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Navigating Through The Complex Decisions of Breast Cancer Surgery

In this blog, I reference three medical articles that provide important information about how breast cancer patients can navigate through a very complex decision-making process and arrive at a treatment plan that is right for them—both to treat their cancer optimally, and also to maximize their quality of life.

The first is a very informative article published in the Journal of Clinical Oncology (JCO) entitled, “Can Women with Early Stage Breast Cancer Make an Informed Decision for Mastectomy?” (Collins ED et al; JCO 27:519-525, 2009). The second is another JCO article titled, “Decision Aids in Breast Cancer: Do They Influence Choice for Surgery and Knowledge of Treatment Options?” ( Waljee JF et al; JCO 25:1067-1073, 2007). Both the 2009 and 2007 articles demonstrate that decision aids for breast cancer patients significantly increase knowledge about breast cancer and treatment options, decrease decision conflict, and increase satisfaction with the decision-making process. Finally, I will quote from a very elegant and thoughtful editorial by Doctors Throckmorton and Esserman ( University of California at San Francisco) titled “When informed, all women do not prefer breast conservation” (JCO 27:484-486, 2009).

In one of the JCO articles, the authors stated: “In general, health literacy is correlated with improved patient outcomes, and patients with inadequate knowledge of their disease states are more likely to be hospitalized and have poorer decision management capabilities. The authors concluded that: “Decision aids have an important role in the treatment process for women with early stage breast cancer… The decision aids increased patient knowledge of treatment options and provided patients with more realistic expectations of outcomes”.

In the other JCO article, the authors assessed the value of a video decision aid and a patient assessment aid. And found that “a notable proportion (35%) of well informed women choose mastectomy. Whereas prior studies have linked objective factors to treatment choice, this study reveals subjective preferences that underlie decision making”.

The authors concluded: “Both researchers and clinicians often view higher rates of breast-conserving treatment as indicative of better care. (Others) caution researchers to ‘move away from a primary focus on rates of mastectomy versus breast–conserving surgery (lumpectomy),and widening the research lens to view the degree to which women are being fully informed.’ This study goes even further to highlight the importance not only of informing patients, but also of eliciting and tailoring care to individual patients’ values and treatment preferences. When women fully comprehend the key facts, many will find that mastectomy, the more invasive procedure, is their preferred choice.”

I will quote from the 2009 JCO editorial that accompanied this article because it beautifully states the approach that all physicians and medical staff should take from the outset of their encounters with a breast cancer patient.

“There are genuine differences between treatment choices among women with similar presentation. It is because the (treatment) options are associated with equivalent survival that it is so critical to make sure that women are full participants in the decision-making process….When informed patients meet with surgeons who are aware of patient values and preferences, the uncertainty resolved for almost all patients…This suggests that if we provide women with the salient facts (in an understandable language), elicit their preferences, and discuss the options in that context, they come to a consultation better informed and more involved in the process.”

‘What the clinician should take away from these studies is that there is great benefit to providing educational materials before consultation; that measuring patient knowledge can help expose gaps in patient understanding of the options; and that there are key questions that the physician can ask to help ensure that the patient is making a decision concordant with her values.”

“The key to offering a choice is respecting the choices patients make. Some people will choose one path, others a different one, we need to accept that women will have different values and will make different choices. Our job is to make sure patients have the choices, the information, the time, and the environment to make an informed, value-driven decision.”

I sure agree with these approaches and their use of educational decision aids! This is an underpinning philosophy on why we spend the time to write blogs and search the internet for informative and trustworthy videos. I repeatedly stated in our Patient Resource Cancer Guides that: “an informed educated patients will almost always get better care” (see our companion website to get a free copy at patientresource.net.

See some of my previous blogs on breast cancer: “Choosing Between a Mastectomy and Lumpectomy” and “Surgical Treatment Options for Breast Cancer”. For those who want a thorough review, see my blog on a 52 minute lecture by Dr Laura Esserman titled “A Detailed Review of Breast Cancer”.

For more written information about breast cancer treatment options, including various types of breast surgery, see our companion website at www.patientresource.net

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