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Journal ArticleDOI

A systematic review of decision aids for patients making a decision about treatment for early breast cancer.

01 Apr 2016-The Breast (Elsevier)-Vol. 26, Iss: 26, pp 31-45
TL;DR: Summary: Decision aids are available and improved decision-related outcomes for many breast cancer treatment decisions including surgery, radiotherapy, and endocrine and chemotherapy, including neoadjuvant systemic therapy and contralateral prophylactic mastectomy can be found.
About: This article is published in The Breast.The article was published on 2016-04-01 and is currently open access. It has received 101 citations till now. The article focuses on the topics: Breast cancer & Decision aids.

Summary (3 min read)

Introduction

  • Over the last 40 years, breast cancer survival rates in developed nations have improved by at least 30% due to earlier detection and better treatments (Jemal, Center et al. 2010).
  • DAs are suited to decisions that are preference-sensitive (i.e. there are legitimate options with different outcomes, which individuals may value differently).
  • These reviews discuss individual DAs only briefly.
  • Prior reviews have focussed on surgical decision-making in early stage breast cancer (Waljee, Rogers et al. 2007, Obeidat, Finnell et al. 2011), but other closely related DAs were not evaluated, such as for radiotherapy or systemic therapy.

Methods

  • This systematic review was designed and conducted according to the principles of the PRISMA statement for reporting of systematic reviews and meta-analyses (Moher, Liberati et al. 2009).
  • (i) original research was reported; (ii) a comparative or noncomparative design was used; and (iii) patient outcome data were reported related to the use of a patient treatment DA for early stage breast cancer, also known as Studies were eligible if.
  • A DA was defined as: a tool or technology, including paper-based, video, audio, electronic or multimedia; and containing information about two or more options and the associated relevant outcomes (Elwyn, O'Connor et al. 2006).
  • After removing duplicate results, titles and abstracts were screened to identify potentially eligible papers.
  • Quality and risk of bias were assessed at a study level using the Qualsyst scoring system, which is designed for use on a variety of study types including randomised, non-randomised comparative, cohort and qualitative studies (Kmet, Lee et al. 2004).

Results

  • After removing 394 duplicates, 1791 unique records were identified .
  • Full text review of these records resulted in inclusion of 33 eligible original research articles for analysis, in which 23 individual treatment DAs were evaluated (Table 1).
  • Outcome measures were heterogeneous across studies, precluding meta-analysis.
  • Some DAs addressed more than one breast-cancer treatment decision, such as the DA by Vodermaier et al (Vodermaier, Caspari et al. 2011) for both surgery and adjuvant chemotherapy, and the DA by Wong for adjuvant endocrine therapy and radiotherapy (Wong, D'Alimonte et al. 2012).
  • Ten were randomised controlled trials (RCTs), including four cluster randomised trials.

Study quality

  • RCTs typically had the highest Qualsyst scores, predominantly due to greater methodological rigour in study design, sampling method (e.g., population sampling), control for potential confounders, and greater detail in reporting of results, including estimates of variance.
  • Studies that scored lower on Qualsyst items generally did not specify whether and how investigators and/or participants were blinded, defined outcomes poorly, did not use well-validated outcome measures and/or employed measure subscales or hybrid measures without justification.

Outcome measures

  • Treatment choice was the most frequently used outcome measure type (17 studies) (Irwin, Arnold et al.
  • The use of this scale suggests that indecision is another primary measure of the efficacy of DAs.
  • The satisfaction with decision (eight studies) (Holmes-Rovner, Kroll et al. 1996), and decisional regret (Brehaut, O'Connor et al. 2003) scales measure how satisfied a person is with their decision before and after the consequences 6.
  • Breast cancer decision aid systematic review of that decision have been experienced, respectively.
  • When assesssed, values-choice agreement was not generally measured using a standardized, validated instrument.

