SAN FRANCISCOCanadian breast cancer patients who tested a
decision aid called the Decision Board in a randomized trial were better
informed about their chemotherapy options and more satisfied with the
decision-making process than a control group of patients who relied on a
traditional medical consultation.
Timothy J. Whelan, BM, BCh, MSc, director of the Supportive
Cancer Care Research Unit at the Hamilton Regional Cancer Centre in Hamilton,
Ontario, reported that the board did not affect how many women chose
chemotherapy: 77% of the women who used the board and 70% of a control group
decided to proceed. It did increase satisfaction, however, in assessments made
at 1 week, 3 months, 6 months, and 1 year. At the end of the study, women who
used the board and those who did not both were reported to favor breast cancer
patients taking a greater role in choosing treatment options.
"This was the first randomized trial to show that a
decision aid can improve comprehension and satisfaction for cancer
patients," Mr. Whelan said.
Filling the Board
Patients and clinicians (either physicians or nurses) use the
board together during the course of a consultation. As described by Mr. Whelan,
the board has three subtitlestreatment choices, outcomes, and probabilities
of outcomebut is otherwise empty at the start of the consultation. The
clinician presents detailed information on cards read aloud to the patient.
These are then attached to the board, and the patient is encouraged to ask
For example, Mr. Whelan showed a selection in which "No
Chemotherapy" was presented as an option. The decision board indicated
that the patient would have a 15% risk of recurrence and an 85% likelihood of
remaining cancer-free if followed by a clinician. The board also presented a
detailed description of these outcomes and the associated quality of life.
One concern, according to Mr. Whelan, was that patient anxiety
levels would go up if they were given a great deal of explicit information.
Another was that explaining everything put on the board would take more of the
clinician’s time than a standard consultation. "We did extensive studies
to make sure these instruments were not upsetting people," Mr. Whelan
said. "The decision board did not affect patient anxiety or time of
consult or the treatment chosen."
The investigators recruited 176 women from six cancer centers
for the trial. All had completed surgery for node-negative breast cancer and
were candidates for adjuvant chemotherapy. Eighty-three used the board in
conjunction with a medical consultation to make their decision. Ninety-three
had only the medical consultation. "In both arms, patients were given an
information pamphlet about breast cancer and asked to return 1 week later to
make the treatment decision," Mr. Whelan said. Women who used the board
also took home a printout of that information.
One week after the consultation, the women were asked to answer
25 true or false questions designed to test their knowledge about breast cancer
and the risks and benefits of adjuvant chemotherapy. The decision board
patients had a mean score of 77.3% compared to 69.3% for control patients,
according to Mr. Whelan. On the risks of recurrence, he reported that 55% in
the board arm correctly identified the risk without chemotherapy compared to
40% of the control group. Similarly, women in the board arm had better recall
of the risk with chemotherapy: 52% answered correctly vs 38% of the controls.
One interesting change, Mr. Whelan noted, was that at the
outset a majority of patients in both groups preferred that decision-making be
shared with the physician or that women have a primary role. Afterward, both
groups preferred a primary role for the patients.
Patricia A. Ganz, MD, of the University of California, Los
Angeles, Schools of Medicine and Public Health, said the presentation
highlights the challenges that physicians face in decision making with breast
cancer patients. "In breast cancer, we are faced with information
overload, and it’s not just information overload for the patient," she
said. "It’s information overload for the practitioner. We have an
enormous amount of data that are available to us."
She praised the study design, but questioned the
representativeness of the study sample, which had a younger age distribution.
The women in the study also had a preponderance of poor prognostic factors,
such as stage II disease and estrogen-receptor- negative tumors, she said.
"The lack of effect on treatment decision probably reflects the high risk
of the women. We need to see the decision board strategy tested in an older
population of women who may not be as interested in shared decision-making and
in women with less absolute benefit from chemotherapy," Dr. Ganz said,
urging that the board also be tested against other decision aids.