Decision Aids and Breast Cancer: Do They Influence Choice for Surgery and Knowledge of Treatment Options?

Shared Decision Making in the Treatment of Rectal Cancer

Background/Objectives: The management of locally advanced rectal cancer has evolved significantly, shaped by advances in multimodal neoadjuvant therapy and a growing emphasis on organ preservation through the watch-and-wait approach. These advancements, however, introduce complex treatment decisions that require careful consideration by both patients and clinicians. Methods: This narrative review explores the evolution of the management of locally advanced rectal cancer and the role of shared decision-making in guiding treatment decisions, particularly for patients facing decisions between surgical resection and watch-and-wait. Additionally, it discusses the development of tools to aid in shared-decision making, current challenges in implementing shared decision-making and future directions for improvement patient centered care in locally advanced rectal cancer management. Results: Considerations for decision making include anatomical considerations that influence surgical options, the potential benefits and risks of watch-and-wait versus surgical resection of the rectum, and the impact of treatment on bowel, urinary, and sexual function. Additionally, patients must weigh the long-term implications of their choices on quality of life. Conclusions: Shared decision-making has emerged as a critical component of patient-centered care and ensures that treatment decisions align with patients' values and priorities. Given the preference-sensitive nature of the management of locally advanced rectal cancer, shared decision-making plays an important role in helping patients navigate these decisions.

Social Media as a Platform for Cancer Care Decision-Making Among Women: Internet Survey-Based Study on Trust, Engagement, and Preferences

BACKGROUND

Decision aids improve patient and clinician decision-making but are underused and often restricted to clinical settings.

OBJECTIVE

Given limited studies analyzing the feasibility of disseminating decision aids through social media, this study aimed to evaluate the acceptability, trust, and engagement of women with social media as a tool to deliver online decision aids for cancer treatment.

METHODS

To prepare for potential dissemination of a breast cancer decision aid via social media, a cross-sectional survey in February 2023 was conducted via Prime Panels, an online market research platform, of women aged 35-75 years in the United States. Demographics, health, cancer information-seeking behaviors, social media use, trust in social media for health information, as well as the likelihood of viewing cancer-related health information and clicking on decision aids through social media, were assessed. Statistical analyses included descriptive statistics, correlations, and multivariable ordinal regression.

RESULTS

Of 607 respondents, 397 (65.4%) had searched for cancer information, with 185 (46.6%) using the internet as their primary source. Facebook (Meta) was the most popular platform (511/607, 84.2%). Trust in social media for health information was higher among Black (14/72, 19.4%) and Asian respondents (7/27, 25.9%) than among White respondents (49/480, 10.2%; P=.003). Younger respondents aged 35-39 years (17/82, 20.7%) showed higher trust than those aged 70-79 years (12/70, 17.1%; P<.001). Trust in social media for health information was linked to a higher likelihood of viewing cancer information and accessing a decision aid online (P<.001). Participants who rated social media as "Trustworthy" (n=73) were more likely to view cancer information (61/73, 83.6%) and click on decision aids (61/73, 83.6%) than those who found it "Untrustworthy" (n=277; view: 133/277, 48.0%; click: 125/277, 45.1%). Engagement with social media positively correlated with viewing online cancer information (Spearman ρ=0.20, P<.001) and willingness to use decision aids (ρ=0.21, P<.001). Multivariable ordinal regression analyses confirmed that perception of social media's trustworthiness is a significant predictor of engagement with decision aids (untrustworthy vs trustworthy β=-1.826, P<.001; neutral vs trustworthy β=-0.926, P=.007) and of viewing cancer information (untrustworthy vs trustworthy β=-1.680, P<.001, neutral vs trustworthy β=-0.581, P=.098), while age and employment status were not significant predictors.

CONCLUSIONS

This exploratory study suggests that social media platforms may increase access to health information and decision aids. No significant differences were observed between demographic variables and the use or trust in social media for health information. However, trust in social media emerged as a mediating factor between demographics and engagement with cancer information online. Before disseminating decision aids on social media, groups should identify existing trust and engagement patterns with different platforms within their target demographic.

Do We Have Sufficient Evidence to Derive Innovative Approaches to Assessing Unmet Need, Delivering Education on Bladder and Bowel Continence Health, and Providing a Better Environment for Joint Decision-Making? ICI-RS 2024

CONTEXT

Improved continence outcomes are reliant on identification of unmet need, education delivery, and shared decision-making. The evidence base on which to derive innovative approaches in these areas was unclear.

METHODS

A debate held at the International Consultation on Incontinence-Research Society meeting, held in Bristol in June 2024, considered ways to improve research requirements to advance these areas.

RESULTS AND CONCLUSION

Artificial intelligence solutions and digital approaches to healthcare are emerging at pace and offer possibilities to improve these three key areas but this must be driven by person-centered approaches. Care must be taken to avoid increasing inequality through digital exclusion and language barriers. Research questions are highlighted to derive innovation in these three key areas.

The Implementation of Decision Aids During Medical Consultations for Lung Cancer Patients: A Focus Group Within I3LUNG Project

Lung cancer patients generally receive several information regarding their illness characteristics and available intervention. Therefore, patients can experience confusion, leading to anxiety and distress that might damage the relationship with physicians and treatment adherence. Literature showed that implementing decision aid tools during consultation can promote patients' knowledge and awareness about lung cancer and available oncological intervention, improving a shared decision-making process. However, not all lung cancer patients always appreciate decision aids' implementation. The present qualitative study explored patients' opinions and preferences regarding the implementation of decision aids during medical consultation. Twenty-two lung cancer patients who have already attended medical consultations for lung cancer voluntarily participated in four online focus groups carried out between January 2023 and December 2024. A thematic analysis with a bottom-up approach highlighted three main themes: the typology and number of information that patients would have received, the relevance of patient-and-doctor relationship, and the effects of providing additional decision-making tools on patients' emotions and preferences. Findings showed controversial opinions among patients, highlighting the relevance of personalized intervention tailored to patients' preferences. Practical implications are given.

Enhancing Breast Cancer Detection: A Machine Learning Approach Using Multielectrode Bioimpedance

Background

Early detection of cancerous tumors is a critical factor in improving treatment outcomes. To address this need, this study explores a simple, effective, and cost-efficient method for early cancer detection by measuring the bioimpedance of living tissues. Bioimpedance-based methods hold significant promise for the early detection of cancerous tumors.

Materials and Methods

The study begins by simulating the impedance behavior of the human breast under two conditions: healthy and containing cancerous tumors. The Cole-Cole model is used to simulate the dielectric properties of both breast and tumor tissues using finite element modeling. In the measurement phase, eight electrodes are evenly distributed around the breast model to ensure comprehensive data collection. Subsequently, a dataset is prepared encompassing three breast sizes (60, 70, and 80 mm) in both the healthy and tumor-afflicted states, with tumor sizes of 5, 8, and 10 mm radius. This dataset is utilized to develop machine learning models, including support vector machines (SVM), convolutional neural networks (CNN), and random forest (RF), for breast cancer detection.

Results

The results of this study demonstrate the practicality of integrating machine learning techniques with multielectrode bioimpedance measurements to achieve precise and automated breast cancer detection. Notably, the RF model outperformed both SVM and CNN in terms of cancer detection accuracy.