DA format

  • Nine DAs took the format of an interactive computer system.
  • Ethnically diverse and/or low literacy American women found a computer-based format universally acceptable (Dhage, Castaneda et al. 2013).
  • Breast cancer decision aid systematic review Belkora et al developed four videos targeting different decisions for early stage breast cancer (DCIS, breast surgery, reconstruction surgery, adjuvant systemic therapy), and one for advanced breast cancer, which were reported to be acceptable and useful (Belkora, Volz et al. 2012).
  • Since very few studies have directly compared different DA formats, or asked patients to review a range of formats and express a preference, the optimal format for DAs remains unclear; it may well be that a variety of formats will be effective or that certain formats are effective for certain populations.

Clinician involvement in DA use

  • All DAs were offered to patients by clinical staff, but clinicians had variable involvement in their use.
  • Impacts on consultation time or clinician-related outcomes were poorly reported, so it is not clear how and whether these different approaches might impact on routine implementation of DAs within the healthcare system.
  • Decision aids for different treatment modalities Several DAs evaluated surgical decision-making for women considering one or more of the options of BCS, mastectomy, (Whelan, Levine et al.

DA efficacy

  • Twelve out of the 17 comparative studies reported a positive primary outcome, most commonly knowledge or decisional conflict score (Whelan, Levine et al.
  • The following section describes features common to those studies where DAs were effective.
  • For a decision such as delayed breast reconstruction where there is often time for decision-making, a DA was less effective (Heller, Parker et al. 2008).
  • One study was unable to demonstrate a difference in decisional conflict, knowledge or decisional regret when testing the benefit of adding a values clarification exercise and risk/benefit diagrams to identical written information (Goel, Sawka et al. 2001).

Gaps in the Literature

  • Multiple DAs have been developed for decisions about breast cancer surgery, endocrine therapy and chemotherapy (Table 4).
  • One has been developed for fertility preservation, three for breast reconstruction surgery and three for radiotherapy.
  • No DAs were found for neoadjuvant systemic therapy, scalp cooling to prevent chemotherapy-induced alopecia or for contralateral prophylactic mastectomy after a breast cancer diagnosis.
  • 10 Breast cancer decision aid systematic review.

Study Recency

  • The majority of DAs did not list their date of most recent update.
  • ‘A patchwork of life’, which was updated in 2013 according to the Ottawa Decision Aid Inventory; and Adjuvant!, also known as The exceptions were.
  • An estimate of recency was made by crossreferencing the time period that the DAs were developed and the publication dates of significant literature impacting on that decision.
  • Standard chemotherapy options have changed since 2005, so DAs that have not been updated since then are likely to be out of date (Group, Peto et al. 2012).

Discussion

  • Early breast cancer patients face a number of complex treatment decisions.
  • The present study is the first review that describes breast cancer treatment DAs across multiple treatment modalities.
  • In order for patients to have the opportunity to access DAs as required, they should be made readily available from a central trusted source such as the Ottawa Decision Aid Inventory (ODAI, https://decisionaid.ohri.ca), with links from other relevant sites.
  • Information within DAs may become out-dated as new treatment options become available.
  • Probabilities may change with new evidence, and choices that were once commonplace may not have the same clinical equipoise that they once did.

Conclusion

  • DAs for early stage breast cancer treatment decisions increase knowledge about options, decrease decisional conflict and are acceptable to patients, without increasing anxiety.
  • Treatment choice as a function of prognostic accuracy: 62% of those who were accurate chose AT compared with 89% of those who were inaccurate (p=0.04).

