Explaining differences in attitude toward adjuvant chemotherapy between experienced and inexperienced breast cancer patients

Decision-Making and Health-Related Quality of Life in Patients with Melanoma Considering Adjuvant Immunotherapy

BACKGROUND

Adjuvant anti-PD1 treatment improves relapse-free survival (RFS) but has not been shown to improve overall survival (OS) in melanoma and is associated with risks of immune-related adverse events (irAEs), some permanent. We identified factors patients consider in deciding whether to undergo adjuvant anti-PD1 treatment and assessed prospective health-related quality of life (HRQoL), treatment satisfaction, and decisional regret.

PATIENTS AND METHODS

Patients with stage IIIB-IV cutaneous melanoma and free of disease, were candidates for adjuvant anti-PD1 immunotherapy, and had not yet discussed adjuvant treatment options with their oncologist were eligible. Participants viewed a 4-minute informational video tailored to their disease stage which communicated comprehensive, quantitative information about the risk of relapse both with and without adjuvant treatment, and risks of each irAE before deciding whether or not to opt for adjuvant therapy. We collected data on demographics, HRQoL, and attitudes toward adjuvant treatment over 1 year.

RESULTS

14/34 patients (41%) opted for adjuvant anti-PD1 immunotherapy, 20/34 (59%) opted for observation. Patients choosing adjuvant immunotherapy scored higher on HRQoL social well-being at pre-treatment, were more likely to endorse positive statements about adjuvant immunotherapy, and to perceive that their physician preferred adjuvant therapy. They had lower decisional regret and higher satisfaction, even if they experienced toxicity or recurrence.

CONCLUSIONS

When provided with comprehensive quantitative information about risks and benefits of adjuvant anti-PD1 immunotherapy, 20/34 (59%) of patients opted for observation. Patients choosing adjuvant immunotherapy had lower decisional regret and higher satisfaction over time even if they had poorer outcomes in treatment.

A New Attitude Towards Treatment Measure Predicts Survival Over 17 Years

BACKGROUND

For patients diagnosed with chronic illness, attitude towards treatment may play an important role in health and survival. For example, negative attitudes towards treatment have been related to poorer adherence to treatment recommendations and prescribed medication across a range of chronic illnesses. In addition, prior research has shown that attitude towards treatment assessed through a psychiatric interview predicted survival at 1 year after bone marrow transplantation with great accuracy (> 90%).

OBJECTIVE

The purpose of this study was to determine the relationship between a self-report attitude to a treatment measure that operationalized a psychiatric interview, and survival over 17 years in a sample of people living with HIV (PLWH).

PARTICIPANTS AND DESIGN

Participants (N = 177) who were in the mid-range of HIV illness at baseline (CD4s 150 to 500, no prior AIDS-defining clinical symptom) were administered the Montreal-Miami Attitude to Treatment (MMAT-20/HIV) scale and followed longitudinally to determine survival at 17 years.

MEASURES

The Montreal-Miami Attitude to Treatment (MMAT-20/HIV) scale is a 20-item self-report questionnaire designed to survey multiple factors that contribute to an overall psychological construct of the treatment process.

RESULTS

The MMAT-20/HIV predicted survival over 17 years controlling for biomedical (baseline CD4, viral load, antiretroviral medications, age) and psychosocial (race, education, antiretroviral medications) variables. Those in the top half on the MMAT-20/HIV were almost twice as likely to survive than those in the lower half. Scores on the MMAT-20/HIV were significantly but modestly correlated with adherence (r = .20, p < .05), but adherence was not a mediator of the relationship between the MMAT-20/HIV and survival.

CONCLUSIONS

An individual's attitude towards the treatment process predicted survival, raising the possibility that optimal clinical management would include ways to probe these attitudes and intervene where possible. The ease of administering the MMAT-20 and adaptability to other illnesses could facilitate this endeavor.

Factors affecting medication beliefs among patients newly prescribed oral oncolytic agents

BACKGROUND

Prescribing oral oncolytic agents (OAs) for advanced cancers is increasing.

