Originally published as JCO Early Release 10.1200/JCO.2006.07.1159 on September 18 2006

This Article Abstract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mandelblatt, J. Articles by Feng, S. Search for Related Content PubMed PubMed Citation Articles by Mandelblatt, J. Articles by Feng, S. Social Bookmarking                            What's this?

What Is the Impact of Shared Decision Making on Treatment and Outcomes for Older Women With Breast Cancer?

Jeanne Mandelblatt, Barbara Kreling, Melissa Figeuriedo, Shibao Feng

From the Department of Oncology, Georgetown University Medical Center; and the Cancer Control Program at Lombardi Comprehensive Cancer Center, Washington, DC

Address reprint requests to Jeanne Mandelblatt, MD, MPH, Georgetown University, 3300 Whitehaven Blvd, Suite 4100, Washington, DC 20007; e-mail: mandelbj{at}georgetown.edu

	ABSTRACT

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION Authors' Disclosures of... Author Contributions REFERENCES

 
PURPOSE: Shared decision making (SDM) has been recommended as a standard of care, especially when there are treatment alternatives or uncertainty in outcomes. However, we know little about use of SDM in cancer care, and even less is known about SDM in older patients. We describe patient and physician determinants of SDM in older women with breast cancer and evaluate whether SDM is associated with treatment patterns or short-term outcomes of care.

PATIENTS AND METHODS: Women age 67 or older treated for early stage breast cancer in 29 sites from five geographic regions comprise the study sample (N = 718). Data were obtained from patients by in-person and telephone interviews. Physician data were collected via survey, and medical records were reviewed to ascertain comorbidity and tumor characteristics. Random effects and logistic regression models were used to assess associations between SDM and other factors.

RESULTS: Women who were age 67 to 74 years (v 75 or older) were accompanied to consultation and who sought information reported the highest SDM, after considering covariates. While SDM was not associated with surgical treatment, greater SDM was associated with higher odds of having adjuvant treatment, controlling for clinical factors. Greater SDM was also associated with improved short-term satisfaction.

CONCLUSION: SDM plays an important role in the process of care for older women with breast cancer. Physicians treating this growing population have a simple, but powerful tool for improving outcomes within their grasp—spending time to engage and involve older women in their breast cancer care.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION Authors' Disclosures of... Author Contributions REFERENCES

 
In 2005, approximately 211,240 women in the United States were diagnosed breast cancer¹; more than half of these new patients were among the 13% of the female population that was 65 or older (hereinafter referred to as older women).² Older women are also the most rapidly growing segment of the population, so that by 2030 one in five women is projected to be 65 or older.³ This demographic imperative, coupled with exponential increases in incidence rates of breast cancer with advancing age, will result in a dramatic increase in the absolute number of older women diagnosed with and treated for breast cancer over the coming decades.⁴

These older women are faced several important decisions and uncertainty in making their breast cancer treatment choices, including a choice between mastectomy (MST) and breast sparing surgery,^5,6 whether to have radiation after breast-conserving surgery (BCS),⁷ and balancing the risks and benefits of adjuvant therapies.^8-10

In such situations, shared decision making (SDM) has been suggested as the preferred approach to treatment decisions and has been linked with positive patient outcomes.^11-13 However, there is a paucity of research about SDM in older patients.

In this study, we use data from a large, national prospective cohort of older women to assess the correlates of SDM, evaluate if SDM is associated with treatment, and assess whether SDM is associated with short-term satisfaction with care and subjective impact of breast cancer on women's lives. We use the construct of SDM described by Charles et al¹⁴ that highlights participation in the process of decision making, information sharing, and elicitation of preferences.

