What matters most: protocol for a randomized controlled trial of breast cancer surgery encounter decision aids across socioeconomic strata

Clinician-Spoken Plain Language in Health Care Encounters: A Qualitative Analysis to Assess Measurable Elements

PURPOSE

Good communication and use of plain language in health care encounters improve outcomes, including emotional health, symptom resolution, and functional status. Yet there is limited research on how to measure and report spoken plain language, which is the use of familiar, clear language. The authors aimed to describe key, measurable elements of spoken plain language that can be assessed and reported back to clinicians for self-reflection.

METHOD

The authors conducted secondary analysis of transcripts from recorded encounters between breast cancer surgeons and patients with early-stage breast cancer. Two coders used a hybrid qualitative analysis with a framework based on U.S. Federal Plain Language Guidelines. To develop major themes, they examined (1) alignment with the Guidelines and (2) code frequencies within and across transcripts. They also noted minor themes.

RESULTS

From 74 transcripts featuring 13 surgeons, the authors identified 2 major themes representing measurable elements of spoken plain language: (1) clinicians had a propensity to use both explained and unexplained medical terms, and (2) clinicians delivered information using either short turns (one unit of someone speaking) with 1 topic or long turns with multiple topics. There were 3 minor themes that were not indicative of whether or not clinicians used spoken plain language. First, clinicians regularly used absolute risk communication techniques. Second, question-asking techniques varied and included open-ended, close-ended, and comprehension checks. Third, some clinicians used imagery to describe complex topics.

CONCLUSIONS

Clinicians' propensity to use medical terms with and without explanation and parse encounters into shorter or longer turns are measurable elements of spoken plain language. These findings will support further research on the development of a tool that can be used in medical education and other settings. This tool could provide direct and specific feedback to improve the plain language practices of clinicians in training and beyond.

Adaptation and Implementation of Pictorial Conversation Aids for Early-Stage Breast Cancer Surgery and Reconstruction: A Quality Improvement Study

Purpose

After a diagnosis of early-stage breast cancer, women of lower socioeconomic position (SEP) report worse outcomes than women of higher SEP. A pictorial conversation aid was shown to improve decision outcomes in controlled contexts. No such intervention existed in France. In Phase 1, our aim was to adapt, for use in France, two pictorial conversation aids for breast cancer surgery and reconstruction. In Phase 2, our aim was to implement them in a regional cancer center serving a diverse population.

Patients and Methods

In phase 1, we used iterative qualitative methods to adapt the conversation aids with a convenience sample of patients and health professionals. In phase 2, we tested their implementation using PDSA cycles with volunteer surgeons.

Results

In phase 1, we interviewed 10 health professionals and 5 patients to reach thematic data saturation. They found the conversation aids usable and very acceptable (especially patients) and suggested small changes to further simplify the layout and content (including a glossary). In phase 2, three surgeons started the first PDSA cycle, for 4 weeks. Only one additional surgeon agreed to take part in the second cycle. The third cycle was cancelled since no new surgeon agreed to take part. Time was a barrier for 2 out of 4 surgeons, potentially explaining the difficulty recruiting for the third cycle. The evaluation was otherwise positive. The surgeons found the conversation aids very useful during their consultations and all intended to continue using them in the future.

Conclusion

It was possible to adapt, for use in France, pictorial conversation aids proven to be effective elsewhere. While the adapted conversation aids were deemed usable by health professionals and very acceptable to patients, their implementation using PDSA cycles proved slow.

Transforming the field: the role of academic health centers in promoting and sustaining equity based community engaged research

Community-based participatory research (CBPR) and community engaged research (CEnR) are key to promoting community and patient engagement in actionable evidence-based strategies to improve research for health equity. Rapid growth of CBPR/CEnR research projects have led to the broad adoption of partnering principles in community-academic partnerships and among some health and academic organizations. Yet, transformation of principles into best practices that foster trust, shared power, and equity outcomes still remain fragmented, are dependent on individuals with long term projects, or are non-existent. This paper describes how we designed our Engage for Equity PLUS intervention that leverages the leadership and membership of champion teams (including community-engaged faculty, community partners and patient advocates) to improve organizational policies and practices to support equity based CBPR/CEnR. This article describes the feasibility and preliminary findings from engaging champion teams from three very different academic health centers. We reflect on the learnings from Engage for Equity PLUS; the adaptation of the intervention design and implementation, including the development of a new institutional assessment using mixed research methods; and our organizational theory of change. In summary, our design and preliminary data from the three academic health centers provide support for new attention to the role of institutional practices and processes needed to sustain equity-based patient and community-engaged research and CBPR and transform the field.