AIMS

To explore changes in medication beliefs and the effects of symptom severity, cognitive effectiveness and depressive symptoms on medication beliefs over 12 weeks.

METHODS

Secondary analysis of a randomized controlled trial, testing an intervention to promote symptom management and adherence [N = 230]. Questionnaires evaluated medication beliefs, symptom severity, depressive symptoms, and cognitive effectiveness. Linear mixed effects models were used for analyses.

RESULTS

OA Necessity beliefs increased over time (mean difference 0.0112, SE = 0.055, p 0.04). Concern beliefs did not change and were lower for advanced cancers (-0.193, SE = 0.067, p < 0.01).Depressive symptoms were related to decreased Necessity beliefs (-0.012, SE = 0.005, p = 0.02), but not Concern beliefs. Medication beliefs were not associated with symptom severity or cognitive effectiveness.

CONCLUSION

Patients with advanced cancer hold different medication beliefs compared to earlier staged cancers, lending insight into potential outcomes beyond adherence.

Patient preferences for allogeneic haematopoietic stem cell transplantation: how much benefit is worthwhile from the patient's perspective?

Oncological studies have shown that patients consider small benefits sufficient to make adjuvant chemotherapy worthwhile. We sought to determine the minimal survival benefits that patients considered enough to legitimate allogeneic haematopoietic stem cell transplantation (HCT) and the factors associated with patient preferences. One hundred eighty-four patients having previously received allogeneic HCT at our centre were included and completed a questionnaire exploring patient expectations elicited by time trade-off scenarios as well as quality of life (QoL), symptoms of graft-versus host disease (GvHD) and sociodemographic characteristics. The majority of patients considered a minimal survival benefit of at least 5 (38.6%) or 10 years (41.9%) sufficient to justify HCT, with less than 5% considering survival < 1 year sufficient to warrant HCT. In terms of minimal cure rate, a cumulative 14.8% of patients accepted cure rates below 30% and 30.6% rates below 50%. Likelihood-ratio tests were significant for the effect of age at transplant on expected minimal survival (p = 0.007) and cure rates (p = 0.0001); that is, younger patients at HCT were more likely to accept smaller survival and cure rates. Pre-transplant risk score, QoL, GvHD score and sociological factors did not seem to influence patients' expectations. In conclusion, patient expectations of treatment were much higher than what had been reported in oncological studies. Patients who experienced HCT considered a survival superior to 1 year and cure rates above 50% sufficient to make it worthwhile. Younger patients were more likely to accept smaller benefits; no other predictors for preferences could be detected.

How adverse events and permanent medication stoppages affect changes in patients' beliefs about oral antineoplastic agents

BACKGROUND

Patients with advanced cancer often experience adverse events related to oral antineoplastic agents (OAAs) and permanent OAA medication stoppages, yet it is unknown how these factors impact medication beliefs. Such beliefs about OAA therapy may lend insight into decisions about continued cancer treatment near the end of life.

PURPOSE

To explore relationships that adverse events and permanent OAA stoppages have on medication beliefs during the first 12 weeks following new OAA initiation.

DESIGN

A secondary data analysis from a National Cancer Institute-funded randomized controlled trial testing an intervention to promote symptom management and OAA adherence.

SETTING/SUBJECTS

Patients ≥ 21 years of age initiating a new course of OAA medication were recruited from six United States Comprehensive Cancer Centers. This analysis was based on a subset of patients with advanced disease (N = 60).

MEASUREMENTS

Beliefs about Medicine Questionnaire, Common Terminology Criteria for Adverse Events, and medical records of permanent OAA stoppages.

RESULTS

Significant decline in beliefs regarding the necessity of OAA medications existed between patients experiencing three or more adverse events and those experiencing a permanent OAA stoppage.

CONCLUSIONS

Beliefs about the necessity of OAA medication change when physicians stop OAA medication or the patient experiences three or more adverse events. Concern regarding OAA medication did not change in response to medication stoppage or adverse events for this sample. Perhaps, patients with advanced cancers may be more accepting of adverse events that occur along the treatment trajectory and are not concerned about OAA medication once it is stopped. Findings suggest the importance of physicians' discussions of adverse events and decisions to permanently stop OAA medication as a means of transitioning to a new phase of cancer care that may include palliative or hospice considerations, given that beliefs about medication necessity are changing during these threats to cancer treatment.