	PATIENTS AND METHODS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION Authors' Disclosures of... Author Contributions REFERENCES

 
Setting and Study Population
Data for this institutional research board-approved study were collected as part of the breast cancer Outcomes and Preferences for Treatment in Older Women Nationwide Study (OPTIONS) project. The study procedures have been described elsewhere.^6,15 Briefly, the study included a convenience sample of 29 hospitals in five geographic regions (Massachusetts, Texas, District of Columbia, western New York State, and New York City) between November 1, 1995, and September 30, 1997. Women were eligible if they were community dwelling, 67 years of age or older, spoke English, and had histologically confirmed primary T₁ or T₂, N_o, N₁, or N_x, or M_o invasive breast cancer. Women with ductal carcinoma in situ, bilateral cancer, or multicentricity were excluded because BCS and MST may not have been considered equivalent choices for these women. Based on pathology reports 1,932 potentially eligible women were identified; 555 of these women were subsequently found to be ineligible due to prior breast cancer, second primary breast cancer, nonlocal or unknown stage (47%), cognitive impairment (9%), severe physical impairments (8%), bring a non-English speaker (9%), administrative delays (20%), residence in a nursing home (4%), and death within 3 months of diagnosis (3%). After these exclusions, 1,377 women were eligible. Physicians' consent was obtained to contact 1,159 (84%) of these eligible women. Of the 784 women (68%) who agreed to participate, 66 were found to be ineligible after the interviews, resulting in 718 women in the final sample.

Surgeons (N = 194) for the 718 participants were contacted to complete a survey; 138 surgeons (70%) returned the survey. Of these, there were 613 pairs (85%) of patients with matching surgeon data. Overall, included and excluded women were similar, although excluded women were older.

Data Collection
Data were collected from patient interviews, medical record abstractions, and physician surveys. Patients were contacted 6 to 24 weeks (mean, 18 weeks) after surgery to complete a face-to-face interview; telephone interviews (28%) were conducted if patients lived more than 100 miles from a study site. Clinical information was obtained through standardized review of medical records. The self-administered mailed surgeon survey included questions about their demographics, self-reported practice patterns, and attitudes toward patient participation in treatment decision making.

Measures
The outcomes of interest included local and adjuvant breast cancer treatment received, satisfaction with care, and the impact of cancer on a woman's life. Local breast cancer treatment received was categorized as BCS with radiotherapy, BCS alone, or MST. Adjuvant breast cancer treatment was self-reported use of treatment consistent with guideline recommendations (for example, chemotherapy for women who were node-positive or estrogen receptor [ER] -negative and/or tamoxifen for those who were ER-positive).⁸

Patients' overall satisfaction with breast cancer surgery and other treatment was assessed by a single item on a 5-point Likert type response scale ranging from "very satisfied" to "very dissatisfied." Because most of the participants (78.3%) selected "very satisfied," we dichotomized this variable into "very satisfied" versus all other responses. Self-rated impact of breast cancer on women's lives was also measured using a simple 5-point Likert scale.

Predictor Variables
Our main predictor variable was SDM. SDM was also the outcome for analyses examining factors associated with SDM. SDM was defined as involving the patient and physician with both participating in the process of decision making, information being shared, and patient's preferences elicited. The scale we used to measure these domains was adapted from an earlier measure of Lerman et al¹⁶ and included four patient report items: "I asked my surgeon to explain breast cancer treatments and/or procedure(s) to me in greater detail," "I asked my surgeon a lot of questions about my breast cancer treatment options," "My surgeon asked me about my worries about breast cancer," and "My surgeon encouraged me to give my opinions about my breast cancer" (Cronbach's = .80). Responses on all four items were rated on a 5-point Likert scale ranging from strongly agree to strongly disagree. Scores were normalized to a 100-point scale with higher scores indicating more SDM.

Controlling Variables
Several variables (sociodemographics, information seeking, clinical factors, regions, and surgeon characteristics) were considered as having the potential to mediate the association between SDM and outcomes. Sociodemographic factors included age, race (white/nonwhite), education, insurance (private supplemental insurance, Medicare only, Medicare and Medicaid), setting of care (health maintenance organization [HMO] v non-HMO), social support (number of adults living together), and marital status. Information seeking was measured by one item asking if women sought breast cancer information from nonphysician sources and one item about whether women were accompanied by other persons to appointments when decisions were discussed. Clinical factors included comorbidity, physical function, cancer stage, and hormone receptor status. Comorbidity was defined as the number of chronic conditions likely to affect treatment choices reported by the patient in the 2 months before breast cancer diagnosis (for example, congestive heart failure, angina, diabetes, and renal failure). Stage was defined as stage I (T1N0M0), IIa (T1N1M0 or T2N0M0), and IIb (T2N1M0), according to pathologic (75%) and/or clinical (25%) staging. ERs and progesterone receptors were considered to be positive, negative, or unknown. Physical function was defined from the Medical Outcomes Study SF 36 physical function subscale.¹⁷ Region was categorized according to the five geographic regions. Surgeon-related variables included sex, specialty training in surgical oncology (yes/no), and attitude toward SDM.¹⁸

