A Bedside Decision Instrument To Elicit a Patient's Preference Concerning Adjuvant Chemotherapy for Breast Cancer
Abstract
▪ The objective of this study was to develop an instrument to help clinicians inform patients with breast cancer of risks and benefits of adjuvant chemotherapy as derived from clinical trials and to help the informed patient decide whether she prefers treatment or no treatment. The instrument consists of a visual aid (called the decision board) and written material. It provides detailed information on a patient's choices (chemotherapy or no chemotherapy), outcomes (recurrence or not), probabilities of outcomes and their meaning, and quality of life associated with treatment choice and outcome. The validity and reliability of the instrument were evaluated in 30 healthy female volunteers. It was first administered using standard estimates of recurrence for node-negative breast cancer (15% risk of recurrence without treatment, which is reduced to 10% with chemotherapy). A preference for treatment (or no treatment) was then elicited. The validity was evaluated by changing the information provided on risks and benefits and determining whether the preference changed in a predictable manner. To test for reliability, the instrument was administered 2 weeks later. Seventeen women chose chemotherapy and 13 chose no chemotherapy. In the former group, 14 women (82%) switched preference when the magnitude of benefit was reduced, and 16 (94%) switched when the toxicity of treatment was increased. For those women who chose not to receive chemotherapy, 12 (92%) switched when the benefit was increased and 100% switched when toxicity was eliminated. The reliability was excellent (κ = 0.86). The instrument has been used to elicit treatment preferences in 37 newly presenting patients with high-risk, node-negative breast cancer and has been found to be acceptable and helpful to the patient.
References
- 1.
Bonadonna G andValagussa P . Adjuvant systemic therapy for resectable breast cancer. J Clin Oncol. 1985;3:259-75. CrossrefMedlineGoogle Scholar - 2.
Henderson C . Adjuvant systemic therapy for early breast cancer. Curr Probl Cancer. 1987;11:125-207. CrossrefMedlineGoogle Scholar - 3.
Fisher B ,Redmond C ,Dimitrov N ,Bowman D ,Legault-Poisson S , andWickerham D . A randomized clinical trial evaluating sequential methotrexate and fluorouracil in the treatment of patients with node-negative breast cancer who have estrogen-receptor-negative tumors. N Engl J Med. 1989;320:473-8. CrossrefMedlineGoogle Scholar - 4.
Mansour E ,Gray R ,Shatila A ,Osborne C ,Tormey D , andGilchrist K . Efficacy of adjuvant chemotherapy in high-risk node-negative breast cancer. N Engl J Med. 1989;320:485-90. CrossrefMedlineGoogle Scholar - 5. . Prolonged disease-free survival after one course of perioperative adjuvant chemotherapy for node-negative breast cancer. N Engl J Med. 1989;320:491-6. CrossrefMedlineGoogle Scholar
- 6.
McGuire W . Adjuvant therapy of node-negative breast cancer. N Engl J Med. 1989;320:525-7. CrossrefMedlineGoogle Scholar - 7.
Devita V . Breast cancer therapy: exercising all our options [Editorial]. N Engl J Med. 1989;320:527-9. CrossrefMedlineGoogle Scholar - 8.
Levine M ,Guyatt G ,Gent M ,De Pauw S ,Goodyear M , andHryniuk W . Quality of life in stage II breast cancer: an instrument for clinical trials. J Clin Oncol. 1988;6:1798-810. CrossrefMedlineGoogle Scholar - 9.
Hillner B andSmith T . Efficacy and cost-effectiveness of adjuvant chemotherapy in women with node-negative breast cancer. A decision-analysis model. N Engl J Med. 1991;324:160-8. CrossrefMedlineGoogle Scholar - 10.
Rose G . Reflections on the changing times. BMJ. 1990;301:683-7. CrossrefMedlineGoogle Scholar - 11.
Brock D andWartman S . When competent patients make irrational choices. N Engl J Med. 1990;332:1595-9. CrossrefGoogle Scholar - 12.
Hughes T andLarson L . Patient involvement in health care. A procedural justice viewpoint. Med Care. 1991;29:297-303. CrossrefMedlineGoogle Scholar - 13.
Cassileth B ,Zupkis R ,Sutton-Smith K , andMarch V . Information and participation preferences among cancer patients. Ann Intern Med. 1980;92:832-6. LinkGoogle Scholar - 14.
Siminoff L ,Fetting J , andAbeloff M . Doctor-patient communication about breast cancer adjuvant therapy. J Clin Oncol. 1989;7:1192-200. CrossrefMedlineGoogle Scholar - 15.
Mackillop W ,Stewart W ,Ginsburg A , andStewart S . Cancer patients' perceptions of their disease and its treatment. Br J Cancer. 1988;58:355-8. CrossrefMedlineGoogle Scholar - 16.
O'Connor A ,Boyd N ,Warde P ,Stolbach L , andTill J . Eliciting preferences for alternative drug therapies in oncology: influence of treatment outcome description, elicitation technique and treatment experience on preferences. J Chron Dis. 1987;40:811-8. CrossrefMedlineGoogle Scholar - 17.
Siminoff L andFetting J . Effects of outcome framing on treatment decisions in the real world: impact of framing on adjuvant breast cancer decisions. Med Decis Making. 1989;9:262-71. CrossrefMedlineGoogle Scholar - 18.
Budescu D andWallsten T . Dyadic decisions with numerical and verbal probabilities. Organizational Behaviour and Human Decision Processes. 1990;46:240-63. CrossrefGoogle Scholar - 19.
Norman G andStreiner D . PDQ Statistics. Toronto: B.C. Decker Inc.; 1986. Google Scholar - 20.
McGuire W ,Tandon A ,Allred D ,Chamness G , andClark G . How to use prognostic factors in axillary node-negative breast cancer patients. J Natl Cancer Inst. 1990;82:1006-15. CrossrefMedlineGoogle Scholar - 21.
Levine M ,Browman G ,Gent M ,Roberts R , andGoodyear M . When is a prognostic factor useful? A guide for the perplexed. J Clin Oncol. 1991;9:348-56. CrossrefMedlineGoogle Scholar - 22.
Mehrez A andGafni A . Quality-adjusted life years (QALYs), utility theory, and healthy-years equivalents. Med Decis Making. 1989;9: 142-9. CrossrefMedlineGoogle Scholar - 23.
Mehrez A andGafni A . The healthy-years equivalents: how to measure them using the standard gamble approach. Med Decis Making. 1991;11:140-6. CrossrefMedlineGoogle Scholar - 24.
Mehrez A andGafni A . Evaluating health related quality of life: an indifference curve interpretation for the time trade-off technique. Soc Sci Med. 1990;24:1281-3. CrossrefGoogle Scholar - 25.
Loomes G andMacKenzie L . The use of QALYs in health care decision making. Soc Sci Med. 1989;28:299-308. CrossrefMedlineGoogle Scholar - 26.
Gafni A . Competent patients and irrational choices [Letter]. N Engl J Med. 1990;323:1353-5. CrossrefGoogle Scholar
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Mark N. Levine,
From the Hamilton Regional Cancer Centre, and McMaster University, Hamilton, Ontario, Canada. For current author addresses, see end of text.
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