Treatment anxiety in breast cancer patients

INTRODUCTION

The aim of the present study was to determine and evaluate the levels of anxiety of breast cancer patients according to the state of treatment, age and education level, as well as the anxiety potential of certain procedures during breast cancer treatment.

METHOD

148 breast cancer patients participated in this prospective cohort study and filled out the questionnaires including the Spielberger state-trait-anxiety-inventory, as well as questions based to stress triggering procedures during breast cancer therapy. The testing was accomplished with the Mann-Whitney U test, the significance level was set to 0.05.

RESULTS

Patients who appeared for tumor board decision showed the highest state-anxiety levels (55.79 SD ± 18.73) followed by patients undergoing surgery (50.24 SD ± 13.84). Patients already undergoing chemotherapy had lower state-anxiety levels than the group of all other patients (p = 0.012). Women undergoing chemotherapy showed lower anxiety levels relating to many procedures of breast cancer treatment. The 25% quartile of patients with the highest levels in the trait score showed a significant poorer education level (p = 0.009). Age showed no statistical influence on the anxiety level of breast cancer patients.  CONCLUSION: Patients with probably high anxiety levels (younger age, low education level, and those appearing for frightening procedures) should receive extra careful clarification and treatment support such as a psycho-oncologist.

Conceptualisation of medication beliefs among patients with advanced cancer receiving oral oncolytic agents using a theory derivation approach

OBJECTIVE

This paper describes a derived model that provides a conceptual framework for understanding medication beliefs among patients with advanced cancer receiving oral oncolytic agents.

METHODS

Theory derivation was used to (a) examine the phenomenon of medication beliefs in cross-disciplinary research; (b) select a parent theory for derivation; (c) identify parent theory concepts and/or structure to use in derivation; and (d) redefine parent theory concepts and structure to create a derived model.

RESULTS

Medication beliefs are shaped by previous experiences, including cognitive and emotional factors, past health and illness encounters, and medication-taking behaviours. Medication beliefs are defined within a larger mental model of illness representation for which medication was prescribed. Individuals independently hold both positive and negative medication beliefs at the same time. This distinction is critical to understanding how dichotomous components of medication beliefs change over time as they are influenced by varying treatment-related factors.

CONCLUSION

This paper contributes to conceptual knowledge regarding the phenomenon of medication beliefs and their impact on health behaviour. Findings can support oncology interventions to improve patient outcomes including medication adherence.

Cognitive effects of cancer systemic therapy: implications for the care of older patients and survivors

The number of patients with cancer who are age 65 years or older (hereinafter "older") is increasing dramatically. One obvious aspect of cancer care for this group is that they are experiencing age-related changes in multiple organ systems, including the brain, which complicates decisions about systemic therapy and assessments of survivorship outcomes. There is a consistent body of evidence from studies that use neuropsychological testing and neuroimaging that supports the existence of impairment following systemic therapy in selected cognitive domains among some older patients with cancer. Impairment in one or more cognitive domains could have important effects in the daily lives of older patients. However, an imperfect understanding of the precise biologic mechanisms underlying cognitive impairment after systemic treatment precludes development of validated methods for predicting which older patients are at risk. From what is known, risks may include lifestyle factors such as smoking, genetic predisposition, and specific comorbidities such as diabetes and cardiovascular disease. Risk also interacts with physiologic and cognitive reserve, because even at the same chronological age and with the same number of illnesses, older patients vary from having high reserve (ie, biologically younger than their age) to being frail (biologically older than their age). Surveillance for the presence of cognitive impairment is also an important component of long-term survivorship care with older patients. Increasing the workforce of cancer care providers who have geriatrics training or who are working within multidisciplinary teams that have this type of expertise would be one avenue toward integrating assessment of the cognitive effects of cancer systemic therapy into routine clinical practice.

Cognitive impairment in older patients with breast cancer before systemic therapy: is there an interaction between cancer and comorbidity?

