CHICAGOResearchers at the Hamilton Regional Cancer Centre (HRCC), Hamilton, Ontario, have developed a decision aid that improves treatment decision-making for women with breast cancer and is widely accepted by the surgeons who have used it in patient counseling, Dr. Tim Whelan said at a quality of life and outcomes symposium, sponsored by Northwestern University and Evanston Northwestern Healthcare. Dr. Whelan is a radiation oncologist at the HRCC and associate professor of medicine, McMaster University.
The cancer center adopted the Decision Board approach in response to problems in communication between patients and physicians that have been identified in the clinical literature. These problems include the unvarying nature of the presentation of facts or treatment measures by physicians, lack of specificity of information, and little or no discussion of the effects of treatment on quality of life. Not surprisingly, patients have tended to overestimate the benefits of treatment and underestimate the risks, Dr. Whelan said.
The first Decision Board instrument was developed to shed light on some of the controversies associated with the benefits and side effects of treatment for node-negative breast cancer. It was initially tested in 30 patients in the early 1990s, and all 30 said they considered it easy to understand and helpful. A randomized trial evaluating the instrument is nearing completion.
The instrumenta visual aid with information cards measuring 2 feet wide by 1½ feet highwas designed to be interactive in that the information on each card can be read by both physician and patient (see figure). For each treatment strategy, different cards present the different choices, outcomes (recurrence or not), probabilities of outcomes, and quality of life associated with each treatment and outcome.
In a subsequent study, another disease-specific Decision Board helped women decide whether to have irradiation after lumpectomy to reduce the risk of breast cancer recurrence. All 30 women whose treatment consultation included the Decision Board felt they had a choice of treatment options; only 20% of 29 women who had a consultation without the Decision Board felt they had a choice, he said.
The most recent study tested use of a Decision Board in counseling women about breast-conserving surgery vs mastectomy. It was developed based on a review of the literature and focus groups with patients and surgeons.
The instrument consists of a series of cards that include detailed descriptions of the two surgical options and of the side effects of each treatment; pictorial depictions of the outcomes of each form of surgical treatment; and presentations of quality of life issues that ask women to reflect on how each treatment option would affect their day-to-day living, relationships, and self-esteem.
The Decision Board was easily understood by 98% of the 175 women in the study; and 81% reported it helped them make a decision. The surgeons who participated in the study were comfortable using the instrument and said they were satisfied with 97% of the consultations they conducted using it. Because of the Decision Board, 57% of women were able to choose their treatment during their consultation with the surgeon, and 98% felt they had been offered clear choices.