Lung Cancer Screening Penetration in an Urban Underserved County

PURPOSE

To compare residential geography, sex, socioeconomic status (SES), and race/ethnicity of patients screened at Montefiore's Lung Cancer Screening Program with those of patients diagnosed with lung cancer, assessing whether screening efforts are appropriately focused.

METHODS

This retrospective cohort study involved patients within a multisite urban medical center undergoing lung cancer screening or diagnosed with lung cancer from January 1, 2015 to December 31, 2019. Inclusion criteria were residence within the Bronx, NY and age between 55 and 80 years. Institutional review board approval was obtained. Data were analyzed using the Wilcoxon two-sample t test and χ².

RESULTS

The cohorts comprised 1568 (50.3%) women and 1551 (49.7%) men (mean age 65.6 ± 6.16). The Southeast Bronx had the most diagnosed lung cancers (29.96%) and screenings (31.22%). Sex did not significantly differ (p = 0.053). Cancer and screening cohorts were from impoverished neighborhoods with mean SES of - 3.11 ± 2.78 and - 3.44 ± 2.80 (p < 0.01). The lower tier SES neighborhoods demonstrated more patients in the screening cohort than cancer cohort (p = 0.01). Both cohorts included a majority of Hispanic patients, although race/ethnicity differed significantly (p = 0.01). Lower SES neighborhoods showed no significant difference in race/ethnicity between cancer and screening cohorts (p = 0.262).

CONCLUSION

Though statistically significant differences were found between cohorts, likely due to sample size, few clinically meaningful differences were found, implying our lung cancer screening program was effective in reaching the desired population. Demographics-based programs should be considered in global efforts to screen vulnerable populations.

Diversity of interpretations of the concept "patient-centered care for breast cancer patients"; a scoping review of current literature

RATIONALE, AIMS AND OBJECTIVES

Patient-centered care is considered a vital component of good quality care for breast cancer patients. Nevertheless, the implementation of this valuable concept in clinical practice appears to be difficult. The goal of this study is to bridge the gap between theoretical elaboration of "patient-centered care" and clinical practice. To that purpose, a scoping analysis was performed of the application of the term "patient-centered care in breast cancer treatment" in present-day literature.

METHOD

For data-extraction, a literature search was performed extracting references that were published in 2018 and included the terms "patient-centered care" and "breast cancer". The articles were systematically traced for answers to the following three questions: "What is patient-centered care?", "Why perform patient-centered care?", and "How to realize patient-centered care?". For the content analysis, these answers were coded and assembled into meaningful clusters until separate themes arose which concur with various interpretations of the term "patient-centered care".

RESULTS

A total of 60 publications were retained for analysis. Traced answers to the three questions "what", "why", and "how" varied considerably in recent literature concerning breast cancer treatment. Despite the inconsistent use of the term "patient-centered care," we did not find any critical consideration about the nature of the concept, regardless of the applied interpretation. Interventions that are supposed to contribute to the heterogeneous concept of patient-centered care as such, seem to be judged desirable, virtually without empirical justification.

CONCLUSIONS

We propose, contrary to previous efforts to define "patient-centered care" more accurately, to embrace the heterogeneity of the concept and apply "patient-centered care" as an umbrella-term for all healthcare that intends to contribute to the acknowledgement of the person in the patient. For the justification of measures to realize patient-centered care for breast cancer patients, instead of a mere contribution to the abstract concept, we insist on the demonstration of desirable real-world effects.

Unexpected Outcomes of Measuring Decision Regret: Using a Breast Cancer Decision-Making Case Example

Shared decision making can help patients feel supported and empowered when deciding between healthcare options. Decision regret can be a meaningful measure of the quality of that encounter. However, in a patient-engaged research study examining shared decision making for breast cancer surgery, decision regret was a difficult construct to assess, and asking questions about decision regret caused the patient to experience that emotion upon reflection. In this article, we consider the complexity of decision regret, and discuss the difficulty of measuring that emotion through existing instruments. We call for clarity in definitions of decision regret and offer suggestions for developing a set of questions that can capture regret in a more meaningful way.