PURPOSE

To determine if older patients with breast cancer have cognitive impairment before systemic therapy.

PATIENTS AND METHODS

Participants were patients with newly diagnosed nonmetastatic breast cancer and matched friend or community controls age > 60 years without prior systemic treatment, dementia, or neurologic disease. Participants completed surveys and a 55-minute battery of 17 neuropsychological tests. Biospecimens were obtained for APOE genotyping, and clinical data were abstracted. Neuropsychological test scores were standardized using control means and standard deviations (SDs) and grouped into five domain z scores. Cognitive impairment was defined as any domain z score two SDs below or ≥ two z scores 1.5 SDs below the control mean. Multivariable analyses evaluated pretreatment differences considering age, race, education, and site; comparisons between patient cases also controlled for surgery.

RESULTS

The 164 patient cases and 182 controls had similar neuropsychological domain scores. However, among patient cases, those with stage II to III cancers had lower executive function compared with those with stage 0 to I disease, after adjustment (P = .05). The odds of impairment were significantly higher among older, nonwhite, less educated women and those with greater comorbidity, after adjustment. Patient case or control status, anxiety, depression, fatigue, and surgery were not associated with impairment. However, there was an interaction between comorbidity and patient case or control status; comorbidity was strongly associated with impairment among patient cases (adjusted odds ratio, 8.77; 95% CI, 2.06 to 37.4; P = .003) but not among controls (P = .97). Only diabetes and cardiovascular disease were associated with impairment among patient cases.

CONCLUSION

There were no overall differences between patients with breast cancer and controls before systemic treatment, but there may be pretreatment cognitive impairment within subgroups of patient cases with greater tumor or comorbidity burden.

Cognitive effects of cancer and its treatments at the intersection of aging: what do we know; what do we need to know?

There is a fairly consistent, albeit non-universal body of research documenting cognitive declines after cancer and its treatments. While few of these studies have included subjects aged 65 years and older, it is logical to expect that older patients are at risk of cognitive decline. Here, we use breast cancer as an exemplar disease for inquiry into the intersection of aging and cognitive effects of cancer and its therapies. There are a striking number of common underlying potential biological risks and pathways for the development of cancer, cancer-related cognitive declines, and aging processes, including the development of a frail phenotype. Candidate shared pathways include changes in hormonal milieu, inflammation, oxidative stress, DNA damage and compromised DNA repair, genetic susceptibility, decreased brain blood flow or disruption of the blood-brain barrier, direct neurotoxicity, decreased telomere length, and cell senescence. There also are similar structure and functional changes seen in brain imaging studies of cancer patients and those seen with "normal" aging and Alzheimer's disease. Disentangling the role of these overlapping processes is difficult since they require aged animal models and large samples of older human subjects. From what we do know, frailty and its low cognitive reserve seem to be a clinically useful marker of risk for cognitive decline after cancer and its treatments. This and other results from this review suggest the value of geriatric assessments to identify older patients at the highest risk of cognitive decline. Further research is needed to understand the interactions between aging, genetic predisposition, lifestyle factors, and frailty phenotypes to best identify the subgroups of older patients at greatest risk for decline and to develop behavioral and pharmacological interventions targeting this group. We recommend that basic science and population trials be developed specifically for older hosts with intermediate endpoints of relevance to this group, including cognitive function and trajectories of frailty. Clinicians and their older patients can advance the field by active encouragement of and participation in research designed to improve the care and outcomes of the growing population of older cancer patients.

Response rates to a mailed survey of a representative sample of cancer patients randomly drawn from the Pennsylvania Cancer Registry: a randomized trial of incentive and length effects

Background

In recent years, response rates to telephone surveys have declined. Online surveys may miss many older and poorer adults. Mailed surveys may have promise in securing higher response rates.

Methods

In a pilot study, 1200 breast, prostate and colon patients, randomly selected from the Pennsylvania Cancer Registry, were sent surveys in the mail. Incentive amount ($3 vs. $5) and length of the survey (10 pages vs. 16 pages) were randomly assigned.