Data Analysis
Bivariate associations between individual variables and the SDM scale were first examined using t tests and one-way analysis of variance. A linear regression model with the SDM scale as the outcome variable was then constructed entering all variables that were significant or marginally significant (P < .10) in the bivariate analyses. A linear mixed model with surgeon random effects was also fitted to control for the correlation of the SDM scores among women treated by the same surgeon. To derive the most parsimonious model, nonsignificant variables (except age and stage) were removed from the final models. Logistic and mixed logistic regression models were further developed to estimate and test the associations between treatment patterns and short-term impact and satisfaction and the SDM scale. Likelihood ratio tests were compared from the logistic and mixed logistic models to determine whether the random surgeon effects were significant in the model. If the random surgeon effects were statistically significant, the mixed logistic model was chosen as the final model. The C statistic was used to assess model fit.

	RESULTS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION Authors' Disclosures of... Author Contributions REFERENCES

 
The women in our sample were on average 75 years old. The majority of patients were white and most had private supplemental insurance in addition to Medicare coverage (Table 1).

	DISCUSSION

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION Authors' Disclosures of... Author Contributions REFERENCES

In other studies of older breast cancer patients, seeking information outside of the physician encounter occurs frequently.^11,19 In our study, seeking outside information was a correlate of SDM. Women in our study who had someone to accompany them to appointments also reported more SDM than those who went alone. This is similar to the result reported by Silliman et al¹¹ that older women would have liked someone accompany them to appointments to help know what questions to ask. These types of patient behaviors also appear to affect physician–patient interactions. For example, Charles et al¹⁴ noted that oncologists felt that patient support and information was a facilitator of SDM.

We expected that SDM would influence use of local surgery. A few studies have found that women (mean age, 60 years) who reported the greatest involvement in decision making actually chose MST.^20,21 In our prior work, we have found that older women's preferences were related to surgery, with women who preferred "getting it over with" being more likely to have MST and women more concerned with their body image receiving BCS.^22,23 These patterns would seem to imply that women were involved in SDM. Possible explanations for our negative result include possible insensitivity of our measure, differences in the aspect of SDM measured in our versus other studies, our lack of data on women's desired level of SDM, and the older age of our cohort compared with that of Katz et al.²⁰

SDM was associated with adjuvant treatment choices, an area with more clinical uncertainty, suggesting appropriate use of SDM. However, this finding was the result of a relationship among women ages 67 to 74, but not among women age 75 or older. This age effect may be result of several factors. First, it is possible that providers are involving younger women with more extensive disease in adjuvant decisions, while not recommending these modalities for the older group of women. Because we had few women with more advanced disease (stage 2b), we could not fully explore this possibility. Second, it is also possible that physicians are communicating differently with different age groups of women. That this communication difference occurred is suggested by several studies that note that physicians spend less time with and involve their older patients less often in their care than their younger patients.^24-26 Third, it is also possible that there are generational differences, with the younger cohort being more used to taking an active role in their care, and the older group being more comfortable in following physician recommendations.^11,26-29 Finally, there may have been differences in cognition and ability to engage in SDM by age. It is not possible to determine which of these ideas explains our results. Direct observation of interactions within the patient-physician dyad could be helpful in understanding the patterns we observed and designing interventions to improve use of SDM.³⁰

Our results show that more SDM is associated with greater satisfaction with treatment. In other research, women who feel that they have shared in the decision-making process are more likely to report being satisfied and have better post-treatment adjustment to cancer than women who feel that they did not participate.^11,13,31-33 For example, Silliman and her colleagues¹¹ found that involvement in care and ratings of patient-physician communication about treatment were positively associated with measures of well being in a sample of women age 55 or older. In addition, women who were engaged in the decision role that most matched their preferences were most likely to report satisfaction with breast cancer care.²¹

We would have hypothesized that SDM would ameliorate many of the negative aspects of breast cancer. However, we found the opposite—women who reported more SDM rated the subjective burden of breast cancer greater than women who reported less SDM. It is possible that women who took a more active role in their treatment decisions were, by nature, more concerned about their health and more worried about the disease. That this may be the case is supported by the result that women who were more depressed at diagnosis rated the impact of the disease as more than women who were less depressed. However, the association of SDM on impact persisted after controlling for baseline mood, suggesting that other pathways were operating. One possibility is that women who engaged in SDM also underwent more aggressive treatment and that we captured the short-term negative impact of treatment on disease burden.

