Decision Making about Surgery for Early-Stage Breast Cancer - 21/12/11

Doi : 10.1016/j.jamcollsurg.2011.09.017

Clara N. Lee, MD, MPP ^a,^⁎ , Yuchiao Chang, PhD ^d, Nesochi Adimorah, BA ^b, Jeff K. Belkora, PhD ^c, Beverly Moy, MD, MPH ^e, Ann H. Partridge, MD, MPH ^f, David W. Ollila, MD ^b, Karen R. Sepucha, PhD ^g
^a Division of Plastic and Reconstructive Surgery at the University of North Carolina, Lineberger Comprehensive Cancer Center, Sheps Center for Health Services Research, Chapel Hill, NC
^b Department of Surgery, University of North Carolina, Chapel Hill, NC
^c Institute for Health Policy Studies, University of California, San Francisco, CA
^d Department of General Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
^e Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
^f Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
^g Health Decision Sciences Center, Harvard Medical School, Boston, MA

Correspondence address: Clara N Lee, MD, MPP, Division of Plastic and Reconstructive Surgery, University of North Carolina CB 7195, Chapel Hill, NC 27599-7195

Résumé

Background

Practice variation in breast cancer surgery has raised concerns about the quality of treatment decisions. We sought to evaluate the quality of decisions about surgery for early-stage breast cancer by measuring patient knowledge, concordance between goals and treatments, and involvement in decisions.

Study Design

A mailed survey of stage I/II breast cancer survivors was conducted at 4 sites. The Decision Quality Instrument measured knowledge, goals, and involvement in decisions. A multivariable logistic regression model of treatment was developed. The model-predicted probability of mastectomy was compared with treatment received for each patient. Concordance was defined as having mastectomy and predicted probability >0.5 or partial mastectomy and predicted probability <0.5. Frequency of discussion about partial mastectomy was compared with discussion about mastectomy using chi-square tests.

Results

Four hundred and forty patients participated (59% response rate). Mean overall knowledge was 52.7%; 45.9% knew that local recurrence risk is higher after breast conservation and 55.7% knew that survival is equivalent for the 2 options. Most participants (89.0%) had treatment concordant with their goals. Participants preferring mastectomy had lower concordance (80.5%) than those preferring partial mastectomy (92.6%; p = 0.001). Participants reported more frequent discussion of partial mastectomy and its advantages than of mastectomy, and 48.6% reported being asked their preference.

Conclusions

Breast cancer survivors had major knowledge deficits, and those preferring mastectomy were less likely to have treatment concordant with goals. Patients perceived that discussions focused on partial mastectomy, and many were not asked their preference. Improvements in the quality of decisions about breast cancer surgery are needed.

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Plan

Methods

Study design

Patient population

Study design and procedures

Measures

Statistical analysis

Results

Patient characteristics

Knowledge

Concordance between goals and treatment

Involvement in decision making

Discussion

Conclusions

Author Contributions

	Disclosure Information: Authors have nothing to disclose. Timothy J Eberlein, Editor-in-Chief, has nothing to disclose.
	Drs Belkora, Lee, and Sepucha were supported by a grant from the not-for-profit Foundation for Informed Medical Decision Making. Dr Lee was supported by NIH/National Center for Resesarch Resources 1KL2RR025746.