Results

Overall, there was a high response rate (AAPOR RR4 = 64%). Neither the amount of the incentive, nor the length of the survey affected the response rate significantly. Colon cancer surveys were returned at a significantly lower rate (RR4 = 54%), than breast or prostate surveys (RR4 = 71%, and RR4 = 67%, respectively; p < .001 for both comparisons). There were no significant interactions among cancer type, length of survey and incentive amount in their effects on response likelihood.

Conclusion

Mailed surveys may provide a suitable alternative option for survey-based research with cancer patients.

Breast cancer adjuvant chemotherapy decisions in older women: the role of patient preference and interactions with physicians

PURPOSE

Breast cancer chemotherapy decisions in patients > or = 65 years old (older) are complex because of comorbidity, toxicity, and limited data on patient preference. We examined relationships between preferences and chemotherapy use.

METHODS

Older women (n = 934) diagnosed with invasive (> or = 1 cm), nonmetastatic breast cancer from 2004 to 2008 were recruited from 53 cooperative group sites. Data were collected from patient interviews (87% complete), physician survey (93% complete), and charts. Logistic regression and multiple imputation methods were used to assess associations between chemotherapy and independent variables. Chemotherapy use was also evaluated according to the following two groups: indicated (estrogen receptor [ER] negative and/or node positive) and possibly indicated (ER positive and node negative).

RESULTS

Mean patient age was 73 years (range, 65 to 100 years). Unadjusted chemotherapy rates were 69% in the indicated group and 16% in the possibly indicated group. Women who would choose chemotherapy for an increase in survival of < or = 12 months had 3.9 times (95% CI, 2.4 to 6.3 times; P < .001) higher odds of receiving chemotherapy than women with lower preferences, controlling for covariates. Stronger preferences were seen when chemotherapy could be indicated (odds ratio [OR] = 7.7; 95% CI, 3.8 to 16; P < .001) than when treatment might be possibly indicated (OR = 1.9; 95% CI, 1.0 to 3.8; P = .06). Higher patient rating of provider communication was also related to chemotherapy use in the possibly indicated group (OR = 1.9 per 5-point increase in communication score; 95% CI, 1.4 to 2.8; P < .001) but not in the indicated group (P = .15).

CONCLUSION

Older women's preferences and communication with providers are important correlates of chemotherapy use, especially when benefits are more equivocal.

Attitudes toward information about genetic risk for cognitive impairment after cancer chemotherapy: breast cancer survivors compared with healthy controls

PURPOSE

The trend toward personalized medicine will involve cancer treatment increasingly being tailored to the genetic characteristics of individuals. However, the availability of genetic information does not imply this information is desired or would impact treatment decision making.

METHODS

One hundred sixty breast cancer survivors (BC group) and 205 healthy controls (HC group) were randomly assigned to respond to two different clinical scenarios varying in genetic-related risk of cognitive impairment (CI; little v very likely) and severity of CI (little v moderate problem) after chemotherapy. Ratings of the importance of being told this genetic information (information importance) and the likelihood this information would affect their decision to receive chemotherapy (information impact) were obtained.

RESULTS

Results indicated the importance ascribed to genetic information was greatest when CI likelihood and severity were both high or low (P < .05). Information impact ratings were not sensitive to differences in CI likelihood or severity; the BC group was less likely to indicate genetic information would affect their decision to receive chemotherapy than the HC group (P < .001).

CONCLUSION

Results suggest lessened enthusiasm for genetic information that maintains or increases uncertainty about a specific course of action and highlight the importance of including clinically relevant groups in treatment decision-making research that employs hypothetical scenarios. Although women generally believe it is important to receive genetic information, they might benefit from assistance (eg, decision aid) in the difficult task of integrating information about survival and risk for adverse late effects from cancer treatment.

