Originally published as JCO Early Release 10.1200/JCO.2003.06.025 on October 27 2003

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Adjuvant Chemotherapy for Breast Cancer: How Presentation of Recurrence Risk Influences Decision-Making

Celia Chao, Jamie L. Studts, Troy Abell, Terence Hadley, Lynne Roetzer, Sean Dineen, Doug Lorenz, Ahmed YoussefAgha, Kelly M. McMasters

From the Division of Surgical Oncology and the Department of Medicine and Behavioral Oncology Program, James Graham Brown Cancer Center; the Departments of Psychological and Brain Sciences and the Biostatistics-Decision Science Program, University of Louisville; and the Division of Medical Oncology, Norton Healthcare, Louisville, KY; Abell Research Consulting, Ouray, CO.

Address reprint requests to Celia Chao, MD, Department of Surgery, University of Texas Medical Branch, 301 University Blvd, Route 0527, Galveston, TX 77555-0527; e-mail: cechao{at}utmb.edu or Jamie L. Studts, PhD, James Graham Brown Cancer Center, 529 S Jackson St, Louisville, KY 40202; e-mail: jamie.studts{at}louisville.edu.

	ABSTRACT

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Purpose: The purpose of this study was to examine the impact of four methods of communicating survival benefits on chemotherapy decisions. We hypothesized that the four methods of communicating mathematically equivalent risk information would lead to different chemotherapy decisions.

Methods: Each participant received two hypothetical scenarios regarding their mother (a postmenopausal woman with an invasive, lymph node-negative, hormone receptor-positive breast cancer) and was asked to decide whether they would encourage their mother to take chemotherapy in addition to surgery and tamoxifen. In the part 1, participants received one of four methods of describing the chemotherapy survival benefit: (1) relative risk reduction, (2) absolute risk reduction, (3) absolute survival benefit, or (4) number needed to treat. In part 2, each participant received all four methods. Following each decision, participants were asked to rate their confidence and confusion regarding their decision.

Results: Participants included 203 preclinical medical students. In part 1, participants who received relative risk reduction information were significantly more likely to endorse chemotherapy. In part 2, there were no treatment decision differences when participants received all four methods of communicating survival benefits of chemotherapy. However, receiving all four methods led to significantly higher ratings of confusion. In deciding on endorsing chemotherapy, participants understood the information best when presented with data in the absolute survival benefit format.

Conclusion: These results support the hypothesis that the method used to present information about chemotherapy influences treatment decisions. Absolute survival benefit is the most easily understood method of conveying the information regarding benefit of treatment.

	INTRODUCTION

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SIGNIFICANT ADVANCES in the treatment of breast cancer have been made during the last several decades through the conduct of large, prospective, randomized clinical trials. These trials offer clinicians clear estimates of cancer mortality risk and survival benefit with the addition of chemotherapy. However, the wealth of clinical trial data has been accompanied by increasing complexity of decision-making, and greater confusion among patients as a result of the myriad options available. This is especially true for postmenopausal patients with estrogen receptor- and/or progesterone receptor-positive tumors, for whom chemotherapy may add marginal extra benefit in addition to hormonal therapy with tamoxifen.¹ Obtaining accurate information regarding the risks and benefits of all treatment options is an integral part of the patients’ decision-making process and subsequent informed consent.² In addition, physician influence has been shown to have a great effect on patient preferences for treatment options.^3,4

This is an exploratory study that aims to establish whether the terminology used by physicians to convey risks and benefits of adjuvant therapy influences patient treatment decisions and contributes to a limited understanding of their prognosis with or without treatment. Mathematical risk estimates are not easy to understand by the average patient. By extension, patients may have difficulty making informed decisions if fundamentally they are confused about the potential benefits of chemotherapy.