Conclusions

This study underscores the potential of bioimpedance-based methods, coupled with machine learning algorithms, for early cancer detection. The findings suggest that RF models hold promise for accurate and automated breast cancer detection, offering a valuable tool for improving patient outcomes.

Personalized anesthesia and precision medicine: a comprehensive review of genetic factors, artificial intelligence, and patient-specific factors

Precision medicine, characterized by the personalized integration of a patient's genetic blueprint and clinical history, represents a dynamic paradigm in healthcare evolution. The emerging field of personalized anesthesia is at the intersection of genetics and anesthesiology, where anesthetic care will be tailored to an individual's genetic make-up, comorbidities and patient-specific factors. Genomics and biomarkers can provide more accurate anesthetic protocols, while artificial intelligence can simplify anesthetic procedures and reduce anesthetic risks, and real-time monitoring tools can improve perioperative safety and efficacy. The aim of this paper is to present and summarize the applications of these related fields in anesthesiology by reviewing them, exploring the potential of advanced technologies in the implementation and development of personalized anesthesia, realizing the future integration of new technologies into clinical practice, and promoting multidisciplinary collaboration between anesthesiology and disciplines such as genomics and artificial intelligence.

Information and communication priorities of patients and healthcare professionals in shared decision making regarding adjuvant systemic breast cancer treatment: A survey study

PURPOSE

To assess information and communication priorities of patients and healthcare professionals in Shared Decision Making about adjuvant systemic treatment of primary breast cancer and identify key decision-relevant information accordingly.

METHODS

Patients (N = 122) and professionals working with breast cancer patients (N = 118), of whom 38 were nurse practitioners and 32 nurses, were recruited using convenience sampling, and surveyed about information/communication aspects key to decision-making, using ranking assignments. We further posed a simple open question, questions about receiving population-based statistics versus personalized statistics concerning treatment outcomes, and their attitude and experience concerning Shared Decision Making. Data were analyzed using descriptive analysis and a qualitative analysis.

RESULTS

Both patients and professionals prioritized information about treatment outcomes (i.e., survival, recurrence) as key decision-relevant information for patients. Patients prioritized information about relatively severe treatment side-effects and late effects (e.g., blood clot, stroke), whilst professionals prioritized information about effects that occur relatively often (e.g., hair loss, fatigue). Patients specifically wanted to know if the benefit of treatment is worth the negative impact. Both groups prioritized personalized statistics over population-based statistics.

CONCLUSIONS

Some differences between patients and professionals were found in information and communication priorities, specifically related to the different side-effects. It seems worthwhile to precisely address these side-effects in Shared Decision Making concerning adjuvant systemic treatment. Furthermore, it seems important to deliberate together on the question if expected benefit of treatment is worth the potential negative impact for the individual patient.

Factors influencing older women's decision-making related to treatment of operable breast cancer: A qualitative systematic review

OBJECTIVE

There is variation in practice in the treatment of older women with breast cancer. International guidelines highlight the importance of patient autonomy in treatment decision-making. The aim of this study is to identify factors which influence decision-making in older women with operable breast cancer, which will enable us to further understand how to support these patients.

METHODS

Systematic review in accordance with the PRISMA guidelines was performed to identify factors which influence treatment decision-making in older women with operable breast cancer. Medline, Web of Science and SCOPUS were searched.

RESULTS

The search yielded 5840 results; 13 articles met the inclusion criteria and reported on a total of 1118 women. Thematic analysis identified three key themes in which decision-making factors could be categorised. These were healthcare-related factors, patient-related factors and impact of treatment. Healthcare-related factors included communication with clinicians and provision of information. Patient-related factors were age, pre-existing knowledge, preconceptions of breast cancer and treatment, decision-making style and co-morbidities. The impact of treatment considerations included body image and effect on quality of life. Decision-making style was frequently reported; older women did not demonstrate one preferred style.

CONCLUSIONS

The findings have highlighted the complex interplay of factors which influence how older women make breast cancer treatment-decisions. Clinicians should have an awareness of the factors highlighted to maximise their ability to provide support and personalised care to older women with breast cancer whilst treatment decisions are made.

Breast cancer patients' needs and perspectives on a one-on-one peer support program: quantitative and qualitative analyses

PURPOSE

Although peer support programs as a health resource have become increasingly popular, only limited studies evaluated the added value of one-on-one peer support for breast cancer patients. This study aims to bridge the knowledge gap by focusing on two related research topics. First, we evaluated emotional well-being and (unmet) needs regarding supportive care. Second, we evaluated patients' perspectives on their experiences after having one-on-one peer support.

METHODS

A quantitative analysis was conducted to provide insight in patients' symptoms of anxiety and depression (HADS), quality of life (EORTC-QLQ-C30), and supportive care needs (CaSUN-questionnaire). Furthermore, approximately 1 year after the implementation of a one-on-one peer support program, focus groups were conducted to evaluate patients' perspectives regarding one-on-one peer support.

RESULTS

Two hundred twenty-five of 537 patients diagnosed with breast cancer between 2019 and 2020 completed the questionnaires. Quantitative analysis showed increased symptoms of anxiety and depression among breast cancer patients and lower scores on all EORTC-QLQ-C30 domains compared to the Dutch normative population. Of all patients, 27.6% (95%CI = 0.22-0.34) reported to have unmet needs regarding emotional support and 23.1% (95%CI = 0.18-0.29) reported an unmet need to talk to someone who has experienced breast cancer. For the qualitative analysis, 19 breast cancer patients who were taking part in the one-on-one peer support program participated in three focus groups. Benefits, limitations, and wishes regarding the one-on-one peer support program were discussed.

CONCLUSION

Breast cancer patients showed increased anxiety and depression and lower quality of life, physical, role, emotional, cognitive, and social functioning compared to the Dutch normative population. Almost one-third of breast cancer patients reported unmet needs regarding emotional support and a desire to talk to other breast cancer patients. These (unmet) needs can successfully be met by providing a low-threshold one-on-one peer support program.

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.

Explaining risks and benefits of loco-regional treatments to patients

Treatment for early-stage breast cancer is complex, requiring multidisciplinary care with a multitude of treatment options available for each patient. Coupled with the rising importance of shared decision-making, patient-physician conversations are progressively more complicated. These conversations require frank disclosure of risks and benefits of the different treatment modalities in a way that is individualized for each patient and simple to understand. In most patients, breast conserving therapy with radiation should be presented as the gold-standard local treatment given similar long-term and improved quality of life outcomes. De-escalation is currently at the forefront of research in loco-regional treatments, and further investigations are required to best determine the optimal patient populations for reduced sentinel lymph node sampling, omission of sentinel lymph node biopsy altogether and omission of radiation treatment. For future trials, better endpoints need to be established considering patient-centered outcomes as well as recurrence.

Implementing shared decision-making interventions in breast cancer clinical practice: a scoping review

BACKGROUND

Shared decision-making (SDM) is a collaborative process whereby patients and clinicians jointly deliberate on the best treatment option that takes into account patients' preferences and values. In breast cancer care, different treatment options have become available to patients in the last decade. Various interventions, including patient decision aids (PtDAs), have been designed to promote SDM in this disease area. This study aimed at investigating the factors that influence the successful adoption and implementation of SDM interventions in real-world healthcare delivery settings.