'If it almost kills you that means it's working!' Cultural models of chemotherapy expressed in a cancer support group

It has long been recognised that cancer is an extraordinarily culturally charged disease. However, while studies have provided valuable insights into the embodied experience of cancer, far less research exists on cancer patients' and survivors' perceptions of the treatments they receive and the meanings they assign to these treatments. This paper focuses specifically on chemotherapy--a highly feared form of treatment that is often popularly depicted to be worse than the experience of cancer itself. Drawing on ethnographic fieldwork over an 8-month period at a cancer support group in western Canada, this article explores patient perceptions of adjuvant chemotherapy. I argue that a widespread cultural model of chemotherapy exists that emphasises the value of suffering as a means of tracking treatment effectiveness and the possibility of cure. However, this framework diverges from biomedical understandings of treatment in important respects, with implications for patient anxiety levels during treatment and their subjective assessments of the future risk of recurrence. Overall, research findings highlight the need to pay closer attention to the meanings patients assign to cancer treatments and call for further research in this area.

Dose variation and regimen modification of adjuvant chemotherapy in daily practice affect survival of stage I-II and operable stage III Taiwanese breast cancer patients

To assess the effect of a non-standard dose and regimen of adjuvant chemotherapy on the clinical outcome in stage I-II and operable stage III Taiwanese breast cancer patients. Variables studied included treatment variation (regimen and dose of adjuvant therapy), lymph node status, tumor size, histologic grade, and hormone receptor status. Cox's multivariate regression analyses were used to select prognostic factors significant for disease-free survival (DFS) and overall survival (OS). In the multivariate analysis, lymph node-positive, a tumor size greater than 5 cm, grade III, hormone receptor-negative status, and non-standard adjuvant chemotherapy were independent prognostic factors for DFS and/or OS. Node-positive patients treated with standard adjuvant chemotherapy had a significantly better DFS (HR=0.6; P=0.032) and OS (HR=0.54; P=0.025) than those treated with non-standard adjuvant chemotherapy. Breast cancer patients receiving standard adjuvant chemotherapy have a better DFS and OS than those receiving non-standard adjuvant chemotherapy.

Women's Interest in Gene Expression Analysis for Breast Cancer Recurrence Risk

Purpose

Genomic and other technologies are improving the accuracy with which clinicians can estimate risk for recurrence (RFR) of breast cancer and make judgments about potential benefits of chemotherapy. Little is known of how patients will respond to genomic RFR testing or interact with their physicians to make informed decisions regarding treatment. We assessed interest in genomic RFR testing and patient preferences for incorporating results into treatment decision making.

Patients and Methods

One hundred thirty-nine women previously treated for early-stage breast cancer completed surveys that presented hypothetical scenarios reflecting different test outcomes and potential decisions. We assessed women's attitudes toward RFR testing, how results would affect their choices about adjuvant treatment, and potential concerns about and perceived benefits of testing.

Results

The majority of participants said they would “definitely” want to be tested (76%), receive their results (87%), and discuss these results with their physicians. They were willing to pay, on average, $997 for testing. Those who expressed more concerns about testing were less interested in testing and in incorporating results into treatment decision making. Participants were more likely to want chemotherapy when presented with high-risk results and would worry more about those results. They were least likely to trust and most likely to express potential anticipated regret in response to intermediate RFR results.

Conclusion

Participants expressed strong interest in testing. Although these decisions were sensitive to RFR, participants’ complex reactions to intermediate RFR suggest care is needed when communicating such results.

Surgical and oncology trials for rectal cancer: Who will participate?

BACKGROUND

The assessment of patients' and clinicians' willingness to participate in clinical trials is advisable as part of a feasibility exercise prior to the commencement of randomized controlled trials (RCTs) to ensure adequate support in terms of likely accrual to achieve the required sample size in a timely fashion. Furthermore, understanding why patients are unwilling to enter RCTs is imperative before the current trend of low participation can be reversed.

METHODS

Patients, colorectal surgeons, and medical and radiation oncologists, were presented with 5 different, detailed treatments for locally advanced rectal cancer. They were asked whether they would be willing to enter an RCT comparing each treatment choice. Patients who would not participate were asked to indicate their reason for refusal.

RESULTS

Patients' willingness to participate in each trial was consistently low (19% to 32%). Similar low levels of participation were indicated by each clinical subspecialty (15% to 38%). Of the scenarios, patients and clinicians were most willing to enter a trial investigating surgery plus preoperative radiotherapy. A dislike of randomization, a desire to be involved in decision-making, and quality of life considerations were the most commonly stated reasons for refusal.

