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The Quality of Patient Decisions about Mastectomy
Clara N. Lee, MD, MPP1, Yuchiao Chang, PhD2, Jeff Belkora, PhD3, Beverly Moy, MD, MPH2, Ann Partridge, MD, MPH4, Karen R. Sepucha, PhD2.
1University of North Carolina Chapel Hill, Chapel Hill, NC, USA, 2Massachusetts General Hospital, Boston, MA, USA, 3University of California San Francisco, San Francisco, CA, USA, 4Dana Farber Cancer Institute, Boston, MA, USA.
Purpose: Early stage breast cancer patients have a choice between mastectomy and breast conservation therapy (BCT). Studies have shown that many informed patients prefer mastectomy; however, clinical guidelines and breast cancer providers tend to favour BCT. This study sought to evaluate decisions about breast cancer surgery, specifically examining patients’ discussions with providers, knowledge about mastectomy and BCT, and the degree of concordance between patient preferences and treatment.
Methods: A cross-sectional survey was conducted in early stage (I-IIIa) breast cancer patients who were clinically eligible for mastectomy or BCT, one to three months after surgery at four sites. The survey included the Decision Quality Instrument, which asks questions about communication with providers, key facts about surgical options, and preferences about surgery. Descriptive statistics were calculated. A multivariate logistic regression model of treatment was developed, which included clinical characteristics and patients’ preferences. To evaluate concordance, the model-predicted probability of mastectomy for each patient was compared to the actual treatment received. Concordance was defined as having a model-predicted probability of mastectomy >=0.5 and undergoing mastectomy, or having a model-predicted probability of mastectomy <0.5 and undergoing BCT.
Results: 266 patients completed surveys (response rate 60%). The mean age was 56.6 years. 10% of patients were non-white, and 41% had less than a college education. Most patients (71.4%) had lumpectomy.
Patient-provider communication: According to patient report, providers discussed the option of lumpectomy more often than they discussed mastectomy (91.4% of patients vs 74.8%, p< 0.001). Providers discussed the advantages of lumpectomy more often than its disadvantages (86.1% vs 39.5%, p<0.001). They discussed the advantages of mastectomy less often than its disadvantages (50.4% vs 57.5% p=0.27). Providers recommended a specific surgery 80.8% of the time but asked for the patient’s preference 66.9% of the time.
Knowledge: Most patients (78.6%) knew that BCT and mastectomy have equivalent survival, but a minority (37.6%) knew that BCT has a higher risk of local recurrence. 64.7% knew that BCT is more likely to require another operation.
Concordance: In the model of treatment, the preferences “remove your breast for peace of mind” (OR 2.08, 95% CI 1.66, 2.59) and “avoid radiation” (OR 1.22, 95% CI 1.03, 1.43) were associated with having mastectomy. The preference “keep your breast” (OR 0.80 95% CI 0.68, 0.94) was associated with having lumpectomy. Women whose preferences predicted lumpectomy were more likely to have concordance (94.2%) than women whose preferences predicted mastectomy (82.8%, p=0.009). Overall, 90.9% of patients had treatment concordant with their preferences.
Conclusions: In discussions about surgery for early stage breast cancer, providers emphasized breast conservation therapy and its advantages and failed to ask many patients about their preference. Patients had substantial knowledge deficits, particularly about the disadvantages of BCT (higher risk of local recurrence and need for additional surgery). Patients who preferred mastectomy were less likely to receive the treatment they preferred.
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