METHODS

A scoping review of scientific and grey literature was conducted for the period 2006-2021 to analyse the support for SDM interventions and their adoption in breast cancer clinical practice. The interpretation of findings was based on the Practical, Robust Implementation and Sustainability Model (PRISM) for integrating research findings into practice.

RESULTS

Overall, 19 studies were included for data synthesis, with more than 70% published since 2017. The availability of SDM tools does not automatically translate into their actual use in clinical settings. Factors related to users' co-creation, the clinical team's attitude and knowledge, organisational support and regulatory provisions facilitate the adoption of SDM interventions. However, overlooking aspects such as the re-organisation of care pathways, patient characteristics, and assigning of resources (human, financial, and facilities) can hinder implementation efforts.

CONCLUSIONS

Compared to the mounting evidence on the efficacy of SDM interventions, knowledge to support their sustained implementation in daily care is still limited, albeit results show an increasing interest in strategies that facilitate their uptake in breast cancer care over time. These findings highlight different strategies that can be used to embed SDM interventions in clinical practice. Future work should investigate which approaches are more effective in light of organisational conditions and external factors, including an evaluation of costs and healthcare system settings.

Decision Aids in the ICU: a scoping review

OBJECTIVE

The purpose of this scoping review was to synthesise the effectiveness and acceptability of decision aids for critically ill patients and family members in the intensive care unit (ICU).

METHODS

A systematic search of four electronic databases and grey literature was undertaken to identify relevant studies on the application of decision aids in the ICU, without publication date restriction, through March 2023. The methodological framework proposed by Arksey and O'Malley was used to guide the scoping review.

RESULTS

Fourteen papers were ultimately included in this review. However, only nine decision aids were available, and it is noteworthy that many of these studies focused on the iterative development and testing of individual decision aids. Among the included studies, 92% (n=13) were developed in North America, with a primary focus on goals of care and life-sustaining treatments. The summary of the effect of decision aid application revealed that the most common indicators were the level of knowledge and code status, and some promising signals disappeared in randomised trials.

CONCLUSIONS

The complexity of treatment decisions in the ICU exceeds the current capabilities of existing decision aids. There is a clear gap in decision aids that are tailored to different cultural contexts, highlighting the need to expand the scope of their application. In addition, rigorous quality control is very important for randomised controlled trial, and indicators for assessing the effectiveness of decision aids need to be further clarified.

Improving shared decision making in virtual breast cancer surgery consultations

With the COVID19 pandemic, use of telehealth has expanded rapidly in subspecialties with limited prior telehealth experience. While telehealth offers many opportunities to improve patient convenience, access, and comfort, the virtual platform poses unique challenges for shared decision making. In this review article, we describe what occurs within a standard in-person breast surgery consult and propose a model for an ideal virtual breast surgery consult, including strategies to foster patient engagement and shared decision making. Our model incorporates pre-visit preparation, deliberate pauses, and targeted engagement as ways to encourage patients to integrate information and actively participate in treatment decisions. Intentional strategies such as these must be adopted to improve shared decision making on the virtual platform.

A Decision Aid to Help Patients Make Informed Choices Between the Laparoscopic Gastric Bypass or Sleeve Gastrectomy

PURPOSE

In the Netherlands, patients can often choose between the laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) as primary bariatric surgery. Yet, patients confronted with medical options may experience decisional conflict when their stakes are high and outcomes uncertain. This study aimed to assess if a decision aid helps patients make informed choices between two bariatric procedures by lowering the level of decisional conflict.

MATERIALS AND METHODS

This study was a single-center comparative cohort of patients who accessed a web-based decision aid (intervention group) and those who did not use the decision aid (control group) to help choose between two bariatric procedures additional to the standard provided care. The primary outcome was the level of decisional conflict in these patients using the decisional conflict scale (DCS). Secondary outcomes were patient satisfaction with the provided information (BODY-QTM-satisfaction with information), preference of involvement in procedure selection, level of shared decision-making (SDM-Q-9 questionnaire), and patient knowledge.

RESULTS

The level of decisional conflict assessed with the decisional conflict scale (DCS) showed a significantly lower mean total DCS of 25.5 ± 11.5 for the intervention group vs. 29.1 ± 12.4 in the control group (p = 0.022). Both groups did not significantly differ in satisfaction regarding provided information, involvement in the selection procedure, shared decision-making, and patient knowledge.

CONCLUSION

The results suggest that the additional use of a decision aid significantly lowers the level of decisional conflict in patients awaiting bariatric surgery. However, the added value should be further investigated.

Increasing socioeconomically disadvantaged patients' engagement in breast cancer surgery decision-making through a shared decision-making intervention (A231701CD): protocol for a cluster randomised clinical trial

INTRODUCTION

Socioeconomic disparities for breast cancer surgical care exist. Although the aetiology of the observed socioeconomic disparities is likely multifactorial, patient engagement during the surgical consult is critical. Shared decision-making may reduce health disparities by addressing barriers to patient engagement in decision-making that disproportionately impact socioeconomically disadvantaged patients. In this trial, we test the impact of a decision aid on increasing socioeconomically disadvantaged patients' engagement in breast cancer surgery decision-making.

METHODS AND ANALYSIS

This multisite randomised trial is conducted through 10 surgical clinics within the National Cancer Institute Community Oncology Research Program (NCORP). We plan a stepped-wedge design with clinics randomised to the time of transition from usual care to the decision aid arm. Study participants are female patients, aged ≥18 years, with newly diagnosed stage 0-III breast cancer who are planning breast surgery. Data collection includes a baseline surgeon survey, baseline patient survey, audio-recording of the surgeon-patient consultation, a follow-up patient survey and medical record data review. Interviews and focus groups are conducted with a subset of patients, surgeons and clinic stakeholders. The effectiveness of the decision aid at increasing patient engagement (primary outcome) is evaluated using generalised linear mixed-effects models. The extent to which the effect of the decision aid intervention on patient engagement is mediated through the mitigation of barriers is tested in joint linear structural equation models. Qualitative interviews explore how barriers impact engagement, especially for socioeconomically disadvantaged women.

ETHICS AND DISSEMINATION

This protocol has been approved by the National Cancer Institute Central Institutional Review Board, and Certificate of Confidentiality has been obtained. We plan to disseminate the findings through journal publications and national meetings, including the NCORP network. Our findings will advance the science of medical decision-making with the potential to reduce socioeconomic health disparities.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03766009).

Decision quality and regret with treatment decisions in women with breast cancer: Pre-operative breast MRI and breast density

PURPOSE

We evaluated self-report of decision quality and regret with breast cancer surgical treatment by pre-operative breast MRI use in women recently diagnosed with breast cancer.

METHODS

We conducted a survey with 957 women aged 18 + with stage 0-III breast cancer identified in the Breast Cancer Surveillance Consortium. Participants self-reported receipt of pre-operative breast MRI. Primary outcomes were process measures in the Breast Cancer Surgery Decision Quality Instrument (BCS-DQI) (continuous outcome) and Decision Regret Scale (dichotomized outcome as any/none). Generalized estimating equations with linear and logit link were used to estimate adjusted associations between breast MRI and primary outcomes. All analyses were also stratified by breast density.