We hypothesized that the way in which the benefit of chemotherapy is explained profoundly influences the patient’s perception of the pros and cons of adjuvant chemotherapy. We examined four equivalent ways to present risk reduction: (1) relative risk reduction (RRR), (2) absolute risk reduction (ARR), (3) absolute survival benefit (ASB), and (4) number needed to treat (NNT). Although all four are acceptable and mathematically equivalent methods to convey risk or benefit, the most optimal method has not been determined. Risk estimates can have negative connotations (eg, risk of death/relapse) or the opposite effect if positively framed (eg, survival benefit or chance of cure).⁵

	METHODS

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Study Population
This study was approved by the appropriate institutional review board, and the questionnaires were distributed to first- and second-year medical students at the University of Louisville. Preclinical medical students were selected for this pilot study because the educational level of the students represents a higher-than-average group of participants who should be able to understand the medical scenario presented, and the statistical descriptions of the potential treatment benefits. We reasoned that this educated group likely represented a conservative assessment of the impact of physician communication styles on patient preferences. The students signed informed consent, understood that their participation was voluntary, and were offered free lunch for their participation.

Assessment of Baseline Moods and Beliefs
Before reading and responding to the scenarios, participants were asked to indicate their current mood using a Likert rating scale from 0 to 10, with scores ranging from "worst mood" to "best mood," respectively. Participants were asked their opinions regarding tolerability of chemotherapy and the degree to which they considered chemotherapy worthwhile. A seven-point Likert scale ranging from 1 (not at all tolerable) to 7 (completely tolerable), and 1 (not at all worthwhile) to 7 (completely worthwhile) was adopted.

Questionnaire Scenarios
The risk estimates were obtained from the computer program on the Mayo clinic Web site, named "Numeracy."^6,7 Patient age, hormone status, tumor size, and number of involved lymph nodes were entered into the program. Numeracy offers a baseline prognosis at 10 years as derived from a panel of experts. For example, if a patient is older than 50 years, has one positive lymph node, and has a tumor 1.5 cm in size that is hormone-sensitive, her baseline prognosis at 10 years (without any adjuvant therapy) is 56%. With the addition of 5 years of tamoxifen only, standard adjuvant chemotherapy only, or the combination of both, her survival at 10 years would be 64.9%, 59.4%, and 68.9%, respectively.⁸ Questionnaires were designed by using a standard hypothetical situation generally employed in medical training: "If the patient was your mother, what would you do?" Figure 1 shows that students were randomly assigned to receive versions of scenarios A (1.9-cm hormone-sensitive breast cancer) and B (2.9-cm hormone-sensitive breast cancer). For part 1, participants were randomized to receive only one of the four possible statements (whether RRR, ARR, ASB, or NNT) to convey prognosis with adjuvant chemotherapy. For part 2, participants received all four statements (RRR, ARR, ASB, and NNT) to convey prognosis with adjuvant chemotherapy. To control for possible order effects, half of the study participants completed scenario A followed by scenario B, and the other half completed scenario B followed by scenario A.

View larger version (32K): [in this window] [in a new window]   Fig 1. Schema. Students answered four hypothetical cases: scenarios A (parts 1 and 2) and B (parts 1 and 2). They were randomized to either scenario A or B first.

Outcome Measures
The primary outcome of the study was whether or not each participant would endorse adjuvant chemotherapy after reading each scenario. Secondary outcomes included participant-rated levels of confidence and confusion regarding each decision, as well as the participant’s ability to interpret the risk and benefit information correctly. Confidence and confusion were measured using seven-point Likert scales after each decision (eg, 1 = not at all confident; 7 = completely confident). Correct interpretation of the risk and benefit information was assessed by asking two factual questions: (1) "On a scale from 0% to 100%, what do you believe is the chance that your mother will survive 10 years if she TAKES the chemotherapy?" (2) "On a scale from 0% to 100%, what do you believe is the chance that your mother will survive 10 years if she DOES NOT TAKE the chemotherapy?"