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Citations
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Journal ArticleDOI
TL;DR: This review aimed to assess the extent to which SDM is applied during surgical consultations, and the metrics used to measure SDM and SDM‐related outcomes.
Abstract: Background Multiple treatment options are generally available for most diseases. Shared decision-making (SDM) helps patients and physicians choose the treatment option that best fits a patient's preferences. This review aimed to assess the extent to which SDM is applied during surgical consultations, and the metrics used to measure SDM and SDM-related outcomes. Methods This was a systematic review of observational studies and clinical trials that measured SDM during consultations in which surgery was a treatment option. Embase, MEDLINE and CENTRAL were searched. Study selection, quality assessment and data extraction were conducted by two investigators independently. Results Thirty-two articles were included. SDM was measured using nine different metrics. Thirty-six per cent of 13 176 patients and surgeons perceived their consultation as SDM, as opposed to patient- or surgeon-driven. Surgeons more often perceived the decision-making process as SDM than patients (43·6 versus 29·3 per cent respectively). SDM levels scored objectively using the OPTION and Decision Analysis System for Oncology instruments ranged from 7 to 39 per cent. Subjective SDM levels as perceived by surgeons and patients ranged from 54 to 93 per cent. Patients experienced a higher level of SDM during consultations than surgeons (93 versus 84 per cent). Twenty-five different SDM-related outcomes were reported. Conclusion At present, SDM in surgery is still in its infancy, although surgeons and patients both think of it favourably. Future studies should evaluate the effect of new interventions to improve SDM during surgical consultations, and its assessment using available standardized and validated metrics.

102 citations

Journal ArticleDOI
TL;DR: It is found that a wide range of internal and external factors impact the FP decision-making process and the implementation of a range of decision support interventions may be of benefit within the clinical care pathway of FP and cancer.
Abstract: Background: Although fertility preservation (FP) treatment options have increased, the existing evidence suggests that many women with cancer do not feel well supported in making these decisions, but find them stressful and complex and fail to take up fertility care at this crucial time Whilst existing reviews have all made important contributions to our understanding of the FP decision-making process, none of them examine solely and specifically these processes for women of reproductive age with a diagnosis of any cancer, leaving a gap in the knowledge base Given the expectation that care is patient-centred, our review aims to address this gap which may be of help to those managing patients struggling to make difficult decisions in the often brief period before potentially sterilising cancer treatment is started Objective and rationale: Underpinning this narrative review was the question “What factors hinder the decision-making process for women with any cancer and contemplating FP treatment?” Our objectives were to i) assess and summarise this existing literature, ii) identify the factors that hinder this decision-making process, iii) explore to what extent these factors may differ for women choosing different methods of FP, and iv) make recommendations for service delivery and future research Search methods: A systematic search of the medical and social science literature from the 1st January 2005 up to the end of January 2016 was carried out using three electronic databases (Web of Science (PubMed), Ovid SP Medline and CINAHL via Ebsco) Included in the review were quantitative, qualitative and mixed-method studies Reference lists of relevant papers were also hand searched From the 983 papers identified, 46 papers were included Quality assessment was undertaken using the Mixed Methods Appraisal Tool and thematic analysis was used to analyse the data Outcomes: From the analysis, six key themes with 15 sub-themes emerged: 1) fertility information provision (lack of information, timing of the information, patient-provider communication); 2) fear concerning the perceived risks associated with pursuing FP (delaying cancer treatment, aggravating a hormone positive cancer, consequences of a future pregnancy); 3) non-referral from oncology (personal situation, having a hormone positive cancer, not a priority, transition between service issues); 4) the dilemma (in survival mode, whether to prioritise one treatment over another); 5) personal situation (parity, relationship status); and 6) costs (financial concerns) Wider implications: This review has found that a wide range of internal and external factors impact the FP decision-making process Key external issues related to current service delivery such as the provision and timing of FP information, and lack of referral from oncology to the fertility clinic However, internal issues such as women’s fears concerning the perceived risks associated with pursuing FP also hindered decision-making but these ‘risks’ were typically overestimated and non-evidence based These findings suggest that the implementation of a range of decision support interventions may be of benefit within the clinical care pathway of FP and cancer Women would benefit from the provision of more evidence-based FP information, ideally received at cancer diagnosis, in advance of seeing a fertility specialist, for example through the implementation of patient decision aids Health care professionals in both oncology and fertility services may also benefit from the implementation of training programs and educational tools targeted at improving the communication skills needed to improve collaborative decision-making and deliver care that is patient-centred Exploration of the current barriers, both intellectual and practical, that prevent some patients from accepting FP will help care providers to do better for their patients in the future Finally, the extent to which a poor prognosis and moral, ethical and religious beliefs influence the FP decision-making process also warrant further research