RESULTS

Survey participation rate was 27.9% (957/3430). Study population was primarily > 60 years, White, college educated, and diagnosed with early-stage breast cancer. Pre-operative breast MRI was reported in 46% of women. A higher proportion of women who were younger age (< 50 years), commercially insured, and self-detected their breast cancer reported pre-operative breast MRI use. In adjusted analysis, pre-operative breast MRI use compared with no use was associated with a small but statistically significantly higher decision quality scores (69.5 vs 64.7, p-value = 0.043). Decision regret did not significantly differ in women who reported pre-operative breast MRI use compared with no use (54.2% v. 48.7%, respectively, p-value = 0.11). Study results did not vary when stratified by breast density for either primary outcome.

CONCLUSIONS AND RELEVANCE

Breast MRI use in the diagnostic work-up of breast cancer does not negatively alter women's perceptions of surgical treatment decisions in early survivorship.

CLINICAL TRIALS REGISTRATION NUMBER

NCT03029286.

Developing a question prompt list for the oncology setting: A scoping review

OBJECTIVE

The purpose of this study was to provide an overview of existing methods used to develop a Question Prompt List (QPL) for an oncology setting.

METHODS

We conducted a search of the literature published between 1999 and 2019 in five online databases followed by a hand search, and extracted data on the methods used to develop a QPL.

RESULTS

A total of 21 studies were included. The review shows differences in the development of older QPLs (1999-2009) and current QPLs (2010-2019). However, most QPLs were developed using interviews or focus groups with patients and an expert session to review or adapt the QPL. Health professionals, patients, and researchers were included in nearly all the studies.

CONCLUSION

To develop a QPL, it is important to combine several information sources and at least to involve health professionals, patients, and researchers in the development process. Review or evaluation steps can improve the appropriateness and acceptance of a QPL.

PRACTICE IMPLICATIONS

Further research is needed to define the type of target population for new QPLs and to develop a framework for their development.

Effect of patient decision aids on decisional conflict and regret associated with breast cancer surgery: a randomized controlled trial

BACKGROUND

Patients with breast cancer encounter difficulties in making surgical treatment decisions. Shared decision-making (SDM) with patient decision aids (PDAs) can minimize patients' decisional conflicts. However, the effect of PDAs in Asia remains inconclusive. This study investigated the effect of SDM assisted by PDAs on the decisional conflict of patients with breast cancer.

METHODS

In this two-group, outcome assessor-blind, randomized controlled trial, 151 patients diagnosed as having breast cancer were assigned to the PDA (SDM with PDA) group or the standard (SDM without PDA) group. Demographic and clinical variables were analyzed to identify variables affecting the treatment choice. The patients' decision-making difficulties were evaluated using the four-item SURE scale during preoperative hospitalization, and decisional conflicts were examined using the five-item Decision Regret scale and Hospital Anxiety and Depression Scale (HADS) 1 month after surgery.

RESULTS

The choice of breast conservation therapy and mastectomy did not significantly differ between the PDA and standard groups. The PDA group had a higher level of depression after making decisions (P = 0.029) than did the standard group. No significant difference in the total scores of the SURE scale and Decision Regret scale were noted between the groups.

CONCLUSION

PDAs did not assist the patients with breast cancer in making breast surgery-related decisions. Clinicians should focus on SDM grounded in evidence-based medicine with care and help patients consider their individual preferences.

TRIAL REGISTRATION

ClinicalTrial.gov, NCT03105076; April 7, 2017 ( http://www.

CLINICALTRIALS

gov ).

The lived experience during the peri-diagnostic period of breast cancer: A scoping review

OBJECTIVES

The aim of this scoping review is to provide an overview of the existing research that investigates the lived experience during the peri-diagnostic period of breast cancer.

METHODS

Nine databases were searched for relevant literature between January 2007 and April 2019. Data were extracted and categorized using deductive and inductive approaches.

RESULTS

A majority of the 66 studies included used qualitative methods to retrospectively explore the treatment decision making process of female breast cancer patients. Patients experienced uncertainty, emotional distress, and a need for more information from providers and relied on social support and family guidance during this period.

CONCLUSIONS

The results of this review show that the burdens experienced during the peri-diagnostic period parallel those in later periods of cancer care. However, these burdens are prompted by different circumstances. More research is needed to explore the lived experience during this period through the use of mixed-methods and by recruiting a diverse sample with regards to role in the breast cancer experience, age, gender, race, and ethnicity.

PRACTICE IMPLICATIONS

Interventions positioned at earlier points in the breast cancer experience should provide informational support, which could be delivered through shared decision making models. Additional support could be facilitated by patient navigation programs and health information technology.

The biopsychosociotechnical model: a systems-based framework for human-centered health improvement

The biopsychosocial model is among the most influential frameworks for human-centered health improvement but has faced significant criticism- both conceptual and pragmatic. This paper extends and fundamentally re-structures the biopsychosocial model by combining it with sociotechnical systems theory. The resulting biopsychosociotechnical model addresses key critiques of the biopsychosocial model, providing a more "practical theory" for human-centered health improvement. It depicts the determinants of health as complex adaptive system of systems; includes the the artificial world (technology); and provides a roadmap for systems improvement by: differentiating between "health status" and "health and needs assessment", [promoting problem framing]; explaining health as an emergent property of the biopsychosociotechnical context [imposing a systems orientation]; focusing on "interventions" vs. "treatments" to modify the biopsychosociotechnical determinants of health, [expanding the solution space]; calling for a participatory design process [supporting systems awareness and goal-orientation]; and including intervention management to support the full lifecycle of health improvement.

Managing Advanced Cancer Pain Together (MACPT) conversation tool: an evaluation of use in clinical practice

Aim: To investigate use of the 'Managing Advanced Cancer Pain Together' conversation tool between individuals with advanced cancer and healthcare professionals (HCPs) during routine consultations. Methods: Twenty-one patients and six HCPs completed questionnaires before and after use of the tool (at their routine consultation 1 and consecutive consultation 2, respectively). Results: Patients and HCPs were satisfied with communication during both consultations. When using the tool, patients most frequently selected physical pain descriptors (95.2%), followed by emotional (81.0%), social (28.6%) and spiritual (28.6%) descriptors. Patients found the tool useful, stating that it helped them describe their pain. HCPs considered the tool difficult to incorporate into consultations. Conclusion: The study highlighted the need to consider the various aspects of cancer pain.

Development and preliminary evaluation of tablet computer-based decision aid for patients participating in cancer clinical trials

OBJECTIVES

Patients often consent to participate in cancer clinical trials despite misunderstanding the trial content. We developed a tablet-based clinical trial decision aid and tested its use with the usual discussion at the time of clinical trial registration.

METHODS

Participants were individuals considering participating in a breast cancer clinical trial. The control participated in usual discussions; the intervention group participated in discussion using the decision aid. Pre- and post-discussion, we investigated knowledge, decision-making conflict, and discussion length.

RESULTS

We enrolled 54 patients, 27 in the control group and 27 in the intervention group. Post-discussion clinical trial knowledge was significantly higher in the intervention group than in the control group (p = 0.003). No significant difference was found in decisional conflict, but the intervention group tended to have lower post-discussion conflict than the control group. There was no between-group difference in the length of discussions with physicians and clinical research coordinators.

CONCLUSION

For women considering participation in cancer clinical trials, a tablet-based decision aid may promote clinical trial understanding without increasing discussion length or patient burden. This pre-learning decision aid incorporating a quiz and bidirectional question prompt lists may improve participants' understanding of clinical trials.