Statistical Methods
Descriptive statistics were used to describe the sample, and contingency table analysis, with accompanying ² statistics for significance, was used to examine potential differences in rates of endorsing chemotherapy, as well as to analyze accuracy of interpretation of risk and benefit information collected. Logistic regression tested for overall differences in chemotherapy endorsement across the four groups, as well as assessing the results of the two factual questions. Repeated measures analysis of variance (RMANOVA) models (4 x 2) tested for potential group differences in confusion and confidence ratings for each scenario as well as within-groups differences comparing ratings from part 1 and part 2 of each scenario.

	RESULTS

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Participants
The characteristics of our study participants are listed in Table 1. Among the first- and second-year medical students invited to participate, 203 volunteered to complete the questionnaire. Participants were predominately younger than 25 years (73%) and single (73%). There was close or equal representation of the classes (100 first-year students and 103 second-year students) and the sexes (50% female). Sixty-seven percent of students reported a personal or family history of cancer, and 47% reported a personal or family history of experiencing chemotherapy.

Participant Preferences
As presented in Table 2, participants randomly assigned to receive the RRR format in part 1 of scenario A (1.9-cm tumor) endorsed chemotherapy more often (51%) than participants randomly assigned to receive the other three formats: ARR (39%), ASB (26%), and NNT (31%). Overall results of a logistic regression model revealed statistically significant differences in chemotherapy endorsement across the four groups (data not shown), both for part 1 of scenario A with the 1.9-cm tumor (²₃ [n = 202] = 8.16; P = .04) and for part 1 of scenario B with the 2.9-cm tumor (²₃ [N = 203] = 15.66; P < .001). Table 3 presents pair-wise contrasts between ASB (the estimate resulting in the lowest percentage of chemotherapy choice) and the other three quantitative estimates. Two trends are apparent. The participants were more likely to choose chemotherapy in the larger tumor (2.9 cm) scenario than in the smaller tumor (1.9 cm) scenario (eg, among those assigned RRR, the endorsement rate was 70.6% v 51.0%, respectively). Secondly, the estimates for relative endorsement between those assigned ASB and the other three quantitative risk approaches were almost identical in each of the two tumor-size scenarios. For example, participants presented with RRR were twice as likely to choose chemotherapy than participants presented with ASB, both in the 1.9-cm tumor scenario (51.0% v 25.5%; relative risk = 2.0) and in the 2.9-cm tumor scenario (70.6% v 33.3%; relative risk = 2.1). These differences are both statistically significant and clinically important.

Participant Confusion and Confidence Ratings
Means, SDs, and 95% CIs, for participant confidence and confusion ratings are provided in Table 2. The only significant outcome by repeated measures analysis of variance was the repeated measures (within-subjects) effect, indicating that confusion ratings were significantly higher after part 2 than confusion ratings after part 1 in both scenarios (P < .001 in each scenario). Thus, receiving all four statements in part 2 may have caused greater uncertainty rather than clarification.

With regard to confidence ratings, results failed to reveal any statistically significant between- or within-groups differences (data not shown).

Accuracy and Understanding of Risk and Benefit Information
Analyses conducted on data involving accuracy and understanding of the risk and benefit information indicated that the group receiving the RRR method was significantly less likely to report accurate absolute risk and benefit information in several situations (Table 4). Using logistic regression, an overall difference was noted between the four groups when participants were asked about their mother’s chance of 10-year survival if she accepted chemotherapy in part 1 of scenario A (²₃ [N = 203] = 46.56; P < .001). Pair-wise comparisons using RRR as the reference group showed that the RRR group reported significantly fewer accurate responses than each of the other three groups: ARR (P < .001); ASB (P < .001); and NNT (P = .02). No overall differences were found concerning accuracy of risk and benefit information if chemotherapy was not taken in part 1 of scenario A, and no group differences were identified for either question in part 2 of scenario A.

