Originally published as JCO Early Release 10.1200/JCO.2008.16.6215 on December 29 2008

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Can Women With Early-Stage Breast Cancer Make an Informed Decision for Mastectomy?

From the Dartmouth Institute for Health Policy and Clinical Practice; Dartmouth Medical School, Hanover; Center for Shared Decision Making; Comprehensive Breast Program, Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Health Decision Research Unit, Massachusetts General Hospital, Boston, MA; and the School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada.

Corresponding author: E. Dale Collins, MD, Dartmouth Hitchcock Medical Center, One Medical Center Dr, Lebanon, NH 03756; e-mail: e.dale.collins{at}hitchcock.org.

Purpose The purpose of this study was to measure the degree to which informed women chose mastectomy, and to reveal their reasons for this choice.

Patients and Methods This was a prospective cohort study of patients radiographically and pathologically eligible for either mastectomy or breast-conserving surgery (BCS; n = 125). Participants completed questionnaires at three time points: baseline, after viewing a decision aid, and after a surgical consultation. Questionnaires assessed clinical history, preference for participation in decision making, information comprehension, values, decisional conflict, and preferred treatment.

Results Of 125 participants, 44 (35%) chose mastectomy. Most understood that BCS and mastectomy offer an equivalent survival benefit (98%) and that BCS has a slightly higher local recurrence risk (63%); most accurately identified the magnitude of ipsilateral local recurrence risk (91%). Values assigned to three treatment attributes/outcomes ("remove breast for peace of mind," "avoid radiation," and "keep breast") clearly discriminated between patients choosing mastectomy or BCS. High decisional conflict scores improved after both the decision aid and surgical consultation.

Conclusion Although conventional wisdom may view BCS as the preferred treatment, a notable proportion of well informed women choose mastectomy. Whereas prior studies have linked objective factors to treatment choice, this study reveals subjective preferences that underlie decision making. The systematic use of a decision aid before the surgical consultation may help women make informed, values-based decisions, while clearly reducing decisional conflict.

Supported by the Foundation for Informed Medical Decision Making.

Presented in part at the 29th Annual San Antonio Breast Cancer Symposium, December 14-17, 2006, San Antonio, TX; and at the 29th Annual Meeting of the Society for Medical Decision Making, October 20-24, 2007, Pittsburgh, PA.

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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