Breast Cancer Treatment Decisions Research Articles

Using Molecular Profiling to Help with Treatment Decisions for Low-Risk Primary Breast Cancer

Using Molecular Profiling to Help with Treatment Decisions for Low-Risk Primary Breast Cancer

Patient-physician concordance: preferences, perceptions, and factors influencing the breast cancer surgical decision.

This study explored patient preferences for involvement in the breast cancer treatment decision and concordance between patients' and physicians' views on decisional role. The impact of demographic and psychosocial characteristics on patients' decisional role was also examined. Women with stage I or II breast cancer who were candidates for either mastectomy or lumpectomy were recruited from a university breast cancer treatment center. Patient interviews were obtained before meeting the surgical oncologist and again after the treatment decision was made but before surgical intervention. Clinician responses were obtained after the consultation. The 101 participants were generally white (97%), married (80%), and well-educated. They reported moderate levels of depression and anxiety but good social support and self-efficacy in communicating with their physician. Before the consultation, 47% of women reported a preference for shared decision making; afterwards, 61% felt they had primary responsibility for the decision. Only 38% of patients agreed with the physician's assessment of how the treatment decision was made. In regression analyses, higher education was significantly associated with patients' preferred level of control (P = .01). There was a trend toward women with greater self-efficacy desiring more active decisional roles (P = .08). Patient preference for decision making did not impact time in the patient-physician encounter, but more influence did increase satisfaction. Limited concordance between patient preference and patient perception and between patient and physician perception in how the treatment decision was made suggests the need for better communication between patient and clinician during a critical treatment encounter for breast cancer patients.

Using a phenomenological perspective in radiation therapy research

Research in radiation therapy is developing as radiation therapists recognise the need for improved evidence-based practice and patient care. However, many radiation therapists have a limited background in the area of research practices and the methodology that may be utilised to answer specific research questions. The purpose of this paper is to describe the development of a research question and the steps involved in determining an appropriate methodology that can be used to answer that research question. To demonstrate application of the approaches and methodologies that are described, an example research question that focuses on the experience of treatment decision-making for early stage breast cancer is considered and referred to throughout the paper. Initially, quantitative and qualitative research paradigms are considered and described to demonstrate the approaches that can be used, the type of data that can be collected and the results that can be analysed and utilised to answer the research question. As a phenomenological approach was found to be appropriate to investigate the question, this approach is explored in greater detail.

Gambling with your life: the process of breast cancer treatment decision making in Chinese women.

Treatment decision making (TDM) studies have primarily focused on assessing TDM quality and predominantly presume rational analytic processes as the gold standard. In a grounded theory study of 22 Hong Kong Chinese women following breast surgery who completed an in-depth interview exploring the process of TDM in breast cancer (BC), narrative data showed that discovery of a breast abnormality and emotional responses to BC diagnosis influence the TDM process. Lack of guidance from surgeons impaired TDM. Decisions were, for the most part, made using intuitive, pragmatic and emotionally driven criteria in the absence of complete information. The experience of TDM, which was likened to gambling, did not end once the decision was made but unfolded while waiting for surgery and the post-operative report. In this waiting period, women were emotionally overwhelmed by fear of death and the uncertainty of the surgical outcome, and equivocated over whether they had made the 'right' choice. This suggests that Chinese women feel they are gambling with their lives during TDM. These women are particularly emotionally vulnerable whilst waiting for their surgery and the post-surgical clinical pathology results. Providing emotional support is particularly important at this time when these women are overwhelmed by uncertainty.

Role of molecular and genetic markers in breast cancer treatment decisions.

Role of molecular and genetic markers in breast cancer treatment decisions.

Participation and Satisfaction with Surgical Treatment Decision-Making in Breast Cancer Among Chinese Women

To report Chinese women's preferred and perceived participation in breast cancer treatment decision making (TDM), describe influences on women's participation preference and participation congruence (PC) (correspondence between preferred and actual amount of participation in TDM), and explore subsequent satisfaction with TDM. Of 172/211 eligible and available Chinese women recently undergoing breast cancer surgery at one of six Hong Kong government hospitals 154 (89.5%) were recruited. Within 12 days after surgery, women provided interview information on preferred and perceived TDM participation, satisfaction with TDM consultation, difficulties in TDM, and medical and demographic information. Half (55%) reported a treatment choice: 33% wanted the choice to be their own, 59% wanted to share and 8% wanted to delegate the decision. Only age predicted participation preference with older women preferring a more passive role. Eighty percent of women participated as much as, 13% more than and 6% less than desired. Adjusted for age, women reporting PC had fewer difficulties in TDM (beta = 0.21, p = 0.009) than women not reporting PC, while over-involved women had more doubts about their choice (beta = -0.23, p = 0.005). PC was associated with being offered a treatment option (chi2 = 15.59, p < 0.001) and surgeons expressing a surgical preference (chi2 = 6.63, p = 0.036). Satisfaction was unrelated to PC. Most Chinese women want shared TDM and to know their surgeon's treatment preference. Over-involved women are at greater risk of difficulties and doubts in TDM and under-involved women perceive a lack of time and information to make their decision.

