Predictors of patients' choices for breast-conserving therapy or mastectomy: a prospective study

Patient Preference for Surgical Methods for Ipsilateral Breast Tumor Recurrence

BACKGROUND

Mastectomy has been the standard surgical treatment for ipsilateral breast tumor recurrence (IBTR). Recently, there has been growing interest in repeat breast-conserving surgery (rBCS) for IBTR among breast surgeons; however, there is currently little information regarding patient preferences for surgical procedure for IBTR. The purpose of this study was to evaluate preference for surgical procedure (mastectomy vs. rBCS) among breast cancer patients who had undergone salvage surgery for IBTR.

METHODS

Overall, 100 breast cancer patients who had undergone salvage surgery for IBTR were asked about their preferred surgical methods for IBTR and the reason. The association of patient preference and the reasons related to various clinical and pathological factors were assessed.

RESULTS

Of the 100 respondents, only 11 patients (11%) preferred rBCS. Patients who had undergone rBCS and radiotherapy for IBTR were significantly more likely to prefer to undergo rBCS than other groups (p = 0.030). The most frequent reason for choosing rBCS was the patient's desire to minimize breast deformity and surgical wounds.

CONCLUSIONS

Our study revealed that there is a low rate of patients who opt to undergo rBCS among patients who had undergone salvage surgery for IBTR. Discrepancies in perceptions regarding the surgical procedure for IBTR between patients and their surgeons may exist.

Association of clinicopathologic variables and patient preference with the choice of surgical treatment for early-stage breast cancer: A registry-based study

INTRODUCTION

Observational studies suggest that breast conserving surgery (BCS) and radiotherapy (RT) offers superior survival compared to mastectomy. The aim was to compare patient and tumour characteristics in women with invasive breast cancer ≤30 mm treated with either BCS or mastectomy, and to explore the underlying reason for choosing mastectomy.

METHODS

Women registered with breast cancer ≤30 mm and ≤4 positive axillary lymph nodes in the Swedish National Breast Cancer Register 2013-2016 were included. Logistic regression analyses were performed to assess the association of tumour and patient characteristics with receiving a mastectomy vs. BCS.

RESULTS

Of 1860 breast cancers in 1825 women, 1346 were treated by BCS and 514 by mastectomy. Adjuvant RT was given to 1309 women (97.1 %) after BCS and 146 (27.6 %) after mastectomy. Variables associated with receiving a mastectomy vs. BCS included clinical detection (Odds Ratio (OR) 4.15 (95 % Confidence Interval (CI) 3.35-5.14)) and clinical stage (T2 vs. T1 (OR 3.68 (95 % CI 2.90-4.68)), N1 vs. N0 (OR 2.02 (95 % CI 1.38-2.96)). Women receiving mastectomy more often had oestrogen receptor negative, HER2 positive tumours of higher histological grade. The most common reported reason for mastectomy was large or multifocal tumours (53.5 %), followed by patient preference (34.5 %).

CONCLUSION

Choice of surgery is strongly associated with key prognostic factors among women undergoing BCS with RT compared to mastectomy. Failure to control for all relevant confounders may bias results in outcome studies in favour of BCS.

What affects women's decision-making on breast reconstruction after mastectomy for breast cancer?

PURPOSE

To establish the breast reconstruction rate in a large Dutch teaching hospital, and to gain insight into the motives of women to opt for or reject post-mastectomy breast reconstruction.

METHODS

In a retrospective, cross-sectional study, all consecutive patients who underwent mastectomy for invasive breast cancer or ductal carcinoma in situ (DCIS) were identified and categorized into two groups based on subsequent breast reconstruction or not. Patient-reported outcomes were assessed with the validated Breast-Q and a short survey about the decision-making process in breast reconstruction. These outcomes were compared between the two groups using univariable analyses, multivariable logistic regression, and multiple linear regression analyses. The Breast-Q scores were also compared to Dutch normative values.

RESULTS

A total of 319 patients were identified of whom 68% had no breast reconstruction. Of the 102 patients with breast reconstruction, the majority (93%) received immediate, instead of delayed breast reconstruction. The survey was completed by 155 (49%) patients. The non-reconstruction group, on average, reported significantly poorer psychosocial well-being, compared to the reconstruction group as well as compared to the normative data. However, the majority of the non-reconstruction group (83%) stated that they had no desire for breast reconstruction. In both groups, most patients stated that the provided information was sufficient.

CONCLUSION

Patients have personal motives to opt for or reject breast reconstruction. It seemed that patients differ in their rating of values that affect their decision since the same arguments were used to opt for or reject reconstruction. Notably, patients were well-informed in their decision making.

A large single-center prospective study to investigate the factors influencing the choice of breast-conserving surgery versus mastectomy in Chinese women with early breast cancer

BACKGROUND

Compared to mastectomy, breast-conserving surgery (BCS) provides the same survival rate and a higher quality of life for patients with early breast cancer (EBC). However, Chinese women with EBC are known to have a low BCS rate. A large prospective cohort study was conducted to investigate the factors influencing the choice of BCS in this population.

METHODS

In 2017, all women with unilateral EBC and eligible for BCS at our institution were enrolled. Before surgery, the patient's trust in the surgeon and her perceived strength of the surgeon's recommendation of BCS were measured through an in-person interview and validated ad hoc questionnaire. Multivariate logistic regressions on BCS procedure vs. mastectomy were used to estimate the odds ratio (OR).

RESULTS

One thousand one hundred thirty-six patients enrolled at analysis had an average age of 51.8 and tumor size of 2.4 cm. 19.9% of patients had BCS. The "strong" level of trust in the surgeon was significantly associated with BCS with an OR of 2.944 (p<0.001) when compared to the "average or under" trust. The "strong" and "moderate" strengths in surgeon recommendation for BCS were also found to be significantly associated with the BCS procedure with ORs of 12.376 (p <0.001) and 1.757 (p =0.040), respectively, compared to the "neutral or dissuaded" strength.

CONCLUSIONS

Stronger trust in surgeons and BCS recommendation by surgeons are associated with a higher rate of BCS in Chinese women with EBC. Interventional trials are needed to confirm this finding.

"No Ink on Tumor" in Breast-Conserving Surgery after Neoadjuvant Chemotherapy

Background/Aim: Patients with Stage I-II breast cancer undergoing breast-conserving surgery after neoadjuvant chemotherapy (BCS-NAC) were retrospectively assessed in order to evaluate the extent of a safe excision margin. Materials and Methods: Between 2003 and 2020, 151 patients underwent risk-adapted BCS-NAC; margin involvement was always assessed at definitive histology. Patients with complete pathological response (pCR) were classified as the RX group, whereas those with residual disease and negative margins were stratified as R0 < 1 mm (margin < 1 mm) and R0 > 1 mm (margin > 1 mm). Results: Totals of 29 (19.2%), 64 (42.4%), and 58 patients (38.4%) were included in the R0 < 1 mm, R0 > 1 mm, and RX groups, respectively, and 2 patients with margin involvement had a mastectomy. Ten instances of local recurrence (6.6%) occurred, with no statistically significant difference in local recurrence-free survival (LRFS) between the three groups. A statistically significant advantage of disease-free survival (p = 0.002) and overall survival (p = 0.010) was observed in patients with pCR. Conclusions: BCS-NAC was increased, especially in HER-2-positive and triple-negative tumors; risk-adapted BCS should be preferably pursued to highlight the cosmetic benefit of NAC. The similar rate of LRFS in the three groups of patients suggests a shift toward the “no ink on tumor” paradigm for patients undergoing BCS-NAC.

