschecked data, and assessed the risk of bias of included studies. RESULTS Of the 1399 titles identified, seven studies, all of which included hypothetical scenarios, met the inclusion criteria. Six studies were quantitative and one was qualitative. Six of the studies were of high quality. Studies covered a diverse range of conditions: ductal carcinoma in situ (3), gastro-oesophageal reflux disease (1), conjunctivitis (1), polycystic ovary syndrome (1) and a bony fracture (1). The terminologies compared in each study varied based on the condition assessed. Based on a narrative synthesis of the data, when a more medicalised or precise term was used to describe the condition, it generally resulted in a shift in preference towards more invasive managements, and/or higher ratings of anxiety and perceived severity of the condition. CONCLUSIONS Different terminology given for the same condition influenced management preferences and psychological outcomes in a consistent pattern in these studies. Changing the terminology may be one strategy to reduce patient preferences for aggressive management responses to low-risk conditions. TRIAL REGISTRATION NUMBER PROSPERO: CRD42016035643.
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Affiliation(s)
- Brooke Nickel
- Wiser Healthcare, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Alexandra Barratt
- Wiser Healthcare, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Tessa Copp
- Wiser Healthcare, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Ray Moynihan
- Wiser Healthcare, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Queensland, Australia
| | - Kirsten McCaffery
- Wiser Healthcare, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
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Partridge AH. Risk communication and decision-making in the prevention of invasive breast cancer. Breast 2017; 34 Suppl 1:S55-S57. [PMID: 28690103 DOI: 10.1016/j.breast.2017.06.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Risk communication surrounding the prevention of invasive breast cancer entails not only understanding of the disease, risks and opportunities for intervention. But it also requires understanding and implementation of optimal strategies for communication with patients who are making these decisions. In this article, available evidence for the issues surrounding risk communication and decision making in the prevention of invasive breast cancer are reviewed and strategies for improvement are discussed.
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Affiliation(s)
- Ann H Partridge
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA.
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Scherer LD, Shaffer VA, Caverly T, Scherer AM, Zikmund-Fisher BJ, Kullgren JT, Fagerlin A. The role of the affect heuristic and cancer anxiety in responding to negative information about medical tests. Psychol Health 2017; 33:292-312. [DOI: 10.1080/08870446.2017.1316848] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Laura D. Scherer
- Department of Psychological Sciences, University of Missouri, Columbia, MO, USA
| | - Victoria A. Shaffer
- Department of Psychological Sciences, University of Missouri, Columbia, MO, USA
- Department of Health Sciences, University of Missouri, Columbia, MO, USA
| | - Tanner Caverly
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Aaron M. Scherer
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of General Internal Medicine, University of Iowa, Iowa, IA, USA
| | - Brian J. Zikmund-Fisher
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, USA
| | - Jeffrey T. Kullgren
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
- VA Center for Informatics Decision Enhancement and Surveillance (IDEAS), Salt Lake City, UT, USA
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Nickel B, Brito JP, Barratt A, Jordan S, Moynihan R, McCaffery K. Clinicians' Views on Management and Terminology for Papillary Thyroid Microcarcinoma: A Qualitative Study. Thyroid 2017; 27:661-671. [PMID: 28322617 DOI: 10.1089/thy.2016.0483] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND There is growing acceptance that the increase in thyroid cancer incidence is in part a result of overdiagnosis of small low-risk papillary microcarcinomas (PMCs) with indolent clinical course. Although surgery is the cornerstone treatment for patients with PMCs, recent management guidelines are shifting toward inclusion of more conservative treatments such as active surveillance. There is little evidence on clinicians' experience in managing PMC patients and their attitudes toward treatment options, including their willingness to accept a nonsurgical option. The aim of this study was to understand how clinicians perceive a diagnosis of PMC, potential changes to terminology, and the treatment options available to patients. METHODS This was a qualitative study using semi-structured interviews conducted between November 2015 and May 2016 with 22 clinicians (seven endocrinologists and 15 thyroid surgeons). Transcribed audio-recordings were thematically coded, and a framework method was used to analyze the data. RESULTS Across a sample of clinicians who manage thyroid cancer patients, awareness of overdiagnosis and overtreatment of PMC was common. However, there was little acceptance of active surveillance to manage these patients. Clinicians did not feel comfortable recommending this management approach, as they were worried about the risk of metastases, did not feel that evidence to support this approach was strong enough, and also believed that patients currently have a high preference for surgery. The majority of clinicians did not believe that changing the terminology of this diagnosis was a viable strategy to reduce patients' anxiety and their perceived preference for more aggressive treatments. However, most clinicians felt that thyroid nodules <1 cm should not be biopsied, which could help minimize the risk of overdiagnosis of PMC. CONCLUSIONS This study, based on a non-representative sample of 22 clinicians, which remains an important limitation, provides revealing insight into clinicians' management preferences and decision making for small low-risk thyroid cancers at a time when management guidelines and practices are evolving. It suggests that clinicians may not be ready to accept nonsurgical options, or changes in terminology, until evidence to support these options and changes is stronger.