88 citations

Journal ArticleDOI
09 Nov 2018
TL;DR: An overview of common cognitive biases that result from how and when information is presented to patients is presented, providing compelling evidence that patient treatment choices are subconsciously influenced by both known and unknown biases.
Abstract: This narrative review presents theoretical and empirical evidence of common cognitive biases that are likely to influence treatment choices of patients with cancer and other illnesses. We present an overview of common cognitive biases that result from how and when information is presented to patients. We supplement these descriptions with cancer-specific examples or those from other health fields if no cancer-specific examples are available. The results provide compelling evidence that patient treatment choices are subconsciously influenced by both known and unknown biases. Shared decision making is ideal in theory, but in reality, it is fraught with risks resulting from cognitive biases and undue influence of even the best-intentioned physicians and family members. Efforts should be made to minimize these concerns and to help patients to make decisions that their future selves are least likely to regret.

50 citations

Journal ArticleDOI
Min-Su Kim, So Young Kim, Jin-Hwan Kim1, Bumjung Park1, Hyo Geun Choi1 
10 Apr 2017-PLOS ONE
TL;DR: Patients undergoing mastectomy for breast cancer experience depression more frequently than healthy people, but young adults overcome their depressive mood symptoms during the postoperative period more quickly than middle-aged and older adults.
Abstract: Objective The objective of this study was to compare the incidence of post-operative depression in breast cancer patients who have undergone mastectomy with the incidence of post-operative depression in non-breast cancer participants (controls). Methods Using data from the Korean Health Insurance Review and Assessment Service (HIRA), we selected 2,130 patients with breast cancer who have undergone mastectomy for this national cohort study and matched these patients 1:4 with 8,520 control participants according to age, sex, income, region, and pre-operative depression. The incidence of post-operative depression was measured from mastectomy year to post-op year 10. The Mann-Whitney U test was used for data analysis, and the false-discovery rate was applied to determine statistical significance (P < 0.05). Results The incidence of depression was higher in the breast cancer with mastectomy group than in the control group up to 3 years after mastectomy). However, there was no difference in the incidence of depression between the breast cancer with mastectomy group and the control group after post-op 4 years. The incidence of depression was higher in the breast cancer with mastectomy group than in the control group up to 2 years after mastectomy, and there was no difference in the incidence of depression between the two groups after post-op 3 years in middle-aged and older adults (≥ 40 years old). In young adults (≤ 39 years old), the incidence of depression was significantly higher in the breast cancer with mastectomy group than in the control group in mastectomy year. Conclusion Patients undergoing mastectomy for breast cancer experience depression more frequently than healthy people. However, patients overcome their depressive mood symptoms during the postoperative period. Young adults overcome their symptoms more quickly than middle-aged and older adults.

48 citations

Journal ArticleDOI
TL;DR: Autonomy-supportive communication by physicians was associated with higher subjective decision quality among women with localized breast cancer, and these results support future efforts to design interventions that enhance autonomy- supportive communication.

42 citations


Cites background from "A systematic review of decision aid..."

  • ...[52] Yet ours is the first study to examine the association between patient perceptions of provider communication style and patient-reported decision quality in breast cancer....