There are several caveats that should be considered in evaluating our results, including measurement of SDM, generalizability, and year of the study. Our measure included only four questions and may not have captured all domains of SDM.¹⁴ However, because there was a strong association between our measure of SDM and women's report of having had a choice in their cancer treatments, the instrument had some criterion validity. In other cancer literature, SDM has been used to describe a more limited construct of decisional preferences (for example, whether the patient, the doctor, or both made/should make the decision).^21,34,35

Adding to the complexity of measuring SDM, it has been reported that there are differences in patient and provider perceptions of what actually occurred in the visit.³⁶ We relied on patient report for our indicator of SDM. We also did not evaluate the match between women's desire for SDM and actual SDM; concordance has been found to be a significant predictor of satisfaction and/or treatment selected.^21,32 The last aspect of our measurement of SDM is that all data were collected in a cross-sectional manner, so that we can not draw conclusions about causality. Also, we were measuring some SDM retrospectively, since we were asking about treatment decision making 6 to 24 weeks after diagnosis.

Our cohort was drawn from a convenience sample of hospitals and does not represent all regions of the United States, so that our results may not be representative of the US population. Our cohort was treated from 1995 to 1997 and patterns of care have been changing over time. However, relationships between SDM, treatment, and outcomes should be internally valid and not effected by the time period.

Despite these caveats, our results demonstrate that SDM plays an important role in the process of care for older women with breast cancer. Physicians treating this growing population have a simple, but powerful tool for improving outcomes within their grasp— spending time to engage and involve older women in their breast cancer care.^36,37

	Authors' Disclosures of Potential Conflicts of Interest

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION Authors' Disclosures of... Author Contributions REFERENCES

 
The authors indicated no potential conflicts of interest.

	Author Contributions

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION Authors' Disclosures of... Author Contributions REFERENCES

 

Provision of study materials or patients: Jeanne Mandelblatt, Melissa Figueiredo Collection and assembly of data: Jeanne Mandelblatt, Barbara Kreling, Melissa Figueiredo, Shibao Feng Data analysis and interpretation: Jeanne Mandelblatt, Barbara Kreling, Melissa Figueiredo, Shibao Feng Manuscript writing: Jeanne Mandelblatt Final approval of manuscript: Jeanne Mandelblatt, Barbara Kreling, Melissa Figueiredo, Shibao Feng

 

	NOTES

 
published online ahead of print at www.jco.org on September 18, 2006.

Supported by Grant No. RO1 HS 08395 from the Agency for HealthCare Research and Quality, Grant No. K05 CA96940 from the National Cancer Institute, and Grant No. KO7 AG191655 from the National Institute on Aging.

Presented at the 24th Annual Meeting of the American Society of Preventive Oncology, San Francisco, CA, March 15, 2005.

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

	REFERENCES

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION Authors' Disclosures of... Author Contributions REFERENCES

 
1. Jemal A, Murray T, Ward E, et al: Cancer statistics, 2005. CA Cancer J Clin 55:10-30, 2005[Abstract/Free Full Text]

2. National Cancer Institute. Surveillance, Epidemiology and End Results (SEER). Bethesda, MD, National Cancer Institute, 2005. www.seer.cancer.gov

3. US Bureau of the Census. Current Population Survey, July 1998. US Bureau of the Census,1998. www.bls.census/gov/cps/cpsmain.htm

4. Lash TL, Silliman RA: Prevalence of cancer. JNCI 90:399-400, 1998[Free Full Text]

5. Fisher B, Redmond C, Fisher ER, et al: Ten-year results of a randomized clinical trial comparing radical mastectomy and total mastectomy with or without radiation. N Engl J Med 312:674-681, 1985[Abstract]

6. Mandelblatt J, Yabroff KR, Kerner JF: Equitable access to cancer services: A review of barriers to quality care. Cancer 86:2378-2390, 1999[CrossRef][Medline]