An absence of equipoise: Examining surgeons' decision talk during encounters with women considering breast cancer surgery

Shared decision-making is recommended for decisions with multiple reasonable options, yet clinicians often subtly or explicitly guide choices. Using purposive sampling, we performed a secondary analysis of 142 audio-recorded encounters between 13 surgeons and women eligible for breast-conserving surgery with radiation or mastectomy. We trained 9 surgeons in shared decision-making and provided them one of two conversation aids; 4 surgeons practiced as usual. Based on a published taxonomy of treatment recommendations (pronouncements, suggestions, proposals, offers, assertions), we examined how surgeons framed choices with patients. Many surgeons made assertions providing information and advice (usual care 71% vs. intervention 66%; p = 0.54). Some made strong pronouncements (usual care 51% vs. intervention 36%; p = .09). Few made proposals and offers, leaving the door open for deliberation (proposals usual care 21% vs. intervention 26%; p = 0.51; offers usual care 40% vs. intervention 40%; p = 0.98). Surgeons were significantly more likely to describe options as comparable when using a conversation aid, mentioning this in all intervention group encounters (usual care 64% vs. intervention 100%; p<0.001). Conversation aids can facilitate offers of comparable options, but other conversational actions can inhibit aspects of shared decision-making.

Impact of a health literacy intervention combining general practitioner training and a consumer facing intervention to improve colorectal cancer screening in underserved areas: protocol for a multicentric cluster randomized controlled trial

BACKGROUND

Colorectal cancer (CRC) is a leading cause of cancer burden worldwide. In France, it is the second most common cause of cancer death after lung cancer. Systematic uptake of CRC screening can improve survival rates. However, people with limited health literacy (HL) and lower socioeconomic position rarely participate. Our aim is to assess the impact of an intervention combining HL and CRC screening training for general practitioners (GPs) with a pictorial brochure and video targeting eligible patients, to increase CRC screening and other secondary outcomes, after 1 year, in several underserved geographic areas in France.

METHODS

We will use a two-arm multicentric randomized controlled cluster trial with 32 GPs primarily serving underserved populations across four regions in France with 1024 patients recruited. GPs practicing in underserved areas (identified using the European Deprivation Index) will be block-randomized to: 1) a combined intervention (HL and CRC training + brochure and video for eligible patients), or 2) usual care. Patients will be included if they are between 50 and 74 years old, eligible for CRC screening, and present to recruited GPs. The primary outcome is CRC screening uptake after 1 year. Secondary outcomes include increasing knowledge and patient activation. After trial recruitment, we will conduct semi-structured interviews with up to 24 GPs (up to 8 in each region) and up to 48 patients (6 to 12 per region) based on data saturation. We will explore strategies that promote the intervention's sustained use and rapid implementation using Normalization Process Theory. We will follow a community-based participatory research approach throughout the trial. For the analyses, we will adopt a regression framework for all quantitative data. We will also use exploratory mediation analyses. We will analyze all qualitative data using a framework analysis guided by Normalization Process Theory.

DISCUSSION

Limited HL and its impact on the general population is a growing public health and policy challenge worldwide. It has received limited attention in France. A combined HL intervention could reduce disparities in CRC screening, increase screening rates among the most vulnerable populations, and increase knowledge and activation (beneficial in the context of repeated screening).

TRIAL REGISTRATION

Registry: ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

2020-A01687-32 . Date of registration: 17th November 2020.

Implementation and sustainability factors of two early-stage breast cancer conversation aids in diverse practices

BACKGROUND

Conversation aids can facilitate shared decision-making and improve patient-centered outcomes. However, few examples exist of sustained use of conversation aids in routine care due to numerous barriers at clinical and organizational levels. We explored factors that will promote the sustained use of two early-stage breast cancer conversation aids. We examined differences in opinions between the two conversation aids and across socioeconomic strata.

METHODS

We nested this study within a randomized controlled trial that demonstrated the effectiveness of two early-stage breast cancer surgery conversation aids, one text-based and one picture-based. These conversation aids facilitated more shared decision-making and improved the decision process, among other outcomes, across four health systems with socioeconomically diverse patient populations. We conducted semi-structured interviews with a purposive sample of patient participants across conversation aid assignment and socioeconomic status (SES) and collected observations and field notes. We interviewed trial surgeons and other stakeholders. Two independent coders conducted framework analysis using the NOrmalization MeAsure Development through Normalization Process Theory. We also conducted an inductive analysis. We conducted additional sub-analyses based on conversation aid assignment and patient SES.