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Affiliation(s)
- Brooke Nickel
- 1 Wiser Healthcare, Sydney School of Public Health, The University of Sydney , Sydney, Australia
- 2 Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney , Sydney, Australia
| | - Juan P Brito
- 3 Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Rochester, Mayo Clinic , Minnesota
| | - Alexandra Barratt
- 1 Wiser Healthcare, Sydney School of Public Health, The University of Sydney , Sydney, Australia
| | - Susan Jordan
- 4 QIMR Berghofer Medical Research Institute , Brisbane, Australia
- 5 School of Public Health, The University of Queensland , St. Lucia, Australia
| | - Ray Moynihan
- 1 Wiser Healthcare, Sydney School of Public Health, The University of Sydney , Sydney, Australia
- 6 Centre for Research in Evidence-Based Practice, Bond University , Robina, Australia
| | - Kirsten McCaffery
- 1 Wiser Healthcare, Sydney School of Public Health, The University of Sydney , Sydney, Australia
- 2 Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney , Sydney, Australia
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The Common-Sense Model of Self-Regulation (CSM): a dynamic framework for understanding illness self-management. J Behav Med 2016; 39:935-946. [DOI: 10.1007/s10865-016-9782-2] [Citation(s) in RCA: 364] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 08/02/2016] [Indexed: 12/15/2022]
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The distribution of ductal carcinoma in situ (DCIS) grade in 4232 women and its impact on overdiagnosis in breast cancer screening. Breast Cancer Res 2016; 18:47. [PMID: 27160733 PMCID: PMC4862233 DOI: 10.1186/s13058-016-0705-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 04/19/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The incidence of ductal carcinoma in situ (DCIS) has rapidly increased over time. The malignant potential of DCIS is dependent on its differentiation grade. METHODS Our aim is to determine the distribution of different grades of DCIS among women screened in the mass screening programme, and women not screened in the mass screening programme, and to estimate the amount of overdiagnosis by grade of DCIS. We retrospectively included a population-based sample of 4232 women with a diagnosis of DCIS in the years 2007-2009 from the Nationwide network and registry of histopathology and cytopathology in the Netherlands. Excluded were women with concurrent invasive breast cancer, lobular carcinoma in situ and no DCIS, women recently treated for invasive breast cancer, no grade mentioned in the record, inconclusive record on invasion, and prevalent DCIS. The screening status was obtained via the screening organisations. The distribution of grades was incorporated in the well-established and validated microsimulation model MISCAN. RESULTS Overall, 17.7 % of DCIS were low grade, 31.4 % intermediate grade, and 50.9 % high grade. This distribution did not differ by screening status, but did vary by age. Older women were more likely to have low-grade DCIS than younger women. Overdiagnosis as a proportion of all cancers in women of the screening age was 61 % for low-grade, 57 % for intermediate-grade, 45 % for high-grade DCIS. For women age 50-60 years with a high-grade DCIS this overdiagnosis rate was 21-29 %, compared to 50-66 % in women age 60-75 years with high-grade DCIS. CONCLUSIONS Amongst the rapidly increasing numbers of DCIS diagnosed each year is a significant number of overdiagnosed cases. Tailoring treatment to the probability of progression is the next step to preventing overtreatment. The basis of this tailoring could be DCIS grade and age.