Association Between Surgery Preference and Receipt in Ductal Carcinoma In Situ After Breast Magnetic Resonance Imaging: An Ancillary Study of the ECOG-ACRIN Cancer Research Group (E4112)

Importance

Guiding treatment decisions for women with ductal carcinoma in situ (DCIS) requires understanding patient preferences and the influence of preoperative magnetic resonance imaging (MRI) and surgeon recommendation.

Objective

To identify factors associated with surgery preference and surgery receipt among a prospective cohort of women with newly diagnosed DCIS.

Design, Setting, and Participants

A prospective cohort study was conducted at 75 participating institutions, including community practices and academic centers, across the US between March 25, 2015, and April 27, 2016. Data were analyzed from August 2 to September 24, 2021. This was an ancillary study of the ECOG-ACRIN Cancer Research Group (E4112). Women with recently diagnosed unilateral DCIS who were eligible for wide local excision and had a diagnostic mammogram within 3 months of study registration were included. Participants who had documented surgery and completed the baseline patient-reported outcome questionnaires were included in this substudy.

Exposures

Women received preoperative MRI and surgeon consultation and then underwent wide local excision or mastectomy. Participants will be followed up for recurrence and overall survival for 10 years from the date of surgery.

Main Outcomes and Measures

Patient-reported outcome questionnaires assessed treatment goals and concerns and surgery preference before MRI and after MRI and surgeon consultation.

Results

Of the 368 participants enrolled 316 (86%) were included in this substudy (median [range] age, 59.5 [34-87] years; 45 women [14%] were Black; 245 [78%] were White; and 26 [8%] were of other race). Pre-MRI, age (odds ratio [OR] per 5-year increment, 0.45; 95% CI, 0.26-0.80; P = .007) and the importance of keeping one's breast (OR, 0.48; 95% CI, 0.31-0.72; P < .001) vs removal of the breast for peace of mind (OR, 1.35; 95% CI, 1.04-1.76; P = .03) were associated with surgery preference for mastectomy. After MRI and surgeon consultation, MRI upstaging (48 of 316 [15%]) was associated with patient preference for mastectomy (OR, 8.09; 95% CI, 2.51-26.06; P < .001). The 2 variables with the highest ORs for initial receipt of mastectomy were MRI upstaging (OR, 12.08; 95% CI, 4.34-33.61; P < .001) and surgeon recommendation (OR, 4.85; 95% CI, 1.99-11.83; P < .001).

Conclusions and Relevance

In this cohort study, change in patient preference for DCIS surgery and surgery received were responsive to MRI results and surgeon recommendation. These data highlight the importance of ensuring adequate information and ongoing communication about the clinical significance of MRI findings and the benefits and risks of available treatment options.

The Emotional Status, Attitudes in Decision-Making Process, and Their Impact on Surgical Choices in Korean Breast Cancer Patients

Purpose

We examined the incidence of emotional distress in women with newly diagnosed breast cancer to determine whether the degree of emotional distress affected their choice of breast-conserving surgery (BCS) or mastectomy and evaluated how the patient's preferred role in decision-making influenced her choice of surgical method.

Methods

This prospective study included 85 patients newly diagnosed with in situ or invasive breast cancer eligible for BCS. Their degree of depression/anxiety and attitude toward the decision-making process were measured using the Hospital Anxiety and Depression Scale (HADS) and Control Preference Scale (CPS), respectively. After receiving information on both surgical methods, the patients indicated their preferred surgical method and completed the CPS at their initial and second visits before surgery.

Results

After the diagnosis of breast cancer, 75.3% of patients showed abnormal or borderline HADS scores for depression and 41.2% for anxiety. Patients with borderline or abnormal degrees of depression were more likely to have coexisting abnormal degrees of anxiety (p < 0.001). However, the presence of depression or anxiety was not associated with patients' surgical choices (p=0.394 and 0.530, respectively). Patients who preferred a more active role in the decision-making process were more likely to choose mastectomy over BCS, while those who were passive or collaborative chose BCS more frequently (p=0.001).

Conclusion

Although many patients with newly diagnosed breast cancer experience depression and anxiety before surgery, these do not affect the choice of surgical method; however, their attitudes toward the decision-making process do.

Decision aids on breast conserving surgery for early stage breast cancer patients: a systematic review

Background

Breast cancer is a worldwide health concern. For early stage breast cancer patients, choosing the surgical method after diagnosis is always a dilemma. Decision aids designed for use by patients are tools which may help with surgical decision making for these patients.

Methods

We screened through MEDLINE, EMBASE, PubMed and Web of Science using the inclusion criteria which included (1) newly diagnosed patients with early stage breast cancer, (2) outcomes/results involving surgical options including breast conserving surgery. The search strategy used these key words or the combination of these words: “breast cancer”, “decision aid”, “decision making”, “decision support”, “breast conserving surgery”, “breast conserving therapy”.

Results

A total of 621 studies were identified, but only seven studies were included. Results were synthesized into narrative format. Various patterns of decision aids designed for use by patients were implemented. Mostly were educational materials via booklet, video or CDROM with or without assistance from surgeons. After decision aids, four studies showed that patients were more likely to change their original choices into mastectomy or modified radical instead of sticking to breast conserving surgery. Other results such as knowledge of breast cancer and treatments, decisional conflict and satisfaction, psychological changes after surgery and quality of life were all showed with a better trend in patients with decision aids in most studies.

Conclusion

Decision aids on breast conserving surgery made it easier for patient involvement in surgical decision making and improved decision-related outcomes in most early stage breast cancer patients. With more attention, improving procedures, and better interdisciplinary cooperation, more research is necessary for the improvement of decision aids. And we believe decision aids with agreed objective information are needed.

Long-term survival outcomes of repeat lumpectomy for ipsilateral breast tumor recurrence: a propensity score-matched analysis

PURPOSE

This study aimed to compare long-term survival outcomes of repeat lumpectomy with total mastectomy after ipsilateral breast tumor recurrence (IBTR) using propensity score matching (PSM).

METHODS

We retrospectively analyzed patients with IBTR who had undergone initial breast-conserving surgery for breast cancer at our institution between January 1990 and December 2013. The Kaplan-Meier method and Cox proportional hazards model were used to compare survival rates between the two groups. PSM was performed using the following covariates: age at initial operation, initial T stage, N stage, hormone receptor status, human epidermal growth factor receptor 2 status, chemotherapy, radiotherapy, and IBTR tumor size.

RESULTS

We enrolled 335 IBTR patients with a median follow-up of 126.6 months. No significant differences were observed in the 5-year overall survival (OS), breast cancer-specific survival (BCSS), OS after IBTR, and BCSS after IBTR and 10-year survival probability between the two groups in a multivariate analysis. After PSM, patients who had undergone repeat lumpectomy and total mastectomy (n = 90 in both groups) were included. No significant differences were observed in the 10-year OS (hazard ratio [HR] 1.08, 95% confidence interval [CI] 0.49-2.39), BCSS (HR 0.83, 95% CI 0.35-1.95), OS after IBTR (HR 0.83, 95% CI 0.38-1.83), and BCSS after IBTR (HR 0.64, 95% CI 0.28-1.47) between the two groups.

CONCLUSIONS

No significant differences were observed in survival outcomes between patients with IBTR who underwent repeat lumpectomy or total mastectomy. Our results can be helpful in selecting the appropriate surgical method for IBTR.