RESULTS

We conducted 73 semi-structured interviews with 43 patients, 16 surgeons, and 14 stakeholders like nurses, cancer center directors, and electronic health record (EHR) experts. Patients and surgeons felt the conversation aids should be used in breast cancer care in the future and were open to various methods of giving and receiving the conversation aid (EHR, email, patient portal, before consultation). Patients of higher SES were more likely to note the conversation aids influenced their treatment discussion, while patients of lower SES noted more influence on their decision-making. Intervention surgeons reported using the conversation aids did not lengthen their typical consultation time. Most intervention surgeons felt using the conversation aids enhanced their usual care after using it a few times, and most patients felt it appeared part of their normal routine.

CONCLUSIONS

Key factors that will guide the future sustained implementation of the conversation aids include adapting to existing clinical workflows, flexibility of use, patient characteristics, and communication preferences.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03136367 , registered on May 2, 2017.

The Impact of Delays in Low-Income Women's Breast Cancer Experiences

BACKGROUND

Low-income, underinsured and uninsured women are less likely to be diagnosed via mammogram and more often diagnosed at later stages, with a resultant negative impact on survival. The New Jersey Cancer Education and Early Detection Program provides access to cancer screening services for low-income, underinsured and uninsured individuals. This program was recently evaluated, and it was found that enrollees were more likely to be diagnosed at later stages than nonenrollees, which may be related to delays in diagnosis and treatment OBJECTIVE: The aim of this study was to determine if there were delays in diagnosis and treatment for program enrollees and, if so, what were the causes of these delays.

METHODS

A qualitative methodology was used incorporating in-depth interviews with 20 women diagnosed with breast cancer through the New Jersey Cancer Education and Early Detection Program. Qualitative content analysis was used for data analysis.

RESULTS

Three themes emerged: poor access to healthcare, lack of knowledge, and sense of spirituality. Nineteen of 20 women experienced delays in care; 9 were diagnosed with late stage (III or IV) disease.

CONCLUSIONS

While the lack of insurance was a factor, fear, family needs, and a tendency to not prioritize their own health were additional reasons for delays in diagnosis and treatment.

IMPLICATIONS FOR PRACTICE

Programs such as this are integral to the care of low-income, uninsured individuals. However, such programs are not sufficient to meet the needs of low-income women. The lack of a usual source of care is likely to be a factor in the delays these women experienced.

Women Who Are Young, Non-White, and with Lower Socioeconomic Status Report Higher Financial Toxicity up to 1 Year After Breast Cancer Surgery: A Mixed-Effects Regression Analysis

PURPOSE

We examined self-reported financial toxicity and out-of-pocket expenses among adult women with breast cancer.

METHODS

Patients spoke English, Spanish, or Mandarin Chinese, were aged 18+ years, had stage I-IIIA breast cancer, and were eligible for breast-conserving and mastectomy surgery. Participants completed surveys about out-of-pocket costs and financial toxicity at 1 week, 12 weeks, and 1 year postsurgery.

RESULTS

Three hundred ninety-five of 448 eligible patients (88.2%) from the parent trial completed surveys. Excluding those reporting zero costs, crude mean ± SD out-of-pocket costs were $1,512 ± $2,074 at 1 week, $2,609 ± $6,369 at 12 weeks, and $3,308 ± $5,000 at 1 year postsurgery. Controlling for surgery, cancer stage, and demographics with surgeon and clinic as random effects, higher out-of-pocket costs were associated with higher financial toxicity 1 week and 12 weeks postsurgery (p < .001). Lower socioeconomic status (SES) was associated with lower out-of-pocket costs at each time point (p = .002-.013). One week postsurgery, participants with lower SES reported financial toxicity scores 1.02 points higher than participants with higher SES (95% confidence interval [CI], 0.08-1.95). Black and non-White/non-Black participants reported financial toxicity scores 1.91 (95% CI, 0.46-3.37) and 2.55 (95% CI, 1.11-3.99) points higher than White participants. Older (65+ years) participants reported financial toxicity scores 2.58 points lower than younger (<65 years) participants (95% CI, -3.41, -1.74). Younger participants reported significantly higher financial toxicity at each time point.