	DISCUSSION

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Treatment choices are offered to patients routinely; however, we have a limited understanding of how to best convey the treatment options and what motivates patients to choose one option over another. What is the best method for clinicians to convey accurately and concisely the risks and benefits of adjuvant chemotherapy? The answer to this question is particularly important because it has been shown that physician recommendation for treatment is the strongest predictor for accepting a prescribed therapy. Indeed, one study showed that 80% of patients chose what their oncologist recommended.¹⁰ Studies document that breast cancer patients prioritize as most important information directly relating to the chance of cure and spread of cancer while side effects of treatment rank medium priority.^11,12 Despite a clear desire for "numbers," Ravdin et al¹³ found that only 39% of women remember receiving a "quantitative estimate" both with and without adjuvant therapy. Interestingly, even in the absence of concrete estimates by their physicians, 68% of patients were able to provide their own survival estimate at five-years with and without the chemotherapy. Indeed, often patient perceptions and understandings of the benefit of adjuvant chemotherapy are discordant with the reality of their situation.

Many factors may influence the patient’s preferences for and processing of information: sex, age, and educational level, cancer type, stage of disease, the proposed treatment plan, including potential benefits, and side effects. Patients may be dissatisfied with, deny, or misunderstand the information as presented.^14,15 In this study, sex, educational level, and denial (since the participants are not actual patients) are likely not confounders contributing to a misunderstanding of prognosis. In our hypothetical scenarios, the participants must take into account the prognostic value of chemotherapy as well as the risks of treatment. The benefits of accepting adjuvant chemotherapy were presented in four mathematically equivalent ways: RRR, ARR, ASB, and NNT. Therefore, any misunderstanding or confusion regarding the risks and benefits of chemotherapy can be attributable solely to the method of presentation.

RRR is not a useful format for patients or physicians^16,17 because benefit estimates are not intuitively obvious. Even among medical students, who by definition have higher educational levels than the average population, this concept is difficult to comprehend. The concept of RRR presupposes that the mathematical formula can be easily calculated and that the patient/participant can convert this information into the true or absolute benefit. Understanding of the true benefit is often completely overestimated (Table 4). Naylor et al¹⁶ surveyed physicians on the therapeutic benefit of a drug by randomly presenting the same data in three different ways: "relative risk reduction," "absolute benefit of the drug," and "person-years of treatment needed to prevent one myocardial infarction." This study confirms our results, since physicians receiving RRR information were more likely to rate the drug as more effective than those who received absolute event data. The participants showed the least enthusiasm for the drug when given the NNT data, indicating that this was a concrete way of attributing benefit by the drug to specific numbers of individuals. By contrast, the medical students in our study found that NNT may be just as confusing as ARR and RRR (Table 2). Also, the NNT approach yielded similar endorsement rates when compared with the ASB and ARR approaches by many of the medical students. By extension, patients faced with accepting a particular drug therapy can be easily misguided if given the RRR format.

There are many studies of preferences for chemotherapy in the metastatic setting.¹⁸ These studies are not relevant in the adjuvant setting. Patients are told the average life expectancy, and a substantial number of patients, when offered the chance to extend their lives for even 1 additional week, will state their enthusiasm for chemotherapy. In the adjuvant setting, Leighl et al¹⁹ audiotaped initial adjuvant therapy consultations with medical and radiation oncologists. In this study, 37% of physicians phrased the benefit of therapy in terms of "relative reduction in risk of relapse" while 61% used "absolute reduction in risk of relapse."