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McCaffery K, Nickel B, Moynihan R, Hersch J, Teixeira-Pinto A, Irwig L, Barratt A. How different terminology for ductal carcinoma in situ impacts women's concern and treatment preferences: a randomised comparison within a national community survey. BMJ Open 2015; 5:e008094. [PMID: 26525720 PMCID: PMC4636630 DOI: 10.1136/bmjopen-2015-008094] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE There have been calls to remove 'carcinoma' from terminology for in situ cancers such as ductal carcinoma in situ (DCIS), to reduce overdiagnosis and overtreatment. We investigated the effect of describing DCIS as 'abnormal cells' versus 'pre-invasive breast cancer cells' on women's concern and treatment preferences. SETTING AND PARTICIPANTS Community sample of Australian women (n=269) who spoke English as their main language at home. DESIGN Randomised comparison within a community survey. Women considered a hypothetical scenario involving a diagnosis of DCIS described as either 'abnormal cells' (arm A) or 'pre-invasive breast cancer cells' (arm B). Within each arm, the initial description was followed by the alternative term and outcomes reassessed. RESULTS Women in both arms indicated high concern, but still indicated strong initial preferences for watchful waiting (64%). There were no differences in initial concern or preferences by trial arm. However, more women in arm A ('abnormal cells' first term) indicated they would feel more concerned if given the alternative term ('pre-invasive breast cancer cells') compared to women in arm B who received the terms in the opposite order (67% arm A vs 52% arm B would feel more concerned, p=0.001). More women in arm A also changed their preference towards treatment when the terminology was switched from 'abnormal cells' to 'pre-invasive breast cancer cells' compared to arm B. In arm A, 18% of women changed their preference to treatment while only 6% changed to watchful waiting (p=0.008). In contrast, there were no significant changes in treatment preference in arm B when the terminology was switched (9% vs 8% changed their stated preference). CONCLUSIONS In a hypothetical scenario, interest in watchful waiting for DCIS was high, and changing terminology impacted women's concern and treatment preferences. Removal of the cancer term from DCIS may assist in efforts towards reducing overtreatment.
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Affiliation(s)
- Kirsten McCaffery
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, New South Wales, Australia
| | - Brooke Nickel
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, New South Wales, Australia
| | - Ray Moynihan
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Jolyn Hersch
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, New South Wales, Australia
| | - Armando Teixeira-Pinto
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Les Irwig
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Alexandra Barratt
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, New South Wales, Australia
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Nickel B, Barratt A, Hersch J, Moynihan R, Irwig L, McCaffery K. How different terminology for ductal carcinoma in situ (DCIS) impacts women's concern and management preferences: A qualitative study. Breast 2015; 24:673-9. [PMID: 26376460 DOI: 10.1016/j.breast.2015.08.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 08/14/2015] [Accepted: 08/19/2015] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE There are increasing rates of mastectomy and bi-lateral mastectomy in women diagnosed with ductal carcinoma in situ (DCIS). To help women avoid decisions that lead to unnecessary aggressive treatments, there have been recent calls to remove the cancer terminology from descriptions of DCIS. We investigated how different proposed terminologies for DCIS affect women's perceived concern and management preferences. MATERIALS AND METHODS Qualitative study using semi-structured interviews with a community sample of 26 Australian women varying by education and cancer screening experience. Women responded to a hypothetical scenario using terminology with and without the cancer term to describe DCIS. RESULTS Among a sample of women with no experience of a DCIS diagnosis, a hypothetical scenario involving a diagnosis of DCIS elicited high concern regardless of the terminology used to describe it. Women generally exhibited stronger negative reactions when a cancer term was used to describe DCIS compared to a non-cancer term, and most preferred the diagnosis be given as a description of abnormal cells. Overall women expressed interest in watchful waiting for DCIS but displayed preferences for very frequent monitoring with this management approach. CONCLUSION Communicating a diagnosis of DCIS using terminology that does not include the cancer term was preferred by many women and may enable discussions about more conservative management options. However, women's preference for frequent monitoring during watchful waiting suggests women need more education and reassurance about this management approach.