Collaborative Initiatives in the Care of Early Stage Breast Cancer: Reduction in Variation of Breast-Conserving Therapy.

Breast-conserving therapy (BCT) has survival results comparable to those obtained with modified radical mastectomy (MST). However, studies suggest variations in the rates of breast-conserving therapy that are not explained by comorbidities or age. The Virginia Health Quality Center collaborated with 40 Virginia hospitals to address patterns of breast cancer treatment. Medicare Peer Review Organization data files were used to identify all Medicare beneficiaries with a primary diagnosis of breast cancer from January 1, 1992, through June 30, 1993. Explicit chart review was performed on a random sample of patients with early stage disease receiving either BCT or MST. At baseline, the BCT rate was 21.1% after controlling for access to radiation facilities, medical conditions, and demographic variables. Hospitals with the highest rates of appropriate BCT served as resources for the project. We provided data on BCT rates to 40 participating hospitals. Hospitals then submitted comprehensive plans to address the performance of BCT. A four-step cooperative improvement intervention was employed to initiate and sustain changes at the hospital level. Interventions included individual hospital feedback, dissemination of model cancer care processes at high-performing institutions, and integration of oncology services for breast cancer treatment decisions. One year after implementation, the overall BCT rate in Virginia increased to 25.5%. Hospitals with the lowest BCT rates increased their average rate from 6.6% to 21.2%. Middle tercile hospitals increased BCT rates by 10%. Variation between the lowest and highest terciles was reduced to 9%. Variation in BCT rates can be reduced by a collaborative program centered on addressing processes of care for breast cancer treatment for Medicare patients with early stage disease.

An embedded decisional model of stress and coping: implications for exploring treatment decision making by women with breast cancer.

Treatment decision making by women with breast cancer has been recognized to be an inherently stressful process. However, past decisional theory and research has failed to fully elucidate the personal, transactional, and relational nature of choice behaviour. The purpose of this paper is to explore an embedded decisional model of stress and coping that locates key assumptions of Janis & Mann's (1977) conflict-theory model of decision making within Lazarus & Folkman's (1984) transactional framework. Through combining decisional and stress and coping theories, a model is developed that addresses the theoretical limitations of the conflict-theory model and provides greater specificity within decision-making research. The paper examines the complexity of treatment decision making within the context of the constructs of causal antecedents, primary appraisal, secondary appraisal, coping, and adaptational outcomes. Examples specific to women with breast cancer are provided to illustrate the potential application of the embedded model. The implications of this inclusive and comprehensive decisional theory for future knowledge development and research in the area of treatment decision making are also discussed.

How breast cancer treatment decisions are made by women in North Dakota

Background: Although equally effective, women in rural midwestern states choose modified radical mastectomy (MRM) over breast conservation surgery for early stage breast cancer. This study assessed treatment decisions by the women of North Dakota. Methods: Surveys were sent to women treated for early stage breast cancer from 1990 through 1992. Separate surveys were sent out to surgeons in the state. The questions assessed physician and patient perceptions of treatment and the decision making process. Results: A majority of surgeons believed that the long-term and disease-free survival was equal and that the preference for choosing MRM was due mostly to inconvenience of radiotherapy. The women reported that the surgeon was the most influential in the treatment decision and that concerns over radiation, duration of treatment, and travel restrictions all were factors in the decision. Conclusions: Education of surgeons and patients plus the early involvement of the radiation oncologist in discussing options is essential in the treatment of early stage breast cancer.

Involve patients in breast cancer treatment decisions

Involve patients in breast cancer treatment decisions

Breast cancer patients' personality style, age, and treatment decision making

Breast cancer patients' personality style, age, and treatment decision making

Breast cancer patients' personality style, age, and treatment decision making.