Other investigators have offered patients a threshold for the magnitude of survival benefit for which they would accept adjuvant chemotherapy. For example, in a survey of breast cancer survivors published by Ravdin et al,¹³ women reported that they would be agreeable to adjuvant chemotherapy if the reduction in the risk of death from breast cancer was as low as 0.5% to 1% (median). Additionally, patients were asked how many months to years of extra life were worth the experience of undergoing chemotherapy; the median acceptable time of life gained was 3 to 6 months. Similar to other studies that report a threshold, the issue of what that number really means is not adequately explored. In the adjuvant setting, time gained by chemotherapy is never stated in terms of months of life gained. Furthermore, time gained can never be precise for one individual but rather, represents data from a collective group of women in similar clinical situations. Although information on individual risk is what patients may want, it is not possible to state benefit in such terms. In fact, "1% reduction in death from breast cancer" (or 1% survival benefit) may easily mean that one extra person of 100 patients will live as a result of the therapy. We do not know if the patient understands that she may be among the 99% who will live anyway without the therapy. It may be likely that she thinks she will be the one that will live as a result of chemotherapy. In a report by Simes, patients were given "time trade-off" questions. In that study, 46% of patients considered a survival of an additional 0.5 years with the addition of chemotherapy equivalent to 5 years survival without chemotherapy.²⁰ For 77% of patients surveyed, an increase of life from 5 to 6 years was considered worthwhile. "Time-trade-off" questions are misleading, in our opinion, in that many patients will mistake the additional time quoted in the hypothetical scenario as time "guaranteed" or "certain" to their particular medical situation.

In contrast to studies where patients would endorse chemotherapy for small survival benefits, Feldman et al presented potential benefit of adjuvant chemotherapy for breast cancer in terms of ASB by referring to a prognostic table.²¹ Among those who may gain a 2% absolute survival advantage, 20% of such patients received chemotherapy before routine use of the table. However, only 14% chose to take adjuvant chemotherapy after use of the table. At a threshold of 4% survival benefit, there was a significant increase in those who agreed to take chemotherapy after institution of the prognostic table (from 42% to 64%). For 6% ASB, the change was more modest: 86% to 89% (before and after use of the table, respectively).

Sometimes, accurate information or more information may not predict increased endorsement of a particular therapy. In a randomized study in which an educational tool was utilized to help patients understand the risks and benefits of adjuvant chemotherapy for breast cancer, Whelan et al²² showed that patients reported an improved understanding of their disease and probability of treatment benefit. However, no statistical differences were noted between those patients who used the tool versus those that did not with respect to endorsing chemotherapy.

Current recommendations call for considering adjuvant chemotherapy for most breast cancers larger than 1 cm even though the long-term risk of relapse from small node-negative tumors is 10% to 20%.²³ The conclusions of our study emphasize that despite "consensus recommendations"^24,25 and "practice guidelines,"²³ the true benefit of chemotherapy in postmenopausal women with estrogen receptor-positive tumors receiving tamoxifen often is not well understood when presented in the RRR format. Perceived benefits of adjuvant chemotherapy may seem less impressive to the informed patient or family members. Counseling in terms of relative risk reduction does not accurately convey the marginal benefits of adding cytotoxic therapy for small, node-negative cancers. In this study, without overt knowledge of published guidelines and when presented with all four methods of risk-benefit information, only 35% of the medical students endorsed chemotherapy for their mother with a hormone-sensitive tumor that was 1.9 cm, and 43% endorsed adjuvant chemotherapy for a hormone-sensitive 2.9-cm tumor.

Limitations of this study included the small sample size, the small number of non-white participants, and the fact that the participants were not actual patients. For this pilot study, medical students were chosen because they represent a subpopulation that has both interest and the background to understand the risk-benefit discussions. They should find the scenarios less confusing compared with an average patient. It has been shown that endorsement of treatments vary significantly especially if the participant actually must face the scenarios presented.¹⁸ Although 47% of the participants have a personal or family history of taking chemotherapy, the type of cancer, stage of disease, and performance status is not known. These and other factors such as socioeconomic and ethnic backgrounds can bias one’s perception of the risk and benefits of adjuvant chemotherapy, however irrelevant these biases may seem in these hypothetical scenarios.

In conclusion, the methods in which physicians present quantitative risk significantly impact patient decision-making. The ASB method results in the lowest endorsement of adjuvant chemotherapy while the RRR methods results in the highest rate of endorsement. Further, the RRR method led to less accurate knowledge of prognosis with and without chemotherapy. Finally, presentation of all four methods led to higher confusion ratings regarding treatment decisions.