CONCLUSIONS

This study highlights the difficulties in performing RCTs in surgery and oncology. However, results suggest that improvements in communication regarding randomization and clinical trial processes and the actual, rather than perceived, side effects of treatments are strategies that may enhance patient participation.

A qualitative study of factors affecting chemotherapy use in older women with breast cancer: barriers, promoters, and implications for intervention

STUDY OBJECTIVE

The incidence of breast cancer increases with advancing age and yet women 65 and older (hereinafter referred to as 'older' women) do not always receive the most intensive treatments, such as adjuvant chemotherapy. The causes of underutilization of chemotherapy in this age group are poorly delineated. The purpose of the study was to explore older breast cancer patients' attitudes towards chemotherapy and factors that influenced their decisions to use or not use this treatment modality.

DESIGN

Qualitative methods were used to conduct race/ethnicity-specific focus groups. A thematic analysis was performed using NVIVO.

SETTING AND PARTICIPANTS

Drawn from the Washington, DC area, participants were 34 ethnically diverse older breast cancer survivors (18 Caucasians, 10 African-Americans, and 6 Latinas). Focus groups were conducted in a local church; a senior center, and the Lombardi Cancer Center.

MAIN RESULTS

Results showed that many women felt they had no 'choice' and did what the doctor told them to do. For those who reported participation in the decision, time spent exchanging information with the woman's physician and the inclusion of family members promoted perceptions of optimum decision-making leading to the use of chemotherapy. Two barriers to using chemotherapy were negative expectations about side effects and lack of information specific to the woman's individuals' circumstances. Women of color reported less physician communication and information, in part due to language difficulties and perceived bias; these factors acted as barriers to chemotherapy.

CONCLUSION

Physicians could provide specific and limited information to patients and family members to promote realistic expectations and optimum decisions about chemotherapy, given the risks involved in this treatment modality. Interventions should be developed and tested to enhance communication that is sensitive to older women's culture, family structure, illness experiences, preferences, and expectations.

Factors affecting patients' perceptions of choice regarding adjuvant chemotherapy for breast cancer

INTRODUCTION

Patients' perceptions of having had freedom of choice in treatment decision-making are shown to have implications for their quality of life. It is, therefore, important to determine what factors underlie these perceptions. One factor that has been studied is whether or not patients believed that their doctor had offered choice of treatment. However, even when choice is actually offered, patients may still feel that they have no choice. Little attention has been paid to other factors that may contribute to patients' perceptions of having had no choice. Our purpose was to explore (1) whether early-stage breast cancer patients perceived to have had a choice with regard to adjuvant chemotherapy, and (2) their reasons for having perceived no choice.

PATIENTS AND METHODS

The determinants of no choice that we examined were: (1) (preferred) involvement in treatment decision-making, (2) perceived clinical benefits of chemotherapy (e.g., cure), (3) perceived psychological benefits (e.g., less worries), and (4) perception of being able to cope with the side effects. All predictors, as well as patient and clinical characteristics, were entered simultaneously in a multiple logistic regression analysis and non-significant predictors were removed step-by-step, until only significant predictors (p<0.05) remained. Because determinants may differ between patients with experience of chemotherapy and those without, both treatment groups were analyzed separately.

RESULTS

Four hundred and forty-six patients filled out the questionnaire (62%). Sixty-six percent of patients who had been treated with chemotherapy and 86% of inexperienced patients had perceived no treatment choice. In both treatment groups, patients who preferred a shared role or a passive role in treatment decision-making were statistically significantly more likely to have perceived no treatment choice than patients who preferred an active role. Surprisingly, beliefs about the clinical and psychological benefits of chemotherapy did not influence patients' perceptions of having had choice of treatment.

CONCLUSION

If we adhere to patient autonomy and shared decision making, we may consider the perception of no treatment choice as a negative outcome of treatment decision-making. However, if this is the result of the patients' preference for less active involvement in treatment decision-making, the topic of perception of no treatment choice may be viewed in a different light.