Breast Cancer Surgery Decision Role Perceptions and Choice of Surgery

BACKGROUND

Retrospective studies have reported that breast cancer patients who perceived more personal responsibility for the surgery decision were more likely to undergo aggressive surgery. We examined this in a prospective study.

METHODS

100 newly diagnosed breast cancer patients identified their decision- making role using the Patient Preference Scale. Chart review captured the initial surgery received. Patient decision role preference, role perception, role concordance, and provider role perception were compared with type of surgery to assess differences between mastectomy and lumpectomy groups and unilateral versus bilateral mastectomy. We compared type of surgery and patient role concordance. Satisfaction with Decision immediately after the visit, Decision Regret and FACT-B quality of life at 2 weeks and 6 months were assessed and compared with type of surgery.

RESULTS

Patient decision role preference (p = 0.49) and perception (p = 0.16) were not associated with type of surgery. Provider perception of patient role was associated with type of surgery, with providers perceiving more passive patient roles in the mastectomy group (p = 0.026). Patient role preference varied significantly by stage of disease (= 0.024), with stage 0 (64%, N = 6) and stage III (60%, N = 6) patients preferring active roles and stage I (60%, N = 25) and stage II (52%, N = 16) patients preferring a collaborative role.

CONCLUSIONS

Patient role preference and perception were not associated with type of surgery, while provider perception of patient role was. Patient role preference varied by stage of disease. Further study is warranted to better understand how disease factors and provider interactions affect decision role preferences and perceptions and surgical choice.

TRIAL REGISTRATION

The study was registered with clinicaltrials.gov (NCT03350854). https://clinicaltrials.gov/ct2/show/NCT03350854 .

Self-reported health and survival in older patients diagnosed with multiple myeloma

PURPOSE

Patient-reported outcomes such as self-reported health (SRH) are important in understanding quality cancer care, yet little is known about links between SRH and outcomes in older patients with multiple myeloma (MM). We evaluated associations between SRH and mortality among older patients with MM.

METHODS

We analyzed a retrospective cohort of patients ages ≥ 65 years diagnosed with first primary MM using the Surveillance, Epidemiology, and End Results (SEER)-Medicare Health Outcomes Survey (MHOS) data resource. Pre-diagnosis SRH was grouped as high (excellent/very good/good) or low (fair/poor). We used Cox proportional hazards models to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for associations between SRH and all-cause and MM-specific mortality.

RESULTS

Of 521 MM patients with mean (SD) age at diagnosis of 76.8 (6.1) years, 32% reported low SRH. In multivariable analyses, low SRH was suggestive of modest increased risks of all-cause mortality (HR 1.32, 95% CI 1.02-1.71) and MM-specific mortality (HR 1.22, 95% CI 0.87-1.70) compared to high SRH.

CONCLUSION

Findings suggest that low pre-diagnosis SRH is highly prevalent among older patients with MM and is associated with modestly increased all-cause mortality. Additional research is needed to address quality of life and modifiable factors that may accompany poor SRH in older patients with MM.

Socioeconomic status differs between breast cancer patients treated with mastectomy and breast conservation, and affects patient-reported preoperative information

PURPOSE

Breast cancer treatment is reported to be influenced by socioeconomic status (SES). Few reports, however, stem from national, equality-based health care systems. The aim of this study was to analyse associations between SES, rates of breast-conserving surgery (BCS), patient-reported preoperative information and perceived involvement in Sweden.

METHODS

All women operated for primary breast cancer in Sweden in 2013 were included. Tumour and treatment data as well as socioeconomic data were retrieved from national registers. Postal questionnaires regarding preoperative information about breast-conserving options and perceived involvement in the decision-making process had previously been sent to all women receiving mastectomy.

RESULTS

Of 7735 women, 4604 (59.5%) received BCS. In addition to regional differences, independent predictors of BCS were being in the middle or higher age groups, having small tumours without clinically involved nodes, being born in Europe outside Sweden, having a higher education than primary school and an intermediate or high income per household. Women with smaller, clinically node-negative tumours felt more often involved in the surgical decision and informed about breast-conserving options (both p < 0.001). In addition, women who perceived that BCS was discussed as an alternative to mastectomy were more often in a partnership (p < 0.001), not born in Sweden (p = 0.035) and had an employment (p = 0.031).

CONCLUSION

Socioeconomic factors are associated with surgical treatment even in a national health care system that is expected to offer all women the same standard of care. This should be taken into account and adapted to in preoperative counselling on surgical options in breast cancer.

Multicentre prospective observational study evaluating recommendations for mastectomy by multidisciplinary teams

BACKGROUND

Recommendations for mastectomy by multidisciplinary teams (MDTs) may contribute to variation in mastectomy rates. The primary aim of this multicentre prospective observational study was to describe current practice in MDT decision-making for recommending mastectomy. A secondary aim was to determine factors contributing to variation in mastectomy rates.

METHODS

Consecutive patients undergoing mastectomy between 1 June 2015 and 29 February 2016 at participating units across the UK were recruited. Details of neoadjuvant systemic treatment (NST), operative and oncological data, and rationale for recommending mastectomy by MDTs were collected.

RESULTS

Overall, 1776 women with breast cancer underwent 1823 mastectomies at 68 units. Mastectomy was advised by MDTs for 1402 (76·9 per cent) of these lesions. The most common reasons for advising mastectomy were large tumour to breast size ratio (530 women, 29·1 per cent) and multicentric disease (372, 20·4 per cent). In total, 202 postmenopausal women with oestrogen receptor-positive (ER+) unifocal tumours were advised mastectomy and not offered NST, owing to large tumour to breast size ratio in 173 women (85·6 per cent). Seventy-five women aged less than 70 years with human epidermal growth factor receptor 2-positive (HER2+) tumours were advised mastectomy and not offered NST, owing to large tumour to breast size ratio in 45 women (60 per cent).

CONCLUSION

Most mastectomies are advised for large tumour to breast size ratio, but there is an inconsistency in the use of NST to downsize tumours in patients with large ER+ or HER2+ cancers. The application of standardized recommendations for NST could reduce the number of mastectomies advised by MDTs.

A Randomized Controlled Trial Evaluating the Impact of Pre-Consultation Information on Patients' Perception of Information Conveyed and Satisfaction with the Decision-Making Process

BACKGROUND

Patient participation in treatment decision-making is a health care priority. This study hypothesized that providing a decision aid before surgical consultation would better prepare patients for decision-making. The objective was to examine the impact of a decision aid versus high-quality websites on patients' perceptions of information conveyed during surgical consultation and satisfaction with the decision process.

METHODS

Patients with stages 0 to 3 breast cancer were randomized. Surveys assessed perceptions of information conveyed, being asked surgical preference, and satisfaction with the decision process. Multivariable logistic regression assessed associations between outcomes and randomization arm, patient factors, and surgeon. Change in Pseudo-R² assessed the comparative effect of these factors on perceptions of the information conveyed.

RESULTS

The median patient age was 59 years. Most of the patients (98%) were white, and 62% were college educated (n = 201). The findings showed no association between randomization arm and perceptions of information conveyed, being asked surgical preference, or satisfaction with the decision process. Most of the patients reported discussing both breast-conserving therapy and mastectomy (69%) and being asked their surgical preference (65%). The surgeon seen was more important than the randomization arm or the patient factors in predicting patients' perceptions of information conveyed (explained 64-69% of the variation), and 63% of the patients were satisfied with the decision process.