DISCUSSION

Younger age, non-White race, and lower SES were associated with higher financial toxicity regardless of costs. Out-of-pocket costs increased over time and were positively associated with financial toxicity. Future work should reduce the impact of cancer care costs among vulnerable groups.

IMPLICATIONS FOR PRACTICE

This study was one of the first to examine out-of-pocket costs and financial toxicity up to 1 year after breast cancer surgery. Younger age, Black race, race other than Black or White, and lower socioeconomic status were associated with higher financial toxicity. Findings highlight the importance of addressing patients' financial toxicity in several ways, particularly for groups vulnerable to its effects.

What matters most: Randomized controlled trial of breast cancer surgery conversation aids across socioeconomic strata

Background

Women of lower socioeconomic status (SES) with early‐stage breast cancer are more likely to report poorer physician‐patient communication, lower satisfaction with surgery, lower involvement in decision making, and higher decision regret compared to women of higher SES. The objective of this study was to understand how to support women across socioeconomic strata in making breast cancer surgery choices.

Methods

We conducted a 3‐arm (Option Grid, Picture Option Grid, and usual care), multisite, randomized controlled superiority trial with surgeon‐level randomization. The Option Grid (text only) and Picture Option Grid (pictures plus text) conversation aids were evidence‐based summaries of available breast cancer surgery options on paper. Decision quality (primary outcome), treatment choice, treatment intention, shared decision making (SDM), anxiety, quality of life, decision regret, and coordination of care were measured from T0 (pre‐consultation) to T5 (1‐year after surgery.

Results

Sixteen surgeons saw 571 of 622 consented patients. Patients in the Picture Option Grid arm (n = 248) had higher knowledge (immediately after the visit [T2] and 1 week after surgery or within 2 weeks of the first postoperative visit [T3]), an improved decision process (T2 and T3), lower decision regret (T3), and more SDM (observed and self‐reported) compared to usual care (n = 257). Patients in the Option Grid arm (n = 66) had higher decision process scores (T2 and T3), better coordination of care (12 weeks after surgery or within 2 weeks of the second postoperative visit [T4]), and more observed SDM (during the surgical visit [T1]) compared to usual care arm. Subgroup analyses suggested that the Picture Option Grid had more impact among women of lower SES and health literacy. Neither intervention affected concordance, treatment choice, or anxiety.

Conclusions

Paper‐based conversation aids improved key outcomes over usual care. The Picture Option Grid had more impact among disadvantaged patients.

Lay Summary

The objective of this study was to understand how to help women with lower incomes or less formal education to make breast cancer surgery choices.

Compared with usual care, a conversation aid with pictures and text led to higher knowledge. It improved the decision process and shared decision making (SDM) and lowered decision regret. A text‐only conversation aid led to an improved decision process, more coordinated care, and higher SDM compared to usual care. The conversation aid with pictures was more helpful for women with lower income or less formal education.

Conversation aids with pictures and text helped women make better breast cancer surgery choices.

A paper‐based pictorial conversation aid (pictures plus text) is beneficial to all patients with early‐stage breast cancer and particularly to disadvantaged patients. Between‐surgeon variation suggests that the maximal impact of such interventions requires standardized physician training combined with these interventions.

Text-only and picture conversation aids both supported shared decision making for breast cancer surgery: Analysis from a cluster randomized trial

OBJECTIVES

To determine if two encounter conversation aids for early-stage breast cancer surgery increased observed and patient-reported shared decision making (SDM) compared with usual care and if observed and patient-reported SDM were associated.

METHODS

Surgeons in a cluster randomized trial at four cancer centers were randomized to use an Option Grid, Picture Option Grid, or usual care. We used bivariate statistics, linear regression, and multilevel models to evaluate the influence of trial arm, patient socioeconomic status and health literacy on observed SDM (via OPTION-5) and patient-reported SDM (via collaboRATE).