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Affiliation(s)
- Brooke Nickel
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, NSW 2006, Australia; Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, NSW 2006, Australia
| | - Alexandra Barratt
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, NSW 2006, Australia; Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, NSW 2006, Australia
| | - Jolyn Hersch
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, NSW 2006, Australia; Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, NSW 2006, Australia
| | - Ray Moynihan
- Faculty of Health Sciences and Medicine, Bond University, QLD 4229, Australia
| | - Les Irwig
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, NSW 2006, Australia
| | - Kirsten McCaffery
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, NSW 2006, Australia; Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, NSW 2006, Australia.
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Morgan DJ, Brownlee S, Leppin AL, Kressin N, Dhruva SS, Levin L, Landon BE, Zezza MA, Schmidt H, Saini V, Elshaug AG. Setting a research agenda for medical overuse. BMJ 2015; 351:h4534. [PMID: 26306661 PMCID: PMC4563792 DOI: 10.1136/bmj.h4534] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/30/2015] [Indexed: 02/06/2023]
Affiliation(s)
- Daniel J Morgan
- Epidemiology, and Public Health, Veterans Affairs Maryland Healthcare System, University of Maryland School of Medicine, 685 W Baltimore St, Baltimore, MD 21201, USA
| | | | - Aaron L Leppin
- Knowledge and Evaluation Research Unit, Mayo Clinic, MN, USA
| | | | | | - Les Levin
- University of Toronto, Toronto, Ontario, Canada
| | - Bruce E Landon
- Department of Health Care Policy, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Mark A Zezza
- Lewin Group's Federal Health And Human Services Practice, Washington, DC, USA
| | - Harald Schmidt
- Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, USA
| | - Vikas Saini
- Lown Institute, Harvard Medical School, Brookline, MA, USA
| | - Adam G Elshaug
- Menzies Centre for Health Policy, Sydney School of Public Health, University of Sydney, Australia Lown Institute, Sydney, Australia
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Vatovec C, Erten MZ, Kolodinsky J, Brown P, Wood M, James T, Sprague BL. Ductal carcinoma in situ: a brief review of treatment variation and impacts on patients and society. Crit Rev Eukaryot Gene Expr 2015; 24:281-6. [PMID: 25403959 DOI: 10.1615/critreveukaryotgeneexpr.2014011495] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Nearly 20% of all breast cancer cases are ductal carcinoma in situ (DCIS), with over 60,000 cases diagnosed each year. Many of these cases would never cause clinical symptoms or threaten the life of the woman; however, it is currently impossible to distinguish which lesions will progress to invasive disease from those that will not. DCIS is generally associated with an excellent prognosis regardless of the treatment pathway, but there is variation in treatment aggressiveness that seems to exceed the medical uncertainty associated with DCIS management. Therefore, it would seem that a significant proportion of women with DCIS receive more extensive treatment than is needed. This overtreatment of DCIS is a growing concern among the breast cancer community and has implications for both the patient (via adverse treatment-related effects, as well as out-of-pocket costs) and society (via economic costs and the public health and environmental harm resulting from health care delivery). This article discusses DCIS treatment pathways and their implications for patients and society and calls for further research to examine the factors that are leading to such wide variation in treatment decisions.