CONCLUSION

Use of a decision aid compared with high-quality websites did not increase patients' perceptions of information conveyed or satisfaction with the decision process. Although the surgeon seen influenced aspects of the patient experience, the surgeon was not associated with satisfaction. Understanding the factors driving low satisfaction is critical because this is increasingly used as a marker of health care quality.

Surgical treatment choices for breast cancer in Newfoundland and Labrador: a retrospective cohort study

BACKGROUND

Mastectomy is often chosen by women for treatment of breast cancer, even when breast-conserving surgery (BCS) is an option. Newfoundland and Labrador has a high mastectomy rate. We documented the number of breast cancers over a given period in the province and their related surgical treatments, and explored the impact of several variables on surgical choice.

METHODS

A retrospective cohort design linked diagnosis data from the Newfoundland and Labrador tumour registry to surgery data from the Canadian Institute for Health Information Discharge Abstract Database. Data were extracted for all women aged 19 years or more in whom breast cancer was diagnosed in 2009-2014.

RESULTS

A total of 2346 cases of breast cancer with a linked surgical procedure were included. Most operations (1605 [68.4%]) were mastectomy procedures, with the remainder being BCS. Logistic regression analysis revealed that women were 1.82 times (95% confidence interval [CI] 1.64-2.02) more likely to have mastectomy for each unit of stage increase from 0 to IV and 1.15 times (95% CI 1.11-1.21) more likely for each unit of driving time increase.

CONCLUSION

Tumour stage and driving time to a radiation facility significantly predicted Newfoundland and Labrador women's surgical treatment choices for breast cancer. Notably, mastectomy was the favoured choice across all age groups, tumour stages and geographical regions of the province. We hope that these results will galvanize efforts to better understand local surgical practices and assist in improving the quality of surgical care of women with breast cancer.

Factors influencing surgical treatment decisions for breast cancer: a qualitative exploration of surgeon and patient perspectives

Background

The rate of mastectomy is much higher in Newfoundland and Labrador than in any other province in Canada, even for women diagnosed at an early stage. In this paper, we present qualitative data from women who have made a decision for surgical treatment and from breast surgeons in an effort to better explicate factors influencing breast cancer (bca) surgical decision-making.

Methods

The study's descriptive, qualitative design involved holding interviews with breast surgeons and holding focus groups and interviews with women who were offered the choice of breast-conserving surgery (bcs) or mastectomy (mt).

Results

Participants included 35 women and 13 surgeons. High interest in mt and increasing requests for prophylactic contralateral mt were evident. A host of factors-clinical, demographic, psychosocial, education-related, and cultural-influenced the decisions. A key factor for women was fear of recurrence and a need to "just get rid of it," but the experiences of others also influenced the decisions. Life stage and family considerations also factored prominently into women's decisions.

Conclusions

Women with early-stage bca more often chose mt and often demanded prophylactic removal of the healthy breast. Findings highlight the importance of ensuring that women at average risk are appropriately counselled about the low likelihood of a subsequent contralateral bca and the lack of survival benefit associated with prophylactic contralateral mt. Findings also revealed other areas of presurgical discussion that might help women think through their personal circumstances and values so as to encourage informed surgical decisions.

Effect of 21-gene recurrence score in decision-making for surgery in early stage breast cancer

Aim

We aimed to assess the role of 21-gene recurrence score (RS) in the decision-making for surgical treatment in early stage breast cancer and compared the outcomes between breast-conserving surgery (BCS) and mastectomy (MAST) among various 21-gene RS groups.

Methods

We included patients with stage T1-2M0M0 and estrogen receptor-positive breast invasive ductal carcinoma who underwent BCS + radiotherapy or MAST between 2004 and 2012 as part of the Surveillance, Epidemiology, and End Results program. Data were analyzed using binomial logistic regression, multivariate Cox proportional hazards models, and propensity score matching (PSM).

Results

We enrolled 34,447 patients including 22,681 (65.8%) and 11,766 (34.2%) who underwent BCS and MAST, respectively. Patients with high-risk RS were more likely to receive MAST. Multivariate analysis indicated that patients with intermediate-risk (P<0.001) and high-risk (P<0.001) RS had poor breast cancer-specific survival (BCSS), as compared to those with low-risk RS. Moreover, patients who underwent MAST also exhibited poor BCSS (P<0.001), as compared to those who underwent BCS. In low-risk (P<0.001) and intermediate-risk (P=0.020) RS groups, patients who underwent MAST had poor BCSS, as compared to those treated with BCS. However, BCSS was comparable between patients who underwent MAST and BCS (P=0.952); similar trends were also observed after PSM.

Conclusion

The 21-gene RS may impact the decision-making for surgery in early stage breast cancer. Our study provides additional support for a shared decision-making process for BCS when both local management options are appropriate choices regardless of the 21-gene RS.

Would Plastic Surgeons Choose Breast Conservation Therapy?

BACKGROUND

Breast conservation therapy is defined as partial mastectomy with subsequent radiation therapy and is the treatment for early-stage breast cancer. However, the unwanted risks of radiation must be considered as well as the impact on future breast reconstruction options. The purpose of this study was to assess the preference of plastic surgeons when given the hypothetical diagnosis of breast cancer.

METHODS

A survey assessing treatment preference of 3 hypothetical breast cancer diagnosis scenarios was designed and distributed by American Society of Plastic Surgeons via e-mail invite to its members.

RESULTS

The risk of cancer recurrence was the most common reason for treatment preferences of all three choices. However, for ductal carcinoma in situ, unilateral mastectomy with implant-based reconstruction is the preferred option with the second most influential reason of avoiding the risks of radiation therapy. For invasive ductal carcinoma node negative, unilateral mastectomy with implant-based reconstruction was the preferred option also due to risks of radiation therapy and anxiety of future surveillance. For invasive ductal carcinoma node positive, bilateral mastectomy with implant-based reconstruction was the preferred choice because of anxiety of future surveillance and also risks of radiation therapy.

CONCLUSIONS

In general, plastic surgeons did not prefer breast conservation therapy for in situ and early-stage breast cancer. Although the most common rationale for total mastectomy was risk of cancer recurrence for all disease severity, risks of radiation therapy are real and play an integral role in the decision-making process. In understanding our own biases, we can help better empathize with patients in consultation for breast reconstruction.

Life After Surgery: Surgeon Assessments of Quality of Life Among Patients With Familial Adenomatous Polyposis

BACKGROUND

Without prophylactic surgery, patients with familial adenomatous polyposis are at high risk for colorectal cancer development. Various surgical options for prophylaxis are available. Patient decision-making for preventative treatments is often influenced by the preferences of healthcare providers.

OBJECTIVE

We determined surgeon preferences for the surgical options available to patients with familial adenomatous polyposis.

DESIGN

We obtained preference estimates for postoperative health states from colorectal surgeons who had treated ≥10 patients with familial adenomatous polyposis.

SETTINGS

Assessments were made at an annual meeting of the American Society of Colon and Rectal Surgeons.

MAIN OUTCOME MEASURES

Utilities were measured through the time trade-off method. We determined utilities for 3 procedures used for prophylaxis, including total proctocolectomy with permanent ileostomy, colectomy with ileorectal anastomosis, and total proctocolectomy with IPAA. We also assessed utilities for 2 short-term health states: 90 days with a temporary ileostomy and 2 years with a poorly functioning ileoanal pouch.