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References
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Journal ArticleDOI
TL;DR: Moher et al. as mentioned in this paper introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses, which is used in this paper.
Abstract: David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses

62,157 citations

Journal Article
TL;DR: The QUOROM Statement (QUality Of Reporting Of Meta-analyses) as mentioned in this paper was developed to address the suboptimal reporting of systematic reviews and meta-analysis of randomized controlled trials.
Abstract: Systematic reviews and meta-analyses have become increasingly important in health care. Clinicians read them to keep up to date with their field,1,2 and they are often used as a starting point for developing clinical practice guidelines. Granting agencies may require a systematic review to ensure there is justification for further research,3 and some health care journals are moving in this direction.4 As with all research, the value of a systematic review depends on what was done, what was found, and the clarity of reporting. As with other publications, the reporting quality of systematic reviews varies, limiting readers' ability to assess the strengths and weaknesses of those reviews. Several early studies evaluated the quality of review reports. In 1987, Mulrow examined 50 review articles published in 4 leading medical journals in 1985 and 1986 and found that none met all 8 explicit scientific criteria, such as a quality assessment of included studies.5 In 1987, Sacks and colleagues6 evaluated the adequacy of reporting of 83 meta-analyses on 23 characteristics in 6 domains. Reporting was generally poor; between 1 and 14 characteristics were adequately reported (mean = 7.7; standard deviation = 2.7). A 1996 update of this study found little improvement.7 In 1996, to address the suboptimal reporting of meta-analyses, an international group developed a guidance called the QUOROM Statement (QUality Of Reporting Of Meta-analyses), which focused on the reporting of meta-analyses of randomized controlled trials.8 In this article, we summarize a revision of these guidelines, renamed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), which have been updated to address several conceptual and practical advances in the science of systematic reviews (Box 1). Box 1 Conceptual issues in the evolution from QUOROM to PRISMA

46,935 citations

Journal ArticleDOI
TL;DR: PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) is introduced, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses.
Abstract: Moher and colleagues introduce PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses. Us...

23,203 citations

Journal ArticleDOI
TL;DR: Lumpectomy followed by breast irradiation continues to be appropriate therapy for women with breast cancer, provided that the margins of resected specimens are free of tumor and an acceptable cosmetic result can be obtained.
Abstract: Background In 1976, we initiated a randomized trial to determine whether lumpectomy with or without radiation therapy was as effective as total mastectomy for the treatment of invasive breast cancer. Methods A total of 1851 women for whom follow-up data were available and nodal status was known underwent randomly assigned treatment consisting of total mastectomy, lumpectomy alone, or lumpectomy and breast irradiation. Kaplan–Meier and cumulative-incidence estimates of the outcome were obtained. Results The cumulative incidence of recurrent tumor in the ipsilateral breast was 14.3 percent in the women who underwent lumpectomy and breast irradiation, as compared with 39.2 percent in the women who underwent lumpectomy without irradiation (P<0.001). No significant differences were observed among the three groups of women with respect to disease-free survival, distant-disease–free survival, or overall survival. The hazard ratio for death among the women who underwent lumpectomy alone, as compared with those wh...

5,235 citations

Frequently Asked Questions (1)
Q1. What are the contributions in this paper?

The full text of potentially eligible papers was then reviewed to create a list of original research articles for inclusion in the review. Studies were rejected if they: did not report on patient outcomes ; did not evaluate a treatment DA ; were a review article without original research results ; or were duplicate results, for example a conference abstract reporting on the same results as a published article. Quality and risk of bias were assessed at a study level using the Qualsyst scoring system, which is designed for use on a variety of study types including randomised, non-randomised comparative, cohort and qualitative studies ( Kmet, Lee et al. 2004 ). Qualsyst produces a score between zero and one, with a higher score indicating higher study quality and lower risk of bias. Data points included: study type, study location, decision support type, decision being targeted, population characteristics, primary and secondary outcomes assessed and bias assessment. The term ‘ decision aid ( DA ) ’ will be used in this paper to describe tools, systems, technologies, interactive decision support and other terms used for decision support modalities. This paper will describe reported patient outcomes from DA use.