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Affiliation(s)
- Christine Vatovec
- Rubenstein School of Environment and Natural Resources & College of Medicine, Vermont Cancer Center, University of Vermont, Burlington, Vermont
| | - Mujde Z Erten
- Department of Surgery, College of Medicine, Vermont Cancer Center, University of Vermont, Burlington, Vermont; Global Health Economics Unit of the Vermont Center for Clinical and Translational Science, University of Vermont, Burlington, Vermont
| | - Jane Kolodinsky
- Department of Community Development and Applied Economics, University of Vermont, Burlington, Vermont
| | - Phil Brown
- Department of Sociology and Anthropology, Department of Health Sciences, Northeastern University, Boston, Massachusetts
| | - Marie Wood
- Department of Medicine, College of Medicine, Vermont Cancer Center, University of Vermont, Burlington, Vermont
| | - Ted James
- Department of Surgery, College of Medicine, Vermont Cancer Center, University of Vermont, Burlington, Vermont
| | - Brian L Sprague
- Department of Surgery, College of Medicine, Vermont Cancer Center, University of Vermont, Burlington, Vermont
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Smith BD. When Is Good Enough Really Good Enough? Defining the Role of Radiation in Low-Risk Ductal Carcinoma In Situ. J Clin Oncol 2015; 33:686-91. [DOI: 10.1200/jco.2014.59.4259] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Narod SA, Rakovitch E. A comparison of the risks of in-breast recurrence after a diagnosis of dcis or early invasive breast cancer. ACTA ACUST UNITED AC 2014; 21:119-24. [PMID: 24940092 DOI: 10.3747/co.21.1892] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND It is controversial whether ductal carcinoma in situ (dcis) is a preinvasive marker of breast cancer or if it is part of a spectrum of small cancers with malignant potential. Comparing clinical outcomes in women with invasive and noninvasive breast lesions might help to resolve the issue. METHODS From a database of 2641 patients with breast cancer, we selected women who had been treated with breast-conserving surgery for a cancer that was 2.0 cm or less in size, node-negative, and nonpalpable. No subject received chemotherapy. Cancers were categorized as noninvasive (stage 0, n = 172) or invasive (stage 1, n = 401) based on a review of the pathology records. We compared the actuarial risks of in-breast recurrence after invasive and noninvasive breast lesions before and after adjusting for tamoxifen and radiotherapy. RESULTS The 18-year cumulative risk of in-breast recurrence was 35.2% for patients with dcis and 12.8% for patients with small invasive cancers (hazard ratio: 2.4; 95% confidence interval: 1.5 to 3.8; p < 0.0003). After adjustment for radiotherapy and tamoxifen treatment, the difference was small and nonsignificant (hazard ratio: 1.4; 95% confidence interval: 0.9 to 2.4; p = 0.22). CONCLUSIONS For women with small, nonpalpable, node-negative breast cancers, the likelihood of experiencing an in-breast recurrence was associated with radiotherapy and with tamoxifen, but not with the presence of cancer cells invading beyond the basement membrane.
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Affiliation(s)
- S A Narod
- Women's College Research Institute, Women's College Hospital, and the Dalla Lana School of Public Health University of Toronto, Toronto, ON
| | - E Rakovitch
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
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Calhoun BC, Livasy CA. Mitigating Overdiagnosis and Overtreatment in Breast Cancer: What Is the Role of the Pathologist? Arch Pathol Lab Med 2014; 138:1428-31. [DOI: 10.5858/arpa.2013-0763-ed] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Benjamin C. Calhoun
- From the Department of Pathology, Carolinas Medical Center, Charlotte, North Carolina (Drs Calhoun and Livasy); and the Department of Pathology, University of North Carolina, Chapel Hill (Dr Livasy). Dr Calhoun is now with the Department of Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio
| | - Chad A. Livasy
- From the Department of Pathology, Carolinas Medical Center, Charlotte, North Carolina (Drs Calhoun and Livasy); and the Department of Pathology, University of North Carolina, Chapel Hill (Dr Livasy). Dr Calhoun is now with the Department of Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio
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Brito JP, Davies L, Zeballos-Palacios C, Morris JC, Montori VM. Papillary lesions of indolent course: reducing the overdiagnosis of indolent papillary thyroid cancer and unnecessary treatment. Future Oncol 2014; 10:1-4. [DOI: 10.2217/fon.13.240] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Juan P Brito
- Knowledge & Evaluation Research Unit, Division of Diabetes, Metabolism & Nutrition, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Louise Davies
- VA Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, VT, USA
| | - Claudia Zeballos-Palacios
- Knowledge & Evaluation Research Unit, Division of Diabetes, Metabolism & Nutrition, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - John C Morris
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Victor M Montori
- Knowledge & Evaluation Research Unit, Division of Diabetes, Metabolism & Nutrition, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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