RESULTS

Twenty-seven surgeons who had cared for >1700 patients with familial adenomatous polyposis participated in this study. The highest utility scores were provided for colectomy with ileorectal anastomosis (0.98). Lower utility scores were provided for total proctocolectomy with permanent ileostomy (0.87) and IPAA (0.89). The number of patients with familial adenomatous polyposis who were treated by participating surgeons did not influence these estimates; however, more-experienced surgeons gave lower utility scores for a poorly functioning ileoanal pouch than less-experienced surgeons (0.15, 0.50, and 0.25 for high-, medium-, and low-volume surgeons; p = 0.02).

LIMITATIONS

This study was limited by the sample size.

CONCLUSIONS

For patients with familial adenomatous polyposis and relative rectal sparing, surgeon preferences are greatest for colectomy with ileorectal anastomosis. Utility estimates provided by this study are important for understanding surgical decision-making and suggest a role for ileorectal anastomosis in appropriately selected patients. See Video Abstract at http://links.lww.com/DCR/A656.

Impact of acculturation on breast cancer treatment and survivorship care among Mexican American patients in Texas

PURPOSE

Given the increasing number and diversity of cancer survivors in the USA and persistent racial/ethnic disparities in breast cancer care, we sought to examine the role of acculturation in adherence to recommended surgical treatment and survivorship care recommendations.

METHODS

Study participants included 343 Mexican American women with stage I to III breast cancer who participated in the Ella Binational Breast Cancer Study and were treated at The University of Texas MD Anderson Cancer Center in Houston, Texas, between March 2007 and June 2011. Participants completed a questionnaire measuring acculturation, and clinical and demographic variables were obtained from an institutional database. Multivariable logistic regression models were constructed to examine differences in surgical procedures received and adherence to long-term survivorship care by acculturation level.

RESULTS

Bilingual (odds ratio [OR] = 1.85; 95% confidence interval [CI] = 0.85-4.02, P = .11) and English-dominant women (OR = 2.39; 95% CI = 1.02-5.61, P = .04) were more likely to receive breast-conserving surgery (versus mastectomy) than were Spanish-dominant women. Among all patients, adherence to surveillance mammography and clinic visits decreased over time; the decline in clinic visit adherence was statistically significant (P = .005). Although no statistically significant association was found between acculturation and adherence to long-term survivorship care, receipt of breast-conserving surgery (versus mastectomy) was significantly associated with higher adherence to surveillance mammograms.

CONCLUSION

Acculturation may play a role in decision-making about surgical management of breast cancer, and further studies with larger samples are needed to explore its role in adherence to survivorship care recommendations. Findings from this study may help identify patients requiring additional support while making decisions pertaining to their cancer treatment and survivorship care.

Creation of a new clinical framework - why women choose mastectomy versus breast conserving therapy

BACKGROUND

Clinical medicine has lagged behind other fields in understanding and utilizing frameworks to guide research. In this article, we introduce a new framework to examine why women choose mastectomy versus breast conserving therapy in early stage breast cancer, and highlight the importance of utilizing a conceptual framework to guide clinical research.

METHODS

The framework we present was developed through integrating previous literature, frameworks, theories, models, and the author's past research.

RESULTS

We present a conceptual framework that illustrates the central domains that influence women's choice between mastectomy versus breast conserving therapy. These have been organized into three broad constructs: clinicopathological factors, physician factors, and individual factors with subgroups of sociodemographic, geographic, and individual belief factors. The aim of this framework is to provide a comprehensive basis to describe, examine, and explain the factors that influence women's choice of mastectomy versus breast conserving therapy at the individual level.

CONCLUSION

We have developed a framework with the purpose of helping health care workers and policy makers better understand the multitude of factors that influence a patient's choice of therapy at an individual level. We hope this framework is useful for future scholars to utilize, challenge, and build upon in their own work on decision-making in the setting of breast cancer. For clinician-researchers who have limited experience with frameworks, this paper will highlight the importance of utilizing a conceptual framework to guide future research and provide an example.

Age exerts a continuous effect in the outcomes of Asian breast cancer patients treated with breast-conserving therapy

Background

Asians are diagnosed with breast cancer at a younger age than Caucasians are. We studied the effect of age on locoregional recurrence and the survival of Asian breast cancer patients treated with breast-conserving therapy.

Methods

Medical records of 2492 patients treated with breast-conserving therapy between 1989 and 2012 were reviewed. The Kaplan–Meier method was used to estimate locoregional recurrence, breast cancer-free survival, and breast cancer-specific survival rates. These rates were then compared using log-rank tests. Outcomes and age were modeled by Cox proportional hazards. Fractional polynomials were then used to test for non-linear relationships between age and outcomes.

Results

Patients ≤ 40 years old were more likely to have locoregional recurrence than were older patients (Hazard ratio [HR] = 2.32, P < 0.001). Locoregional recurrence rates decreased year-on-year by 4% for patients with luminal-type breast cancers, compared with 8% for those with triple-negative cancers. Similarly, breast cancer-free survival rates increased year-on-year by 4% versus 8% for luminal-type and triple-negative cancers, respectively. Breast cancer-specific survival rates increased with age by 5% year-on-year. Both breast cancer-free survival and breast cancer-specific survival rates in patients with luminal cancers exhibited a non-linear (“L-shaped”) relationship—where decreasing age at presentation was associated with escalating risks of relapse and death. The influence of age on overall survival was confounded by competing non-cancer deaths in older women, resulting in a “U-shaped” relationship.

Conclusions

Young Asian breast cancer patients have a continuous year-on-year increase in rates of disease relapse and cancer deaths compared with older patients with no apparent threshold.

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

Introduction:

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

Method:

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

Results:

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

Conclusion:

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

What Drives Patient Choice: Preferences for Approaches to Surgical Treatments for Breast Cancer Beyond Traditional Clinical Benchmarks

IMPORTANCE

Understanding what drives breast cancer (BC) patient's surgical decision-making and why, as survival continues to improve, are women continuing to choose mastectomy in increasing numbers.

OBJECTIVE

We sought to understand better what drives patient choice in surgical decision-making regarding BC treatment options.

DESIGN

We used a dynamic model, adaptive conjoint-based survey experiment, to assess multiple factors concurrently impacting patient choice, conducted from December 2016 to January 2017 using the Army of Women.

SETTING

Army of Women, is a U.S.-based nation-wide registry of women, both healthy and previous BC patients.

PARTICIPANTS

An e-mail invitation was sent to the AWOL's 108,933 members, with 1,233 signing up to participate and 858 responding (548 healthy, 310 previous BC). Two hundred thirty-nine BC patients who underwent treatment > 5 years were excluded due to potential recall bias and changes in BC treatment paradigms. All subjects who did not complete the adaptive conjoint-based survey were also excluded due to inability to calculate preferences. The final sample consisted of 522 healthy women and 71 previous BC patients.

INTERVENTIONS OR EXPOSURES

Study of patient preference and decision drivers, without, interventions or exposures.

MAIN OUTCOMES AND MEASURES

Shares of preferences for various surgical treatment options were calculated using the highest-ranked factors, by the importance that drove patient decision-making.

RESULTS

Survey response rate was 69.5%. Among healthy women, the most important of the 9 factors in making a surgical choice were doctor's recommendation at 21.4% (SD, 13.6%) and overall survival (OS) at 20.5% (SD, 9.8%) while among previous BC patients, the most important factor was OS at 19% (SD, 9%) and doctor's recommendation at 17.2% (SD, 10.3%).