	APPENDIX

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Example: Scenario A, Part 1
Each student was randomized to receive only 1 of the 4 questions (given the same scenario below):

Your mother underwent surgery to remove a 1.9 cm tumor that was determined to be estrogen and progesterone receptor positive (ie, the tumor is hormonally-sensitive to an antihormone drug called TAMOXIFEN). Also, the tumor has not spread to the lymph nodes. Without any additional therapy (other than surgery), her chance of surviving in the next 10 years is 81%. She has started Tamoxifen therapy.

She has been offered chemotherapy in addition to surgery and Tamoxifen. Chemotherapy will not guarantee that survival will be 100%. Many patients are cured without chemotherapy at all. Some patients may have microscopic tumor cells which may be reduced by chemotherapy; these patients will benefit from chemotherapy. Some tumor cells may be resistant to chemotherapy, which is why chemotherapy may not benefit all patients. We cannot predict which patients may benefit. Because she is healthy, the side effects are probably tolerable, especially with medications that treat the side effects. Side effects of chemotherapy are generally temporary and include possible infection when the immune system is suppressed, anemia, fatigue, hair loss, some symptoms of menopause, and possible nausea and vomiting. The only possible permanent side effect would be a small risk of heart failure.

Using the information provided, your mother has asked you to advise her on her decision. The survival benefit is stated in each case. Please read the following scenario and decide whether or not you would advise your mother to take the chemotherapy. Please circle YES if you think the benefit of chemotherapy is worth the risk and circle NO if you think the risk of chemotherapy is not worth the benefit.

1. With your mother’s treatment of surgery and Tamoxifen, her risk of dying in the next ten years is 15%. This means that out of 100 people with conditions similar to hers, 15 will die in the next ten years. By adding chemotherapy to her treatment she can reduce her relative risk of death in the next ten years by 12%. Do you advise her to take the chemotherapy?
   YES NO
   
2. With your mother’s treatment of surgery and Tamoxifen, her risk of dying in the next ten years is 15%. This means that out of 100 people with conditions similar to hers, 15 will die in the next ten years. By adding chemotherapy to her treatment she can reduce the risk of death in the next ten years by 2% (from 15% to 13%). Do you advise her to take the chemotherapy?
   YES NO
   
3. With your mother’s treatment of surgery and Tamoxifen, her chance of surviving for the next ten years is 85%. This means that out of 100 people with conditions similar to hers, 85 will survive the next ten years. By adding chemotherapy to her treatment she can increase the chance of surviving by 2% (from 85% to 87%). Do you advise her to take the chemotherapy?
   YES NO
   
4. With your mother’s treatment of surgery and Tamoxifen, her chance of surviving for the next ten years is 85%. This means that out of 100 people with conditions similar to hers, 85 will survive the next ten years. Chemotherapy can be added to her treatment. When 50 patients are treated with chemotherapy, one more patient will survive the next ten years. (We hope, but do not know, if that person will be your mother.) Do you advise her to take the chemotherapy?
   YES NO
   

Example of Scenario A, Part 2:
Each student was given the same scenario but then all 4 ways of presenting prognosis was disclosed:

Please examine all the information presented in items 1 to 4 to make your decision.

1. By adding chemotherapy to her treatment she can reduce her relative risk of death in the next ten years by 12%
   
2. By adding chemotherapy to her treatment she can reduce the risk of death in the next ten years by 2% (From 15% to 13%)
   
3. By adding chemotherapy to her treatment she can increase the chance of surviving by 2% (from 85% to 87%).
   
4. Chemotherapy can be added to her treatment. When 50 patients are treated with chemotherapy, one more patient will survive the next ten years. (We hope, but do not know, if that person will be your mother).
   

Do you advise her to take the chemotherapy?

YES NO

	AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

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The authors indicated no potential conflicts of interest.

	NOTES

 
Supported by the Center for Advanced Surgical Technologies (CAST) of Norton Hospital, Louisville, Kentucky and the Links for Life Foundation, Louisville, Kentucky.

Both C.C. and J.L.S contributed equally to this work.