An Adaptation, Extension and Pre-Testing of an Interactive Decision Aid for Men Diagnosed with Localized Prostate Cancer in Iceland: A Mixed-Method Study

In this study an interactive decision aid (DA) for men diagnosed with localized prostate cancer was adapted, extended and pre-tested. The DA's prototype was based on a literature review and other empirically tested DAs. Semi-structured interviews with 12 men (age 65-80) diagnosed with localized prostate cancer were conducted to get feedback on content, usability, and the DA's layout. The interviews were analyzed using thematic analysis and themes were identified using deductive and inductive coding. Participants found the accessibility of the information and the explicit values clarification tool helpful. Four themes were identified: (1) usability and design, (2) content and knowledge, (3) deciding factors of decision-making, and (4) social support. Participants valued receiving extensive and realistic information on surgery/radiation therapy side effects and getting unbiased presentations of treatment options. Following the thematic analysis, the DA was revised and tested in a survey among 11 newly diagnosed prostate cancer patients (age 60-74). The participants valued the DA and found it helpful when making a treatment decision, and all reported that they would recommend it to others making a prostate cancer treatment decision. The DA is currently being tested in a randomized clinical trial (RCT). This is the first DA developed for prostate cancer patients in Iceland and if the results of the RCT show that it is more effective than standard care in assisting newly diagnosed patients with their treatment decision, the DA can be easily translated and adapted to cultures similar to Iceland such as the Nordic countries.

Patient-Provider Communication, Decision-Making, and Psychosocial Burdens in Palliative Radiotherapy: A Qualitative Study on Patients' Perspectives

CONTEXT

Patient-provider communication impacts how patients with cancer make decisions about treatment.

OBJECTIVES

To examine patient perceptions of discussions, decision-making, and psychosocial burdens related to receiving palliative radiotherapy (RT), in order to inform best practices for communication about palliative RT.

METHODS

We conducted an exploratory qualitative study using oral questionnaires and semi-structured interviews. Seventeen patients receiving their first course of palliative RT for lung or bone metastases at a comprehensive cancer center were interviewed. Patient interviews were transcribed verbatim and thematically analyzed using NVivo software.

RESULTS

Themes that impacted patients' decisions to initiate RT included a desire to minimize pain, optimism about what RT could provide for the future, perception of having "no other choice," disappointment about cancer progression, and unfamiliarity with RT. Most patients preferred shared decision-making regarding RT initiation and reported patient empowerment, effective communication, and team collaboration as contributing to shared decision-making. Most patients preferred their physicians to make decisions about RT treatment intensity and described trust in their physicians, institutional reputation, and RT expertise as motivators for this preference. Patients who possessed a proactive decisional mindset about initiating RT as opposed to having "no other choice" were less likely to report experiencing psychosocial burdens.

CONCLUSION

Most patients prefer shared decision-making regarding RT initiation but prefer their radiation oncologists to make decisions regarding treatment intensity. Communication that empowers patients in their desired level of engagement for RT decision-making may help patients make informed decisions, contribute toward a proactive decisional mindset, and reduce their perception of psychosocial burdens.

Occurrence of residual disease in specimens of re-excision surgery in patients with positive margins of primary quadrantectomy

Performing a re-intervention following a positive margin after primary lumpectomy in patients with breast cancer entails several disadvantages such as additional costs and postponing the follow-up treatments. In the present study, we sought to measure the incidence rate of residual disease in specimens taken from breast cancer patients who had positive margins after quadrantectomy and also compare the clinical and pathological factors between patients with and without a residual disease after the secondary surgery. All of the medical records of patients undergoing quadrantectomy from December 1994 to December 2019 were collected from Shiraz Breast Cancer Registry (SBCR). Patients were divided into two subgroups of patients with and without residual disease from the secondary surgery and also with and without positive margin from the first operation. Two groups were compared in terms of all clinicopathological factors. The records of 4843 patients undergoing quadrantectomy were reviewed, of which 132 (2.3%) had involved margins. Of these, 112 patients underwent a secondary surgery and 28 had residual disease (25%). No clinicopathological factor was correlated with presence of residual cancer. Also, bigger tumor size (p < 0.001) and the presence of in situ component (p < 0.001) were associated with positive margin and hence the need for a re-excision surgery. These results revealed that the significant rate of residual disease in the specimens of the secondary surgery indicates that a re-operation (either re-excision or simple mastectomy) cannot be omitted after obtaining a positive margin from the primary quadrantectomy.

Acceptability of 3D-printed breast models and their impact on the decisional conflict of breast cancer patients: A feasibility study

PURPOSE

To evaluate the acceptability and impact of 3D-printed breast models (3D-BMs) on treatment-related decisional conflict (DC) of breast cancer patients.

METHODS

Patients with breast cancer were accrued in a prospective institutional review board-approved trial. All patients underwent contrast-enhanced breast magnetic resonance imaging (MRI). A personalized 3D-BM was derived from MRI. DC was evaluated pre- and post-3D-BM review. 3D-BM acceptability was assessed post-3D-BM review.

RESULTS

DC surveys before and after 3D-BM review and 3D-BM acceptability surveys were completed by 25 patients. 3D-BM were generated in two patients with bilateral breast cancer. The mean patient age was 48.8 years (28-72). The tumor stage was Tis (7), 1 (8), 2 (8), and 3 (4). The nodal staging was 0 (19), 1 (7), and 3 (1). Tumors were unifocal (15), multifocal (8), or multicentric (4). Patients underwent mastectomy (13) and segmental mastectomy (14) with (20) or without (7) oncoplastic intervention. Neoadjuvant therapy was given to seven patients. Patients rated the acceptability of the 3D-BM as good/excellent in understanding their condition (24/24), understanding disease size (25/25), 3D-BM detail (22/25), understanding their surgical options (24/25), encouraging to ask questions (23/25), 3D-BM size (24/25), and impartial to surgical options (17/24). There was a significant reduction in the overall DC post-3D-BM review, indicating patients became more assured of their treatment choice (p = 0.002). Reduction post-3D-BM review was also observed in the uncertainty (p = 0.012), feeling informed about options (p = 0.005), clarity about values (p = 0.032), and effective (p = 0.002) Decisional Conflict Scale subscales.

CONCLUSIONS

3D-BMs are an acceptable tool to decrease DC in breast cancer patients.

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.

Breast-conserving surgery with or without irradiation in women with invasive ductal carcinoma of the breast receiving preoperative systemic therapy: A cohort study

Purpose

To investigate the outcomes of adjuvant whole breast radiation therapy (WBRT) in patients with invasive ductal carcinoma of the breast (breast IDC) receiving preoperative systemic therapy (PST) and breast-conserving surgery (BCS), and their prognostic factors, considering overall survival (OS), locoregional recurrence (LRR), distant metastasis (DM), and disease-free survival.

Patients and methods

Patients diagnosed as having breast IDC and receiving PST followed by BCS were recruited and categorized by treatment into non-breast radiation therapy [BRT] (control) and WBRT (case) groups, respectively. Cox regression analysis was used to calculate hazard ratios (HRs) and confidence intervals (CIs).