Previous studies have shown that whereas nearly all cancer patients want information, far fewer wish to make treatment decisions. Although breast cancer patients who were given a choice of lumpectomy versus mastectomy and were encouraged to make the decision were believed to do better psychologically, a 1994 study refuted this. Some authors suggest that patient personality style is an important consideration in decisional preference. Newly diagnosed breast cancer patients (n = 76) were surveyed within 6 months of surgery. They answered seven questions about patient and physician roles in the decision-making process. Additionally, they completed the Miller Behavioral Style Scale (MBSS), which categorizes "monitors," or information seekers, and "blunters," or information avoiders. Chi-square analyses were used to explore the relationship of personality style and age to treatment decision-making preferences. Although 80% of women wanted a role in decision making, 74% wanted their surgeons to make a recommendation and when given, 94% followed the recommended treatment plan. Monitors and blunters were equally likely to want physician recommendations. Younger women, particularly those under age 40, were more likely to want a physician's recommendation. Of those women who had specific fears about their cancer (76%), only half of them revealed such fears to their doctors. The notion that health care consumers, particularly younger ones, desire an independent choice of treatment was contradicted in this study. Physicians are encouraged to provide information and to probe regarding the fears of breast cancer patients in order to reduce anxiety while recognizing that treatment recommendations are desired by most women.

The influence of older age on breast cancer treatment decisions and outcome

Purpose : Information concerning the differences between older and younger women with breast cancer, treated with standard therapy, is lacking from many prospective series. The purpose of this study is to identify factors that influence treatment decisions and determine of women age 65 and older are treated differently than younger women. The outcomes of older women would then be compared to younger women to determine if treatement differences influence of women. Methods and Materials : The records of 558 women with early invasive breast cancer who were treated with breast conserving surgery and radiation therapy were retrospectively reviewed. Four hundred thirty-two women under the age of 65 (range: 24–64) and 126 women age 65 and older (range: 65–85) were assessed for treatment differences including breast reexcision, extent of axillary dissection, extent of breast and nodal irradiation, and the use of chemotherapy or hormonal therapy. Differences in the treatment of the two groups were determined and the end points of local control, disease-free survival, and overall survival were compared. Median follow-up was 5.5 years. Results : The two treatment groups had identical pathologic TNM staging with the exception that 21% of the older age group and 5% of the younger age group did not undergo axillary dissection. Women age 65 and older were less likely to have a reexcision, extensive axillary dissection, chemotherapy, or nodal irradiation. They were more likely to receive hormonal therapy. Reexcision in older women was positively influenced by a family history of breast cancer and negatively influence by a history of previous malignancy. None of the patients who were treated without an axillary dissection suffered a regional recurrence. Although local control was better in older patients, there were no differences in disease-free or overall survival for the two groups. Discussion : The findings of this study reveal that older patients have significant treatment differences as compared to younger patients; however, despite these differences, similar local control and survival were achieved at 5 and 10 years. With the expected survival of older women increasing, the prospective evaluation of treatment options for older women should be considered.

Review of known prognostic variables.

The prognosis of patients with primary breast cancer depends on prognostic factors per se and on treatment. In certain subgroups of patients, the overall treatment benefits of systemic adjuvant therapy are modest. Therefore, proper selection of patients and treatment modalities is absolutely necessary. Patients with primary breast cancer and a very good prognosis can be classified by known prognostic factors such as tumor size T < or = 1 cm, grade 1, hormone receptor positive tumors, and no other factors indicating poor prognosis. [table: see text] Patients with very poor prognosis are characterized by young age (< 35 years), large tumor size (T > 3 cm), grade 3, hormone receptor-negative tumors, and high S-phase fractions. Tumor size is the best prognostic factor for the decision to treat (breast conservation surgery, primary preoperative or adjuvant systemic therapy) or not to treat. Table 4 shows possible treatment decisions (type and timing of therapy) in primary breast cancer based on known prognostic and predictive variables. The decision to treat or not to treat outside clinical trials should be based on this kind of information. The type and aggressiveness of adjuvant systemic treatment should depend on the receptor status of the tumor and on the age and menopausal status of the patient, as classical predictive factors; however, prognosticators which can describe the metastatic potential of breast cancer cells have yet to be defined.

The influence of age on breast cancer treatment decisions and outcome

The influence of age on breast cancer treatment decisions and outcome

Variations in breast cancer treatment decisions and their impact in mounting trials

Clinical trials are often hindered by insufficient participation. Difficulties may arise if a clinician is generally reluctant to enroll patients in clinical trials, if the clinician is unwilling to enroll a patient in a particular trial, or if the patient refuses to participate. In our three-stage survey of clinicians treating breast cancer, we found that a favorable orientation to trials in principle can be attenuated when clinicians do not like the treatment regimens in a particular trial. We also found a lack of consensus as to appropriate treatment for breast cancer coupled with a high confidence by individual clinicians in their own treatment decisions (a phenomenon we term “micro-certainty/macro-uncertainty”). Accordingly, in the most controversial situations, it may be hardest to mount trials. Trial design is also complicated by the variation among clinicians in the importance they assign to various patient characteristics in making their treatment decisions. This variation can lead to difficulties in establishing patient subgroups that will be accepted by the clinical community. The trial designer will need to be alert to these considerations; efforts to build consensus on which data are necessary and which therapies are acceptable should improve the design and application of clinical trials.