	REFERENCES

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3. Kinney AY, Richards C, Vernon SW, et al: The effect of physician recommendation on enrollment in the breast cancer chemoprevention trial. Prevent Med 27:713–719, 1998[CrossRef][Medline]

4. Smilt MC, Heltzel M: Women’s use of resources in decision making for early stage breast cancer: Results of a community based survey. Ann Surg Oncol 4:564–569, 1997[CrossRef][Medline]

5. Lobb EA, Butow PN, Kenny DT, et al: Communicating prognosis in early breast cancer: Do women understand the language used? Med J Australia 171:290–294, 1999

6. Loprenzi CL, Thome SD: Understanding the utility of adjuvant therapy for primary breast cancer. J Clin Oncol 19:972–979, 2001[Abstract/Free Full Text]

7. Mayo Clinic: Adjuvant Systemic Therapy Tools. http://www.mayoclinic.com/calcs

8. Loprenzi CL, Ravdin PM: Decision-making for patients with resectable breast cancer: Individualized decisions for and by patients and their patients. JNCCN 1:189–196, 2003

9. Flesch R: A new readability yardstick. J Appl Psychol 32:221–233, 1948[CrossRef][Medline]

10. Siminoff LA, Fetting JH, Abeloff MD: Doctor-patient communication about breast cancer adjuvant therapy. J Clin Oncol 7:1192–1200, 1989[Abstract]

11. Degner LF, Krisjanson LJ, Bowman D, et al: Information needs and decisional preferences in women with breast cancer. JAMA 277:1485–1492, 1997[Abstract/Free Full Text]

12. Luker KA, Beaver K, Leinster SJ, et al: The information needs of women newly diagnosed with cancer. J Adv Nurs 22:134–141, 1995[CrossRef][Medline]

13. Ravdin PM, Siminoff LA, Harvey JA: Survey of breast cancer patients concerning their knowledge and expectations of adjuvant therapy. J Clin Oncol 16:515–521, 1998[Abstract]

14. Mackillop WJ, Stewart WE, Ginsburg AD, et al: Cancer patients’ perceptions of their disease and its treatment. Br J Cancer 58:355–358, 1998

15. Gattellari M, Butow PN, Tattersall MH, et al: Misunderstandings in cancer patients: Why shoot the messenger? Ann Oncol 10:39–46, 1999[Abstract/Free Full Text]

16. Naylor CD, Chen E, Strauss B: Measured enthusiasm: Does the method of reporting trial results alter perceptions of therapeutic effectiveness? Ann Inter Med 117:916–921, 1992[Abstract/Free Full Text]

17. Rajagopal S, Goodman PJ, Tannock IF: Adjuvant chemotherapy for breast cancer: Discordance between physician’s perception of benefit and the results of clinical trials. J Clin Oncol 12:1296–1304, 1994[Abstract/Free Full Text]

18. McQullelon RP, Muss HB, Hoffman SL, et al: Patient preferences for treatment of metastatic breast cancer: A study of women with early-stage breast cancer. J Clin Oncol 13:858–868, 1995[Abstract]

19. Leighl N, Gattellari M, Butow P, et al: Discussing adjuvant cancer therapy. J Clin Oncol 19:1768–1778, 2001[Abstract/Free Full Text]

20. Simes RJ, Coates AS: Patient preferences for adjuvant chemotherapy of early breast cancer: How much benefit is needed? J Natl Cancer Inst Mono 30:146–152, 2001

21. Feldman M, Stanford R, Catcheside A, et al: The use of a prognostic table to aid decision making on adjuvant therapy for women with early breast cancer. Eur J Surg Oncol 28:615–619, 2002[CrossRef][Medline]

22. Whelan T, Sawka C, Levine M, Gafni A, et al: Helping patients make informed choices: A randomized trial of a decision aid for adjuvant chemotherapy in lymph node-negative breast cancer. J Natl Cancer Inst 95:581–587, 2003[Abstract/Free Full Text]

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Submitted June 6, 2003; accepted July 30, 2003.

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