Results

Multivariate Cox regression analyses indicated that non-BRT, cN3, and pathologic residual tumor (ypT2–4) or nodal (ypN2–3) stages were poor prognostic factors for OS. The adjusted HRs (aHRs; 95% CIs) of the WBRT group to non-BRT group for all-cause mortality were 0.14 (0.03–0.81), 0.32 (0.16–0.64), 0.43 (0.23–0.79), 0.23 (0.13–0.42), 0.52 (0.20–1.33), and 0.34 (0.13–0.87) in the ypT0, ypT1, ypT2–4, ypN0, ypN1, and ypN2–3 stages, respectively. The aHRs (95% CIs) of the WBRT group to non-BRT group for all-cause mortality were 0.09 (0.00–4.07), 0.46 (0.26–0.83), 0.18 (0.06–0.51), 0.28 (0.06–1.34), 0.25 (0.10–0.63), 0.47 (0.23–0.88), and 0.32 in the cT0–1, cT2, cT3, cT4, cN0, cN1, and cN2–3 stages, respectively. The WBRT group exhibited significantly better LRR-free and DM-free survival than the non-BRT group, regardless of the clinical T or N stage or pathologic response after PST.

Conclusion

WBRT might lead to superior OS and LRR-free and DM-free survival compared with the non-BRT group, regardless of the initial clinical TN stage or pathologic response.

•

Outcome patterns of adjuvant RT for patients with breast cancer receiving preoperative systemic therapy and breast-conserving surgery.

•

Non-breast radiation therapy, cN3, pathologic residual tumor (ypT2–4), or nodal (ypN2–3) stages are poor prognostic factors for survival.

•

The beneficial effects of RT are superior OS and LRR-free and DM-free survival compared with the non-RT group.

Preferences for Weight Loss Treatment Amongst Treatment-Seeking Patients with Severe Obesity: A Discrete Choice Experiment

BACKGROUND

Treatment options for weight loss vary considerably with regard to risks and benefits, but the relative importance of treatment characteristics in patient decision-making is largely unknown, particularly amongst patients with severe obesity. Developing such services requires insight into the preferences of recipients for service attributes.

OBJECTIVE

The objective of this study was to quantify, using a discrete choice experiment, the preferences of treatment-seeking patients with severe obesity within the Irish population regarding different attributes of various obesity treatments.

METHODS

Within a cohort of patients with severe obesity attending a hospital-based weight management programme, patients' attitudes to and perceptions of three distinct treatment modalities were compared to those regarding not having treatment. The treatments included a structured lifestyle modification programme, lifestyle modification alongside weight loss medication, and bariatric surgery.

RESULTS

On average, patients with severe and complicated obesity who were attending a weight management programme were more enthusiastic about participating in a programme to help improve their diet and physical activity than they were about having surgery if the methods of treatment had equivalent results and costs.

CONCLUSION

The findings provide insights into preferences that might assist the development of more appropriate treatments for severe obesity.

Elicitation of preferences in the second half of the shared decision making process needs attention; a qualitative study

BACKGROUND

It is known that the use of a Patient Decision Aid (PtDA), combined with advice for professionals on how and when to use it, can enhance the involvement of patients in the treatment decision. However, we need more knowledge with respect to the intention-behaviour gap. This study aims to analyse patients' experiences with the Shared Decision Making (SDM) process to find clues to close this gap.

METHODS

This qualitative study was part of a pilot study aiming to implement SDM in early adopter breast cancer teams. Patients were given access to a personalised PtDA. Breast cancer teams were instructed on how and when to deliver the PtDA. We interviewed 20 patients about their experience with the PtDA and SDM in general.

RESULTS

Most patients experienced SDM, though to a certain extent. Choice talk and option talk were commonly experienced, however the elicitation of preferences and decision talk was rare. The PtDA was used by the majority of patients (N = 13), all indicating that it was useful, especially to recall all the information given. Patients appreciated the contribution of breast cancer nurses in the SDM process. They considered them as true case managers, easy to approach and supportive.

CONCLUSION

Although patients felt well-informed and satisfied about risk-communication, the elicitation of preferences appeared very limited to non-existent. We recommend that breast cancer teams divide tasks in the SDM process and reallocate the elicitation of preferences to the nurses in a well-defined clinical pathway.

Patient-Guided Breast Reconstruction Education

Background

Breast reconstructive surgeons must discuss large amounts of information in an expedient manner to a growing group of women. Our aim is to identify the breast reconstruction resources women prefer and how they desire information to be conveyed in order to develop patient-guided reconstruction education.

Methods

A preoperative and postoperative breast reconstruction survey was given to women planning to undergo breast reconstruction or who have already undergone reconstruction. The surveys asked women to rank educational resources utilized. Questions on the timing of information gathering, desired educational content, and wish to speak with other breast reconstruction women were included.

Results

One hundred and fifty consecutive women were enrolled in the study, 50 in the preoperative group and 100 in the postoperative group. Preoperatively, women wish to utilize their surgeon more than any other resource, and the postoperative survey identified that patients utilize their surgeon even more than expected (p < 0.05). Internet and pamphlets were utilized second and third most frequently. Women desired an interactive compact disc significantly more than this resource is currently being utilized (p < 0.05). There was a strong desire to speak to women who had undergone the process. Sixty-six per cent of women indicated they would attend two or more meetings to learn about breast reconstruction.

Conclusion

The reconstructive surgeon remains the most important educational resource for their patients. Providing consultation over more than one meeting, adding uncommonly discussed content (specifics on postoperative care, body image changes and expectations) to the consultation, and connecting reconstruction patients may improve preoperative consultations and satisfaction with the process of breast reconstruction.

Does receipt of preference sensitive care impact patient reported outcomes following breast cancer surgery?

BACKGROUND

Patients with early breast cancer have multiple surgical options, with their choice being based on personal values, and ultimately being preference sensitive. Most patients will choose breast conserving surgery (BCS) as their preferred management, with some ultimately requiring mastectomy. These patients may have lower satisfaction with this approach than others choosing mastectomy as their preferred option.

METHODS

The BREAST-Q patient reported outcomes (PRO) measurement tool was retrospectively administered to patients undergoing mastectomy.

RESULTS

Patients choosing an index mastectomy had higher satisfaction with breasts score than those originally having BCS (58.0 vs 44.0; p = 0.012). Quality of life domains were also higher in those originally choosing a mastectomy, including: psychosocial (72.5 vs 63.0; p = 0.019), sexual (48.0 vs 36.0; p = 0.042), and physical well being of the chest domains (80.0 vs 72.0; p = 0.031).

CONCLUSION

Patients undergoing mastectomy after initial breast conserving surgery report lower PRO's than those initially choosing mastectomy. This suggests that patient preferences need to be considered when interpreting PRO's following breast cancer surgery.

The Impact of Surgeons on the Likelihood of Mastectomy in Breast Cancer

OBJECTIVE

This study evaluates the impact of individual surgeons and institutions on the use of mastectomy or breast conserving surgery (BCS) among elderly women with breast cancer.

SUMMARY OF BACKGROUND DATA

Current literature characterizes patient clinical and demographic factors that increase likelihood of mastectomy use. However, the impact of the individual provider or institution is not well understood, and could provide key insights to biases in the decision-making process.

METHODS

A retrospective cohort study of 29,358 women 65 years or older derived from the SEER-Medicare linked database with localized breast cancer diagnosed from 2000 to 2009. Multilevel, multivariable logistic models were employed, with odds ratios (ORs) used to describe the impact of demographic or clinical covariates, and the median OR (MOR) used to describe the relative impact of the surgeon and institution.