CONCLUSION AND RELEVANCE

While OS accounted for the largest single driver of patient choice at ~20 %, it is notable that 80% of patient decision-making was driven by factors unrelated to survival such as cost, intensity and recovery time, and breast image. By understanding what drives choice, we can provide better patient-centric education and treatments.

Meta-analysis of neoadjuvant therapy and its impact in facilitating breast conservation in operable breast cancer

Background

Neoadjuvant therapy (NAT) for operable breast cancer may facilitate more breast-conserving surgery (BCS). It seems, however, that this benefit is not being realized fully.

Methods

A systematic review of the literature was performed. RCTs were included. The criteria for inclusion were: documentation of surgical assessment before and after NAT, surgery performed (BCS or mastectomy), and clinical and pathological responses.

Results

A total of 1452 patients from seven RCTs met the inclusion criteria. After NAT, the feasibility of BCS increased from 43·3 to 60·4 per cent (P &lt; 0·001), but BCS was performed in only 51·8 per cent (P = 0·04). Only 31 per cent of patients who became eligible for BCS (assessed on clinical response) underwent BCS (pooled rate ratio 0·31, 95 per cent c.i. 0·22 to 0·44; P &lt; 0·001). Of the mastectomy candidates who achieved a pathological complete response after NAT, only 41 per cent underwent BCS (pooled rate ratio 0·41, 0·23 to 0·74; P = 0·003). The main factors that influenced the decision not to shift to BCS, even though it was feasible, were clinical assessment before NAT, multicentricity and tumour size at presentation.

Conclusion

Breast surgery performed after NAT does not reflect tumour response, resulting in potentially unnecessary radical surgery, especially mastectomy. The barriers to maximizing the surgical benefits of NAT need to be better understood and explored.

Improving Breast Cancer Surgical Treatment Decision Making: The iCanDecide Randomized Clinical Trial

Purpose This study was conducted to determine the effect of iCanDecide, an interactive and tailored breast cancer treatment decision tool, on the rate of high-quality patient decisions-both informed and values concordant-regarding locoregional breast cancer treatment and on patient appraisal of decision making. Methods We conducted a randomized clinical trial of newly diagnosed patients with early-stage breast cancer making locoregional treatment decisions. From 22 surgical practices, 537 patients were recruited and randomly assigned online to the iCanDecide interactive and tailored Web site (intervention) or the iCanDecide static Web site (control). Participants completed a baseline survey and were mailed a follow-up survey 4 to 5 weeks after enrollment to assess the primary outcome of a high-quality decision, which consisted of two components, high knowledge and values-concordant treatment, and secondary outcomes (decision preparation, deliberation, and subjective decision quality). Results Patients in the intervention arm had higher odds of making a high-quality decision than did those in the control arm (odds ratio, 2.00; 95% CI, 1.37 to 2.92; P = .0004), which was driven primarily by differences in the rates of high knowledge between groups. The majority of patients in both arms made values-concordant treatment decisions (78.6% in the intervention arm and 81.4% in the control arm). More patients in the intervention arm had high decision preparation (estimate, 0.18; 95% CI, 0.02 to 0.34; P = .027), but there were no significant differences in the other decision appraisal outcomes. The effect of the intervention was similar for women who were leaning strongly toward a treatment option at enrollment compared with those who were not. Conclusion The tailored and interactive iCanDecide Web site, which focused on knowledge building and values clarification, positively affected high-quality decisions largely by improving knowledge compared with static online information. To be effective, future patient-facing decision tools should be integrated into the clinical workflow to improve decision making.

Understanding Women's Choice of Mastectomy Versus Breast Conserving Therapy in Early-Stage Breast Cancer

OBJECTIVE

To identify factors that influence Saskatchewan women's choice between breast conserving therapy (BCT) and mastectomy in early-stage breast cancer (ESBC) and to compare and contrast underlying reasons behind choice of BCT versus mastectomy.

METHODS

Interpretive description methods guided this practice-based qualitative study. Data were analyzed using thematic analysis and presented in thematic maps.

RESULTS

Women who chose mastectomy described 1 of the 3 main themes: worry about cancer recurrence, perceived consequences of BCT treatment, or breast-tumor size perception. In contrast, women chose BCT because of 3 different themes: mastectomy being too radical, surgeon influence, and feminine identity.

CONCLUSIONS

Although individual reasons for choosing mastectomy versus BCT have been discussed in the literature before, different rationale underlying each choice has not been previously described. These results are novel in identifying interdependent subthemes and secondary reasons for each choice. This is important for increased understanding of factors influencing a complicated decision-making process.

Study protocol: A Randomized Controlled Trial of a Comprehensive Breast Cancer Treatment Patient Decision Tool (iCanDecide)

Background

Patients newly diagnosed with breast cancer face a series of complex decisions regarding locoregional and systemic treatment. There is a need to improve the quality of locoregional and systemic decisions for breast cancer patients, and to help patients understand the role of evaluative tests in this decision process. We are now conducting a randomized controlled trial (RCT) of an online decision tool—called iCanDecide, which we expect will help patients with these difficult decisions. Furthermore, the results of this RCT will be highly relevant to future breast cancer patients making these decisions and to their clinicians.

Methods

This is a two-arm randomized controlled trial with the target of 222 participants per arm. Participants are recruited from 25 surgical practices (total 40 surgeons) and 2 medical oncology practices (total 2 oncologists) in Michigan, Georgia, Tennessee, and California. Participants are newly-diagnosed female breast cancer patients between 21 and 84 years, with stage I-II invasive breast cancer or ductal carcinoma in situ (DCIS) and who are eligible for and considering either mastectomy or lumpectomy with radiation, and who may be eligible for adjuvant systemic treatment.

The RCT tests an interactive, tailored website, called iCanDecide (intervention arm), compared to a static version of the website (control arm). The static control arm is designed to include the same basic content as the intervention version, but without tailoring and interactive features. The primary outcome includes the rate of making a high-quality decision. The hypothesis is that patients randomized to the interactive version of iCanDecide will have higher rates of high quality decisions (informed and values-concordant), and will appraise their decision-making process more positively, for both surgical and systemic treatment.

Discussion

The goal of this study is to evaluate the impact of the iCanDecide interactive website on decision-making for locoregional and systemic breast cancer treatments. The results of this study will be important for future breast cancer patients and their clinicians as we determine how to better individualize decision making across this complex treatment landscape.

Trial registration

ClinicalTrials.gov ID NCT01840163.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Surgeons' Perspectives of Contralateral Prophylactic Mastectomy

BACKGROUND

Contralateral prophylactic mastectomy (CPM) is commonly performed for the treatment of breast cancer, despite its limited oncologic benefit. Little is known about surgeons' perceptions of performing CPM. We hypothesized that a proportion of surgeons would report discomfort with performing CPM, particularly when there is discordance between patients' perceived benefit from CPM and the expected oncologic benefit.

METHODS

A survey was sent to members of the American Society of Breast Surgeons seeking self-reports of surgeons' practice patterns, perceptions, and comfort levels with CPM.