RESULTS

From 311 recordings, OPTION-5 scores were 73/100 for Option Grid (n = 40), 56.3/100 for Picture Option Grid (n = 144), and 41.0/100 for usual care (n = 127; p < 0.0001). Top collaboRATE scores were 81.6 % for Option Grid, 80.0 % for Picture Option Grid, and 56.4 % for usual care (p < 0.001). Top collaboRATE scores correlated with an 8.60 point (95 %CI 0.66, 13.7) higher OPTION-5 score (p = 0.008) with no correlation in the multilevel analysis. Patients of lower socioeconomic status had lower OPTION-5 scores before accounting for clustering.

CONCLUSIONS

Both conversation aids led to meaningfully higher observed and patient-reported SDM. Observed and patient-reported SDM were not strongly correlated.

PRACTICE IMPLICATIONS

Healthcare providers could implement these conversation aids in real-world settings.

Social determinants of health and outcomes of ventral hernia repair in a safety-net hospital setting

PURPOSE

Lower socioeconomic status has been shown to be predictive of poorer surgical outcomes in ventral hernia repair. Recently, safety-net hospitals have been attempting to address these disparities to improve the care of patients of lower socioeconomic status.

METHODS

A query of all patients undergoing ventral hernia repair at our institution between 2010 and 2019 was completed (n = 580). Patients not from identifiable New Jersey ZIP-codes were excluded (n = 572). ZIP codes were assigned quartiles based off socioeconomic variables including median household income, percent below poverty line, and high school graduation rate. Patients were then assigned to socioeconomic status quartiles based off their residential ZIP-code. Outcomes of ventral hernia surgery were compared across ZIP-code quartiles. Logistic regression was used to analyze predictors of poor outcomes.

RESULTS

Patients from lower socioeconomic brackets were more likely to be younger (p < 0.001), female (p = 0.014), black (p < 0.001), and/or Hispanic (p = 0.003). Most notably, outcomes of ventral hernia were not significantly different between patients of different socioeconomic status ZIP-code quartiles. The risk of any post-operative morbidity was higher for longer procedures (p < 0.001) and for hernia repairs being done with other procedures (p < 0.001). Risk of prolonged length of stay and related 30-day readmission was higher with longer procedures (p < 0.001 and p = 0.003, respectively).

CONCLUSION

We found that outcomes of ventral hernia repair at a safety-net hospital were unaffected by socioeconomic status. This supports the important role that safety-net institutions play in providing quality care to their vulnerable populations. Future studies at other safety-net hospitals should be done to further assess the updated impact of socioeconomic status on ventral hernia outcomes.

Dynamic Changes Of Body Image And Quality Of Life In Breast Cancer Patients

Purpose

Dynamic changes of body image and quality of life (QoL) in breast cancer patients were not commonly investigated. We aimed to compare the dynamic changes in QoL and body image of breast cancer survivors receiving breast-conserving surgery or total mastectomy within 5–10 years after surgery.

Methods

Patients with non-metastatic breast cancer who received surgery were invited to complete the World Health Organization Quality of Life–Brief (WHOQOL-BREF) questionnaire and the Body Image Scale (BIS) within 10 years after surgery. We applied kernel smoothing methods to capture the dynamic changes of the patients’ QoL and body image within 5 years after surgery. We also constructed multiple linear regression models to identify predictive factors for QoL and body image.

Results

A total of 581 patients were collected, and 211 of them received breast-conserving surgery. There were no statistically significant differences in QoL and body image for breast-conserving surgery versus total mastectomy, but the former showed fluctuating trends. BIS was a predictor of every item and domain in the WHOQOL-BREF in the multiple linear regression model, and explanatory of the trends of dynamic change over time. Patients without lymph node dissection seemed to have less positive feelings but were more satisfied with sexual activities.

Conclusion

Body image is predictive of the QoL of breast cancer patients. Dynamic changes of body image and QoL would be useful for shared decision-making regarding surgery in breast cancer patients.

Encounter Decision Aids Can Prompt Breast Cancer Surgery Cost Discussions: Analysis of Recorded Consultations