RESULTS

Six thousand five hundred ninety-four women (22.4%) underwent mastectomy. Unadjusted rates of mastectomy ranged from 0% in the bottom quintile of surgeons to 58.0% in the top quintile. On multivariable analysis, the individual surgeon (MOR 1.97) had a greater impact on mastectomy than did the institution (MOR 1.71) or all other clinical and demographic variables except tumor size (OR 3.06) and nodal status (OR 2.95). Surgeons with more years in practice, or those with a lower case volume were more likely to perform mastectomy (P < 0.05).

CONCLUSION

The individual surgeon influences the likelihood of mastectomy for the treatment of localized breast cancer. Further research should focus on physician-related biases that influence this decision to ensure patient autonomy.

Effect of Surgeon Factors on Long-Term Patient-Reported Outcomes After Breast-Conserving Therapy in Older Breast Cancer Survivors

BACKGROUND

The effect of surgeon factors on patient-reported quality-of-life outcomes after breast-conserving therapy (BCT) is unknown and may help patients make informed care decisions.

METHODS

We performed a survey study of women aged ≥ 67 years with non-metastatic breast cancer diagnosed in 2009 and treated with guideline-concordant BCT, to determine the association of surgeon factors with patient-reported outcomes. The treating surgeon was identified using Medicare claims, and surgeon factors were identified via the American Medical Association Physician Masterfile. The primary outcome was patient-reported cosmetic satisfaction measured by the Cancer Surveillance and Outcomes Research Team (CanSORT) Satisfaction with Breast Cosmetic Outcome instrument, while secondary outcomes included BREAST-Q subdomains. All patient, treatment, and surgeon covariables were included in a saturated multivariable linear regression model with backward elimination applied until remaining variables were p < 0.1.

RESULTS

Of 1650 women randomly selected to receive the questionnaire, 489 responded, of whom 289 underwent BCT. Median age at diagnosis was 72 years and the time from diagnosis to survey was 6 years. The mean adjusted CanSORT score was higher for patients treated by surgical oncologists than patients treated by non-surgical oncologists (4.01 [95% confidence interval [CI] 3.65-4.38] vs. 3.53 [95% CI 3.28-3.77], p = 0.006). Similarly, mean adjusted BREAST-Q Physical Well-Being (91.97 [95% CI 86.13-97.80] vs. 83.04 [95% CI 80.85-85.22], p = 0.006) and Adverse Radiation Effects (95.28 [95% CI 91.25-99.31] vs. 88.90 [95% CI 86.23-91.57], p = 0.004) scores were better among patients treated by surgical oncologists.

CONCLUSIONS

Specialized surgical oncology training is associated with improved long-term patient-reported outcomes. These findings underscore the value of specialized training and may be useful to patients choosing their care team.

Assessing the quality and communicative aspects of patient decision aids for early-stage breast cancer treatment: a systematic review

PURPOSE

Decision aids (DAs) support patients in shared decision-making by providing balanced evidence-based treatment information and eliciting patients' preferences. The purpose of this systematic review was to assess the quality and communicative aspects of DAs for women diagnosed with early-stage breast cancer.

METHODS

Twenty-one currently available patient DAs were identified through both published literature (MEDLINE, Embase, CINAHL, CENTRAL, and PsycINFO) and online sources. The DAs were reviewed for their quality by using the International Patient Decision Aid Standards (IPDAS) checklist, and subsequently assessed to what extent they paid attention to various communicative aspects, including (i) information presentation, (ii) personalization, (iii) interaction, (iv) information control, (v) accessibility, (vi) suitability, and (vii) source of information.

RESULTS

The quality of the DAs varied substantially, with many failing to comply with all components of the IPDAS criteria (mean IPDAS score = 64%, range 31-92%). Five aids (24%) did not include any probability information, 10 (48%) presented multimodal descriptions of outcome probabilities (combining words, numbers, and visual aids), and only 2 (10%) provided personalized treatment outcomes based on patients and tumor characteristics. About half (12; 57%) used interaction methods for eliciting patients' preferences, 16 (76%) were too lengthy, and 5 (24%) were not fully accessible.

CONCLUSIONS

In addition to the limited adherence to the IPDAS checklist, our findings suggest that communicative aspects receive even less attention. Future patient DA developments for breast cancer treatment should include communicative aspects that could influence the uptake of DAs in daily clinical practice.

Tools to facilitate communication during physician-patient consultations in cancer care: An overview of systematic reviews

Tools have been developed to facilitate communication and support information exchange between people diagnosed with cancer and their physicians. Patient-reported outcome measures, question prompt lists, patient-held records, tape recordings of consultations, decision aids, and survivorship care plans have all been promoted as potential tools, and there is extensive literature exploring their impact on patient outcomes. Eleven systematic reviews of studies evaluating tools to facilitate patient-physician communication were reviewed and summarized in this overview of systematic reviews. Across the systematic reviews, 87 publications reported on 84 primary studies involving 15,381 participants. Routine use of patient-reported outcome measures and feedback of results to clinicians can improve pain management, physician-patient communication, and symptom detection and control; increase utilization of supportive care; and increase patient involvement in care. Question prompt lists can increase the number of questions asked by patients without increasing consultation length and may encourage them to reflect and plan questions before the consultation. There is limited benefit in audio recording consultations or using patient-held records during consultations. Physicians should be supported by adequately resourced health services to respond effectively to the range of clinical and broader patient needs identified through the routine use of tools to facilitate communication.

The impact of decision aids in patients with colorectal cancer: a systematic review

OBJECTIVES

Our aim was to conduct a systematic review of the literature to determine the impact of patient decision aids (PDA) on patients facing treatment decisions for colorectal cancer.

DESIGN

Systematic review.

DATA SOURCES

Sources included Embase, Medline, Web of Science, CINAHL and the Cochrane Library from inception to June, 20, 2019.

ELIGIBILITY CRITERIA

We included randomised controlled trials (RCTs), cohort studies, mixed methods and case series in which a PDA for colorectal cancer treatment was used. Qualitative studies were excluded from our review.

DATA EXTRACTION AND SYNTHESIS

Following execution of the search strategy by a medical librarian, two blinded independent reviewers identified articles for inclusion. Two blinded reviewers were also responsible for data extraction, risk of bias and study quality assessments. Any conflict in article inclusion or extraction was resolved by discussion.

RESULTS

Out of 3773 articles identified, three met our inclusion criteria: one RCT, one before-and-after study and one mixed-method study. In these studies, the use of a PDA for colorectal cancer treatment was associated with increased patient knowledge, satisfaction and preparation for making a decision. On quality assessment, two of three studies were judged to be of low quality.

CONCLUSION

A paucity of evidence exists on the effect of PDA for colorectal cancer treatment with existing evidence being largely of low quality. Further investigation is required to determine the effect of decision aids for colorectal cancer treatment as well as reasons for the lack of PDA development and implementation in this area.

PROSPERO REGISTRATION NUMBER

CRD42018095153.

Barriers to eliciting patient goals and values in shared decision-making breast cancer surgery consultations: An ethnographic and interview study

OBJECTIVE

Previous research has demonstrated the importance of eliciting patients' goals and values during shared decision-making (SDM), but this does not occur in most SDM conversations. Understanding challenges to eliciting patients' goals and values is crucial. This study assessed how clinicians balanced sharing medical information and considering patients' goals and values during breast cancer surgery consultation in an integrated health care system.