RESULTS

Of the 2436 members surveyed, 601 responded (response rate = 24.7 %). The median age of respondents was 52 years, and 59 % of responders were women. The majority (58 %) reported that 80 % of their practice was devoted to the treatment of breast disease. Fifty-seven percent (n = 326) of respondents reported discomfort with performing CPM at some point in their practice. While most surgeons (95 %) were comfortable with CPM on a patient with a deleterious BRCA mutation, only 34 % were comfortable performing CPM on an average-risk patient. The most common reasons reported for surgeon discomfort with CPM were a concern for overtreatment, an unfavorable risk/benefit ratio, and inadequate patient understanding of the anticipated risks and benefits of CPM.

CONCLUSIONS

Despite the increasing use of CPM for the treatment of breast cancer, many surgeons report discomfort with CPM. Concerns with performing CPM predominantly focus on ambiguities surrounding the oncologic benefit and relative risk of this procedure. Further research is needed to define optimal shared decision-making practices in this area.

A case-control study of treatment choices made by doctors diagnosed with early breast cancer

INTRODUCTION

Doctors who are diagnosed with breast cancer form a small subset of women with unique insight into their disease. The aim of this study was to compare key treatment decisions in medically-qualified doctors with equivalent degree-educated, matched controls diagnosed with early breast cancer.

METHODS

Patients diagnosed with breast cancer between 01/01/2006 and 31/12/2011 were included and screened for occupation by 2 independent investigators. Allied health professionals with a medical background (e.g. nurses, physiotherapists) were excluded. Patient controls were matched by age, nodal status and grade. If there were more than 5 possible matches then those patients with the closest tumour size were selected.

RESULTS

5259 of 8623 patients had signed the generic research consent form. 619 of these were either doctors, or had received tertiary level education and could form appropriate controls. After exclusions, 46 medically-qualified doctors and 230 matched control patients were included in the analysis. No statistical differences in age or tumour characteristics were identified between doctors with breast cancer and matched controls. No differences were identified between the two groups in the uptake of mastectomy, chemotherapy, immediate breast reconstruction or post-mastectomy radiotherapy.

CONCLUSION

Medically-qualified patients diagnosed with early breast cancer are no more likely to opt for mastectomy, chemotherapy, immediate breast reconstruction or post-mastectomy radiotherapy than non-medically-qualified controls. The level of information generally provided to patients with breast cancer is adequate for a similar decision to be made by control patients with equivalent levels of education, independent of any knowledge of pathology or understanding of the medical system that medically-qualified patients may possess.

Patients' satisfaction in early breast cancer treatment: Change in treatment over time and impact of HER2-targeted therapy

Although breast cancer remains a major cause of cancer death, its related death rate has dropped in the last years through early tumor detection and better available treatments. With the development of innovative techniques and new molecules as well as new routes of administration, local treatment and adjuvant therapy of early breast cancer have evolved, from mutilating, time-consuming and/or painful procedures to breast-conservative ones, sparing healthy tissues, reducing the total dose of treatment and the treatment time which in turn reduce the occurrence and severity of toxicity. In parallel with these improvements leading to an increase in survival rate, patients' health-related quality of life has become a major concern. This review aims at describing the evolution of early breast cancer treatment, and its impact on patients' quality of life, convenience, and satisfaction, including a special insight into emerging human epidermal growth factor receptor 2 (HER2)-targeted therapy.

Patterns of locoregional treatment for nonmetastatic breast cancer by patient and health system factors

BACKGROUND

The purpose of this study was to examine local definitive therapy for nonmetastatic breast cancer with the Patterns of Care Breast and Prostate Cancer (POCBP) study of the National Program of Cancer Registries (Centers for Disease Control and Prevention).

METHODS

POCBP medical record data were re-abstracted in 7 state/regional registry systems (Georgia, North Carolina, Kentucky, Louisiana, Wisconsin, Minnesota, and California) to verify data quality and assess treatment patterns in the population. National Comprehensive Cancer Network clinical practice treatment guidelines were aligned with American Joint Committee on Cancer staging at diagnosis to appraise care.

RESULTS

Six thousand five hundred five of 9142 patients with registry-confirmed breast cancer were coded as having primary disease with stage 0 to IIIA tumors and were included in the study. Approximately 88% received guideline-concordant locoregional treatment. However, this outcome varied by age group: 92% of women < age 50 versus 80% of women ≥ age 70 years old received guideline care (P < 0.01). Characteristics that best discriminated receipt (no/yes) of guideline-concordant care in receiver operating curve analyses were the receipt of breast-conserving surgery (BCS) versus mastectomy (C = 0.70), patient age (C = 0.62), a greater tumor stage (C = 0.60), public insurance (C = 0.58), and the presence of at least mild comorbidity (C = 0.55). Radiation therapy (RT) after BCS was the most omitted treatment component causing nonconcordance in the study population. In multivariate regression, the effects of the treatment facility, ductal carcinoma in situ, race, and comorbidity on nonconcordant care differed by age group.

CONCLUSIONS

Patterns of underuse of standard therapies for breast cancer vary by age group and BCS use, with which there is a risk of omission of RT.

A qualitative study of rural women's views for the treatment of early breast cancer

AIM

Identify what factors rural women perceived to influence their surgical choice for EBC.

BACKGROUND

Higher rates of mastectomy still remain for women with early breast cancer (EBC) in rural areas. While access to radiotherapy is a commonly identified barrier, there is growing debate around other factors which are also important influences on surgical choice.

METHODS

Qualitative study with 70 interviews with women diagnosed with EBC in rural Gippsland, Australia. Twenty-nine women had a mastectomy and 41 had breast conserving surgery (BCS).

RESULTS

Patient led psychosocial and surgeon led factors influenced surgical choice. Psychosocial factors were a greater influence for the mastectomy group. These included a high fear of cancer recurrence and radiotherapy, negative views of the body and breast, a family history of cancer, wanting to avoid the negative treatment experiences they had seen significant others go through, and not wanting to travel for treatment. Surgeon led factors were a greater influence for the BCS group, in particular, the direct recommendation made by the surgeon for BCS. For both groups, urgency to act was a shared psychosocial factor. Trust and confidence in the expertise and reputation of the surgeon and their consultation style were surgeon led factors shared by the groups.

CONCLUSIONS

To ensure women achieve the best treatment outcome, patients and clinicians need to work together to identify how important and influential the various factors are for the women and, if necessary, to seek support to ensure informed decisions are made.

Otorhinolaryngologists' personal treatment preferences (total laryngectomy or laryngeal preservation) when faced with advanced stage laryngeal cancer

OBJECTIVE

To analyse the treatment options that otorhinolaryngologists would consider if faced with advanced stage laryngeal cancer amenable to total laryngectomy or an organ preservation protocol.

MATERIAL AND METHODS

Prospective study conducted in a French Teaching Hospital based on questionnaires filled in by 163 otorhinolaryngologists in 2012, studying the percentage chance of cure that they would be prepared to trade-off to preserve their larynx, defining the additional information that they would like to receive and identifying any statistical associations between these parameters and various medical and socioeconomic variables.

RESULTS

A total of 42.3% of otorhinolaryngologists would not consider the slightest trade-off to preserve their larynx and preferred to undergo total laryngectomy. In the group of otorhinolaryngologists who would consider a larynx preservation protocol (57.6%), the percentage chance of cure that they would be willing to trade-off to preserve their larynx ranged between 5 to 100% (median: 15%) and 4.2% of them were willing to trade-off all chances of cure (100%) to avoid total laryngectomy. The percentage of otorhinolaryngologists who would not consider trading off the slightest chance of survival to preserve their larynx increased from 29.3 to 49.5% (P=0.01) when they participated in multidisciplinary consultation meetings. In the group of otorhinolaryngologists who would consider a larynx preservation protocol, the median percentage survival trade-off that they would consider in order to preserve their larynx (i) decreased from 20 to 10% (P=0.004) when they participated in multidisciplinary consultation meetings and (ii) increased regularly with their number of years of practice (P=0.03) and their age (P=0.025). Finally, 25.1% of otorhinolaryngologists wanted to receive additional information, although none of the variables analysed affected this desire for more information.

