▪ 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.


  • 1. Bonadonna G and Valagussa 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 BRedmond CDimitrov NBowman DLegault-Poisson S, and Wickerham 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 EGray RShatila AOsborne CTormey D, and Gilchrist 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 MGuyatt GGent MDe Pauw SGoodyear M, and Hryniuk 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 and Smith 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 and Wartman S. When competent patients make irrational choices. N Engl J Med. 1990;332:1595-9. CrossrefGoogle Scholar
  • 12. Hughes T and Larson L. Patient involvement in health care. A procedural justice viewpoint. Med Care. 1991;29:297-303. CrossrefMedlineGoogle Scholar
  • 13. Cassileth BZupkis RSutton-Smith K, and March V. Information and participation preferences among cancer patients. Ann Intern Med. 1980;92:832-6. LinkGoogle Scholar
  • 14. Siminoff LFetting J, and Abeloff M. Doctor-patient communication about breast cancer adjuvant therapy. J Clin Oncol. 1989;7:1192-200. CrossrefMedlineGoogle Scholar
  • 15. Mackillop WStewart WGinsburg A, and Stewart S. Cancer patients' perceptions of their disease and its treatment. Br J Cancer. 1988;58:355-8. CrossrefMedlineGoogle Scholar
  • 16. O'Connor ABoyd NWarde PStolbach L, and Till 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 and Fetting 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 and Wallsten T. Dyadic decisions with numerical and verbal probabilities. Organizational Behaviour and Human Decision Processes. 1990;46:240-63. CrossrefGoogle Scholar
  • 19. Norman G and Streiner D. PDQ Statistics. Toronto: B.C. Decker Inc.; 1986. Google Scholar
  • 20. McGuire WTandon AAllred DChamness G, and Clark 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 MBrowman GGent MRoberts R, and Goodyear M. When is a prognostic factor useful? A guide for the perplexed. J Clin Oncol. 1991;9:348-56. CrossrefMedlineGoogle Scholar
  • 22. Mehrez A and Gafni A. Quality-adjusted life years (QALYs), utility theory, and healthy-years equivalents. Med Decis Making. 1989;9: 142-9. CrossrefMedlineGoogle Scholar
  • 23. Mehrez A and Gafni 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 and Gafni 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 and MacKenzie 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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