Background. Patients frequently worry about care costs, but clinicians seldom address the topic. Cost information is not typically included in patient decision aids (DAs). We examined whether including cost information in an encounter DA, with clinician training, influenced cost conversations. Method. As part of a larger trial, 14 surgeons from 4 cancer centers were randomized to 1 of 3 interventions: (1) Picture Option Grid DA that included a prompt to discuss relative treatment costs, hereafter called "cost prompt group"; (2) a text-only Option Grid DA that did not include cost information; (3) usual care. Groups 2 and 3 hereafter are referred to as "non-cost prompt groups." Adult (18+) female patients, with stages I-IIIA breast cancer, eligible for both breast-conserving surgery and mastectomy were included. We gave surgeons feedback about adherence to the study protocol at 3, 6, and 12-months. We adapted a checklist to code the content of the audio-recorded clinical encounters. Results. 424/622 (68%) patients consented; 311 (73%) were eligible and successfully recorded (143 in the cost prompt group, 168 in the non-cost prompt groups). Costs were discussed in 132/311 (42.4%) encounters, and occurred more often in the cost prompt versus non-cost prompt groups (66.7% versus 33.3%; p<.001). Surgeons initiated the cost discussion in 86.4% of encounters in the cost prompt group vs. 34.1% in the non-cost prompt groups (p<0.001). In the non-cost prompt groups, insurance or employment questions led patients to ask about costs. Cost discussions lasted about 34 seconds when present and had sparse comparative details. Conclusions. Encounter DAs containing cost information trigger cost discussions. Additional support should help clinicians improve the quality of cost discussions and address financial distress.

Personal factors influencing breast cancer patients' perception of breast conservation surgery in West China

Background

Breast cancer patients' understanding of therapies is a very important factor during their surgical treatment decision-making. To date, there has been no report in this area about Chinese patients. Aiming to evaluate the perception of breast conservation surgery (BCS) in Chinese breast cancer patients (CBCP) and explore influencing factors.

Methods

A self-structured questionnaire was distributed to 1,496 CBCPs, eliciting information on patients' age, religion, sexual history, occupation, education, whether they were pre- or postoperative, understanding of BCS and their means of gaining information.

Results

A total of 1,324 (88.5%) patients completed the questionnaire. Only 2.42% of patients had more understanding of BCS. Patients' perception about BCS was associated with their age, religion, occupation, education background and whether they were postoperative or not (P<0.01). Surgeon was the most commonly way being used to obtain information (68.9%); however, this was not significant in affecting patients' perception [odds ratios (OR) =1.034; 95% confidence intervals (CI): 0.762-1.402]. Patients using books and/or internet to obtain information on BCS had better understanding (OR =1.665; 95% CI: 1.249-2.193), but only 20.2% patients used this way to search for information.

Conclusions

The study indicated that CBCP' perception of BCS was poor, they lacked access to information. Therefore, educating patients and making them master knowledge about BCS were a hard work in China.

Breast Cancer Knowledge and Decisions Made for Contralateral Prophylactic Mastectomy: A Survey of Surgeons and Women in the General Population

BACKGROUND

Decisions made to undergo contralateral prophylactic mastectomy, in women at low risk for bilateral disease, are often attributed to a lack of knowledge. This study examines the role knowledge plays in determining surgical treatment for unilateral breast cancer made by laywomen and surgeons for themselves or loved ones.

METHODS

The study cohort had three groups: (1) laywomen in the general population, (2) breast surgeons, and (3) plastic surgeons. Laywomen were recruited using Amazon Mechanical Turk Crowd Sourcing. Breast and plastic surgeons from nine states were sent electronic surveys. Demographic and contralateral prophylactic mastectomy-specific data on decisions and knowledge were collected and analyzed.

RESULTS

Surveys from 1333 laywomen, 198 plastic surgeons, and 142 breast surgeons were analyzed. A significantly greater proportion of laywomen in the general population favored contralateral prophylactic mastectomy (67 percent) relative to plastic (50 percent) and breast surgeons (26 percent) (p < 0.0001). Breast surgeons who chose contralateral prophylactic mastectomy were younger (p = 0.044) and female (0.012). On assessment of knowledge, 78 percent of laywomen had a low level of breast cancer knowledge. Laywomen with higher levels of breast cancer knowledge had lower odds of choosing contralateral prophylactic mastectomy (OR, 0.37; 95 percent CI, 0.28 to 0.49).

CONCLUSIONS

Fewer women are likely to make decisions in favor of contralateral prophylactic mastectomy with better breast cancer-specific education. A knowledge gap likely explains the lower rates with which surgeons choose contralateral prophylactic mastectomy for themselves or loved ones; however, some surgeons who were predominantly young and female favor contralateral prophylactic mastectomy. Improving patient education on surgical options for breast cancer treatment is critical, with well-informed decisions as the goal.