CONCLUSION

Treatment options considered by otorhinolaryngologists faced with advanced stage laryngeal cancer were almost equally divided between total laryngectomy and larynx preservation. Number of years of practice and regular participation in head and neck cancer multidisciplinary consultation meetings were variables that significantly influenced this choice.

Breast cancer diagnosis and factors influencing treatment decisions in Ghana

Researchers in this study explored the reactions of women with breast cancer and identified factors influencing treatment decisions. A qualitative exploratory approach was employed. Participants were recruited from a tertiary hospital and a breast cancer support group. Purposive sampling recruited 12 women. It was found that women identified breast lesions accidentally or intentionally and that diagnosis was delayed. Emotional reactions to diagnosis included shock and sadness. Factors that influenced treatment were the influence of other people, alternative sources of treatment, faith and support, knowledge, "tuning the mind," and effects on intimacy. Health professionals should develop effective communication and counseling skills for clients.

Predictors of bariatric surgery among an interested population

BACKGROUND

Severely obese patients considering bariatric surgery face a difficult decision given the tradeoff between the benefits and risks of surgery. The objectives of this study was to study the forces driving this decision and improve our understanding of the decision-making process.

METHODS

A 64-item survey was developed to assess factors in the decision-making process for bariatric surgery. The survey included the decisional conflict scale, decision self-efficacy scale, EuroQol 5D, and the standard gamble. Patients were recruited from a regularly scheduled bariatric surgery interest group meeting associated with a large, university-based bariatric practice and administered a survey at the conclusion of the interest group. Logistic regression models were used to predict who pursued or still planned to pursue surgery at 12 months.

RESULTS

200 patients were recruited over an 8-month period. Mean age was 45 years; mean BMI was 48 kg/m(2), and 77% were female. The 12-month follow-up rate was 95%. At 12 months, 33 patients (17.6%) had surgery and 30 (16.0%) still planned to have surgery. There was no association between age, gender, or obesity-associated conditions and surgery or plan to have surgery. Patients having surgery or still planning to have surgery had significantly worse scores for quality of life and better scores for decisional conflict (indicating readiness to make a decision).

CONCLUSION

The decision to have bariatric surgery is strongly associated with patients' perceptions of their current quality of life. In addition, lower decisional conflict and higher self-efficacy are predictive of surgery. Interestingly, factors that clinicians might consider important, such as gender, age, and the presence of obesity-associated co-morbidities did not influence patients' decisions.

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

Background

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

Methods

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

Results

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

Conclusions

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

Breast conserving surgery versus mastectomy: the influence of comorbidities on choice of surgical operation in the Department of Defense health care system

BACKGROUND

Studies on the effect of comorbidities on breast cancer operation have been limited and inconsistent. This study investigated whether pre-existing comorbidities influenced breast cancer surgical operation in an equal access health care system.

METHODS

This study was based on linked Department of Defense cancer registry and medical claims data. The study subjects were patients diagnosed with stage I to III breast cancer during 2001 to 2007. Logistic regression was used to determine if comorbidity was associated with operation type and time between diagnosis and operation.

RESULTS

Breast cancer patients with comorbidities were more likely to receive mastectomy (odds ratio [OR] = 1.27; 95% confidence interval [CI], 1.14 to 1.42) than breast conserving surgery plus radiation. Patients with comorbidities were also more likely to delay having operation than those without comorbidities (OR = 1.27; 95% CI, 1.14 to 1.41).

CONCLUSIONS

In an equal access health care system, comorbidity was associated with having a mastectomy and with a delay in undergoing operation.

A qualitative study of breast cancer treatment decisions: evidence for five decision-making styles

Being diagnosed with breast cancer requires that women make a number of decisions about their medical treatments. To gain insight into the variety of forces that shape a woman's breast cancer treatment decisions, we conducted semistructured interviews with 44 breast cancer survivors. Through an interpretive analysis, we identified five treatment decision-making styles: (a) medical expert, (b) self-efficacy, (c) relationship embedded, (d) inhibition, and (e) constellation of information, which are differentiated by two dimensions: (a) low versus high information needs and (b) self versus other preferences.

Chemotherapy use and patient treatment preferences in advanced colorectal cancer: a prospective cohort study

BACKGROUND

The objective of this study was to determine how patient preferences guide the course of palliative chemotherapy for advanced colorectal cancer.

METHODS

Eligible patients with metastatic colorectal cancer (mCRC) were enrolled nationwide in a prospective, population-based cohort study. Data were obtained through medical record abstraction and patient surveys. Logistic regression analysis was used to evaluate patient characteristics associated with visiting medical oncology and receiving chemotherapy and patient characteristics, beliefs, and preferences associated with receiving >1 line of chemotherapy and receiving combination chemotherapy.

RESULTS

Among 702 patients with mCRC, 91% consulted a medical oncologist; and among those, 82% received chemotherapy. Patients ages 65 to 75 years and aged ≥75 years were less likely to visit an oncologist, as were patients who were too sick to complete their own survey. In adjusted analyses, patients aged ≥75 years who had moderate or severe comorbidity were less likely to receive chemotherapy, as were patients who were too sick to complete their own survey. Patients received chemotherapy even if they believed that chemotherapy would not extend their life (90%) or that chemotherapy would not likely help with cancer-related problems (89%), or patients preferred treatment focusing on comfort even if it meant not living as long (90%). Older patients were less likely to receive combination first-line therapy. Patient preferences and beliefs were not associated with receipt of >1 line of chemotherapy or combination chemotherapy.

CONCLUSIONS

The majority of patients received chemotherapy even if they expressed negative or marginal preferences or beliefs regarding chemotherapy. Patient preferences and beliefs were not associated with the intensity or number of chemotherapy regimens.

Increasing readiness to decide and strengthening behavioral intentions: evaluating the impact of a web-based patient decision aid for breast cancer treatment options (BresDex: www.bresdex.com)

OBJECTIVES

To undertake a quantitative evaluation of a theory-based, interactive online decision aid (BresDex) to support women choosing surgery for early breast cancer (Stage I and II), based on observations of its use in practice.

METHODS

Observational cohort study. Website log-files collected data on the use of BresDex. Online questionnaires assessed knowledge about breast cancer and treatment options, degree to which women were deliberating about their options, and surgery intentions, pre- and post-BresDex.

RESULTS

Readiness to make a decision significantly increased after using BresDex (p<.001), although there was no significant improvement in knowledge. Participants that were 'less ready' to make a decision before using BresDex, spent a longer time using BresDex (p<.05). Significant associations between surgery intentions and choices were observed (p<.001), with the majority of participants going on to have BCS. Greater length of time spent on BresDex was associated with stronger intentions to have BCS (p<.05).

CONCLUSION

The use of BresDex appears to facilitate readiness to make a decision for surgery, helping to strengthen surgery intentions.

PRACTICE IMPLICATIONS

BresDex may prove a useful adjunct to the support provided by the clinical team for women facing surgery for early breast cancer.