METHODS

We conducted interviews with clinicians (n = 6) and patients (n = 11) and conducted naturalistic, ethnographic observations of eight surgical consultations in a multidisciplinary breast cancer clinic. We analyzed the data following the template method using the qualitative software NVivo 10.

RESULTS

Clinicians prioritized sharing medical information. We identified four patient factors necessary to integrate patients' values and goals into the conversation in addition to sharing medical information: ability to process large quantities of information quickly, willingness to embrace swift decision-making, ability to quickly formulate one's values, and prioritization of surgical choice as the goal of the conversation.

CONCLUSIONS

We found that SDM implementation results in practices that emphasize information and choice, with less focus on patient goals and values. More research is needed to explore factors that may encourage the elicitation of patients' goals and values.

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.

Heading in a new direction? Recommendations for future research on patient decision aids

Decision aids can improve a number of patient outcomes, but they are not commonly used in clinical practice. This commentary paper provides suggestions for potential next steps of decision aid research, with the aim to facilitate their implementation. We suggest to further standardise clinically meaningful outcomes and outcome measures that should be used to examine the impact of decision aids. Second, using mediation analysis and active control groups could help tease out and explore variables that influence decision aids' effectiveness to help healthcare providers decide when and how to use them in clinical practice. Third, effectiveness trials should be clearly reported and replicated to investigate under what circumstances decision aids work best. Specific checklists for decision aid trials should be used to ensure that all relevant factors are reported in detail. Addressing the above issues will help identify what specific components of decision aids are effective and should be implemented. We can then move towards conducting implementation trials which help increase the use of decision aids in "real-world" healthcare.

Factors Affecting Surgical Decisions in Newly Diagnosed Young Women with Early-Stage Breast Cancer

Given that young women with breast cancer often have concerns and priorities attributable to their life stage, we conducted a series of interviews to better understanding the surgical decision-making experience among women diagnosed at age ≤40. Women spoke of how the potential effect of an extended recovery was affecting their decision and, in some cases, contributing to decisional conflict. Several women described their worry of leaving cancer cells behind; others cited the need for continued surveillance as a consideration. Attention to situational anxiety and concerns about recurrence are warranted to ensure that decisions are made in a supportive and patient-centered setting.

Patient decision aid for contralateral prophylactic mastectomy for use in the consultation: a feasibility study

Background

Rates of contralateral prophylactic mastectomy (cpm) continue to rise internationally despite evidence-based guidance strongly discouraging its use in most women with unilateral breast cancer. The purpose of the present study was to develop and assess the feasibility of a knowledge translation tool [a patient decision aid (da)] designed to enhance evidence-informed shared decision-making about cpm.

Methods

A consultation da was developed using the Ottawa Patient Decision Aid Development eTraining in consultation with clinicians and knowledge translation experts. The final da was then assessed for feasibility with health care professionals and patients across Canada. The assessment involved a survey completed online (health care professionals) or by telephone (patients). Survey data were analyzed using descriptive statistics for closed-ended questions and qualitative content analysis for open-ended questions.

Results

The 51 participants who completed the survey included 39 health care professionals and 12 patients. The da was acceptable; 88% of participants viewed it as having the right amount of information or slightly more or less information than they would like. Almost all participants (98%) felt that the da would prepare patients to make better decisions. The aid was perceived to be usable, with 73% of participants stating that they would be willing to use or share the da.

Conclusions

The cpm patient da developed for the present study was viewed by health care professionals and patients across Canada to be acceptable and usable during the clinical consultation. It holds promise as a knowledge translation tool to be used by clinicians in consultation with women who have unilateral breast cancer to enhance evidence-informed and shared decision-making with respect to undergoing cpm.

Feasibility and Efficacy of Decision Aids to Improve Decision Making for Postmastectomy Breast Reconstruction: A Systematic Review and Meta-analysis

Background. The decision-making process for women considering breast reconstruction following mastectomy is complex. Research suggests that fewer than half of women undergoing mastectomy have adequate knowledge and make treatment decisions that are concordant with their underlying values. This systematic review assesses the feasibility and efficacy of preoperative decision aids (DAs) to improve the patient decision-making process for breast reconstruction. Methods. A systematic review was performed using PubMed, Ovid MEDLINE, EMBASE, CINAHL, and Cochrane Databases published prior to January 4, 2018. Studies that assessed the impact of a DA on patient decision making for breast reconstruction were identified. The effect of preoperative DAs on decisional conflict in randomized controlled trials (RCTs) was measured with inverse variance-weighted mean differences (mean difference [MD] ± 95% confidence interval [CI]). Results. Among 1299 unique articles identified, 1197 were excluded after reviewing titles and abstracts against selection criteria. Among the 17 studies included in this review, 11 assessed the efficacy of DAs for breast reconstruction and 6 additional studies described the development and usability of these DAs. Studies suggest that DAs reduce patient-reported decisional conflict (MD, –4.55 [95% CI, –8.65 to –0.45], P = 0.03 in the fixed-effects model and MD, –4.70 [95% CI, –10.75 to 1.34], P = 0.13 in the random-effects model). Preoperative DAs also improved patient satisfaction with information and perceived involvement in the decision-making process. Conclusions. The existing literature suggests that DAs reduce decisional conflict, improve self-reported satisfaction with information, and improve perceived involvement in the decision-making process for women considering breast reconstruction.

Impact of pre-diagnosis depressive symptoms and health-related quality of life on treatment choice for ductal carcinoma in situ and stage I breast cancer in older women

PURPOSE

To examine whether pre-diagnosis patient-reported health-related quality of life (HRQOL) and depressive symptoms are associated with local treatment for older women with ductal carcinoma in situ (DCIS) and stage I breast cancer (BC).

METHODS

Using the SEER-MHOS dataset, we identified women ≥ 65 years old with DCIS or stage I BC diagnosed 1998-2011 who completed surveys ≤ 24 months before diagnosis. Depressive symptoms were measured by major depressive disorder (MDD) risk and HRQOL was measured by Physical and Mental Component Summary scores (PCS and MCS, respectively) of the SF-36/VR-12. Associations with treatment choice (breast-conserving surgery [BCS] and radiation therapy [RT], BCS alone, mastectomy) were assessed with multivariable multinomial logistic regression, controlling for patient characteristics.

RESULTS

We identified 425 women with DCIS and 982 with stage I BC. Overall, 20.4% endorsed depressive symptoms placing them at risk for MDD pre-diagnosis; mean MCS and PCS scores were 52.3 (SD = 10.1) and 40.5 (SD = 11.5), respectively. Among women with DCIS, those at risk for MDD were more likely to receive BCS (adjusted odds ratio [AOR] 2.04, 95% CI 1.04-4.00, p = 0.04) or mastectomy (AOR 1.88, 95% CI 0.91-3.86, p = 0.09) compared to BCS + RT. For DCIS, MCS score was not associated with treatment; higher PCS score was associated with decreased likelihood of receiving mastectomy versus BCS + RT (AOR 0.71 per 10-point increase, 95% CI 0.54-0.95, p = 0.02). For BC, none of the measures were significantly associated with treatment.

CONCLUSION

Older women at risk for MDD before DCIS diagnosis were less likely to receive RT after BCS, compared to BCS alone or mastectomy.