Chemotherapy: The patient's choice

Abstract

In Australia 1 in 13 women who live to be 74 yearsold will be diagnosed with breast cancer (Coates et al 1991). With the increase in participation in mammographic screening programmes we are seeing more women with 'early' breast cancer. Of those diagnosed, many will require adjuvant chemotherapy. A randomised trial comparing doxorubicin and cyclophosphamide (A/C) to cyclophosphamide/methotrexate/flurouracil (CMF) reported that there was no significant difference in disease-free survival, distant disease-free survival or survival (Fisher et al 1990). If either treatment regime could be considered the optimum adjuvant therapy for early breast cancer, who should be involved in making a choice? What in the past would have been a decision made by the oncologist may now become a decision for the patient and their family. When looking at the literature on decision making in breast cancer, most studies focused on decisions relating to surgery (Leinster et al 1989, Morris & Ingham 1988, Ward et al 1989). In these studies there were similarities in the influences affecting the client's decision making. One study found there were 11 categories of influence which included age, opinion of significant other, physician's preference and other people's positive and negative experiences (Ward et al 1989). Valanis and Rumpler (1985) also found a physician's preference and the experience of others to be significant influencing factors in decision making. A study by Hilton (1994) looking at the family decision-making processes in early breast cancer found that there were four main processes that families fell into. These included 'deference to physician', 'minimal exploration', 'joint engagement' and 'extensive examination'. Hilton found that though a substantial number of families defer to the doctor's authority, s~me do this because they feel they have no choice. It is therefore important for doctors and nurses to explain the choices clearly so that they are easily understood. A study by Beaver et al (1996) in the UK looked at the degree of control that women with newly diagnosed breast cancer have over their treatment decision making. They found that the majority of women preferred to leave treatment decision making to the doctor. This may be due to the fact that they are still in the 'shock' phase of being newly diagnosed. A number of studies have shown that in this state a person may not be able to recall or retain the information required to make an informed decision (Hughes 1993). They did, however, state that although the majority wished to take a passive role, there were still some women who wished to be involved in decision making. They also hypothesized that more women would want to take a more active role once they were over the 'shock' phase. The Breast Consensus Development Conference in Australia in June 1994 assisted in the development of both 'Clinical Practice Guidelines for the Management of Early Breast Cancer' and 'A Consumers Guide to Early Breast Cancer' . In these guidelines A/C or CMF are the recommended adjuvant chemotherapy for early breast cancer. Following this conference, the oncology team (consisting of an oncologist, oncology nurses and the oncology pharmacist) of the Illawarra Cancer Care Centre, Australia, decided to offer those women requiring adjuvant chemotherapy a choice of the two treatment regimes. All women were educated by the team as to the difference in treatments, which included side-effects, duration of administration and number of needles involved. The women were also given written information which they could take home to discuss with their family before making a choice.