Decision-Making Strategies Could Influence Breast Cancer Treatment

Patients with breast cancer who are more rational may strongly consider contralateral mastectomy.

When combined with their values, the way patients approach decisions may impact which type of breast cancer treatment they receive, according to a study published by Cancer.

The authors found that more than half of patients with early stage breast cancer may consider prophylactic contralateral mastectomy, despite only having cancer in a single breast. As this procedure becomes more common, these findings could reveal why patients may opt for aggressive surgery.

To better understand what is contributing to the increase in mastectomies, the investigators asked patients how they approach decision-making, including whether they regret their choices, if they are more rational or intuitive, and how much direction they want from their physicians, according to the study.

"The decision-making process is complicated. We found there are a lot of values that come into play," said lead study author Sarah T. Hawley, PhD, MPH.

Included in the study were 2362 women with early stage breast cancer. Patients were asked if they considered prophylactic contralateral mastectomy and various details about their values and decision-making styles.

The authors found that 54% of patients considered the surgery, with one-quarter strongly considering it, according to the study.

Interestingly, patients who reported concerns about making bad decisions more commonly considered mastectomy compared with other patients. Additionally, patients who considered themselves to be logical were less likely to consider the surgery compared with those who reported they were more intuitive, according to the study.

The authors also discovered that cancer recurrence and radiation exposure were commonly linked to the consideration of aggressive surgery; however, the researchers noted that the surgery does not necessarily mean that those concerns would be avoided.

"Fears about radiation are common, so it is very important to make sure women are fully informed before they make the decision to pursue much more aggressive surgery than they need," said study author Reshma Jagsi, MD, DPhil. "We need to make sure women understand how far technology has advanced to make radiation treatment safe and tolerable. We also need to make sure women understand that even after mastectomy radiation might be recommended, if the cancer has certain features.”

Additionally, patients who typically do not rely on their physician’s input were more likely to strongly consider a double mastectomy, suggesting that the uptick in surgery may be driven by patient preference.

"It goes against what the traditional shared decision-making model would suggest, which is when you involve people and inform them fully, most people would be inclined to choose less extensive treatment," Dr Hawley said.

The authors suggest that patient values should be considered when determining treatment decisions.

"If physicians have feedback that a patient likes to make decisions a certain way, they can understand the patient's emotional processing and help the patient make a decision that meets her needs physically and emotionally," Dr Hawley said.

Since many patients overestimate the risk of recurrent disease and may not fully understand the impact of aggressive surgery, the authors urge physicians to educate patients about misconceptions, according to the study.

"A lot of these conversations around therapy - including extensive therapy that may not be truly beneficial in terms of survival - may come down to emotional values,” Dr Hawley concluded. “Physicians need to help patients feel comfortable with treatment decisions within their underlying nature and values. This includes helping patients understand when less extensive treatment might be the right option. Patients need to feel secure in knowing that choice will give them their best chance at survival.”