7. Hughes KS, Schnaper LA, Berry D, et al: Lumpectomy plus tamoxifen with or without irradiation in women 70 years of age or older with early breast cancer. N Engl J Med 351:971-977, 2004[Abstract/Free Full Text]

8. National Comprehensive Cancer Network: Clinical practice guidelines in oncology. J Natl Comp Cancer Network, 2006. http://www.nccn.org/professionals/physician_gls/default.asp

9. Early Breast Cancer Trialists' Collaborative Group: Tamoxifen for early breast cancer: An overview of the randomised trials. Lancet 351:1451-1467, 1998[CrossRef][Medline]

10. Early Breast Cancer Trialists' Collaborative Group (EBCTCG): Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: An overview of the randomised trials. Lancet 365:1687-1717, 2005[CrossRef][Medline]

11. Silliman RA, Dukes KA, Sullivan LM, et al: Breast cancer care in older women: Sources of information, social support and emotional health outcomes. Cancer 83:706-711, 1998[CrossRef][Medline]

12. Street RL, Voigt B: Patient participation in deciding breast cancer treatment and subsequent quality of life. Med Decis Making 17:298-306, 1997[Abstract/Free Full Text]

13. Moyer A: Psychosocial outcomes of breast-conserving surgery: A meta analytic review. Health Psych 16:284-298, 1997[CrossRef]

14. Charles C, Gafni A, Whelan T: Shared decision-making in the medical encounter: What does it mean? (Or it takes at least two to tango). Soc Sci Med 44:681-692, 1997[CrossRef][Medline]

15. Mandelblatt J, Edge S, Meropol N, et al: Sequelae of axillary lymph node dissection in older women with stage 1 and 2 breast carcinoma. Cancer 95:2445-2454, 2002[CrossRef][Medline]

16. Lerman CE, Brody DS, Caputo GC, et al: Patients' perceived involvement in care scale: Relationship to attitudes about illness and medical care. J Gen Intern Med 5:29-33, 1990[Medline]

17. Ware JE, Sherbourne CD: A 36-item short form health survey (SF-36), I. Conceptual framework and item selection Med Care 30:473-483, 1992

18. Liberati A, Apolone G, Nicolucci A, et al: The role of attitudes, beliefs, and personal characteristics of Italian physicians in the surgical treatment of early breast cancer. Am J Pub Health 81:38-42, 1991[Abstract/Free Full Text]

19. Nair MG, Hickok JT, Morrow GR, et al: Sources of information used by patients to learn about chemotherapy side effects. J Cancer Educ 15:19-22, 2000[Medline]

20. Katz SJ, Lantz PM, Janz NK, et al: Patient involvement in surgery treatment decisions for breast cancer. J Clin Oncol 23:5526-5533, 2005[Abstract/Free Full Text]

21. Keating NL, Guadagnoli E, Landrum MB, et al: Treatment decision making in early-stage breast cancer: Should surgeons match patients desired level of involvement? J Clin Oncol 20:1473-1479, 2002[Abstract/Free Full Text]

22. Mandelblatt J, Hadley J, Kerner J, et al: Patterns of breast carcinoma treatment in older women: Patient preferences and clinical and physician influences. Cancer 89:561-573, 2000[CrossRef][Medline]

23. Figueiredo MI, Cullen J, Hwang YT, et al: Breast cancer treatment in older women: Does getting what you want improve your long-term body image and mental health? J Clin Oncol 22:4002-4009, 2004[Abstract/Free Full Text]

24. Keeler E, Solomon D, Beck JC, et al: Effect of patient age on duration of medical encounters with physicians. Med Care 20:1101-1108, 1982[CrossRef][Medline]

25. Radecki SE, Kane RL, Solomon D, et al: Do physicians spend less time with older patients? J AM Geriatr Soc 36:713-718, 1988[Medline]

26. Greene MG, Adelman R, Charon R, et al: Ageism in the medical encounter: An exploratory study of the doctor-elderly patient relationship. Lang Commun 6:113-124, 1986[CrossRef][Medline]

27. Degner LF, Kristjanson LJ, Bowman D, et al: Information needs and decisional preferences in women with breast cancer. JAMA 277:1485-1492, 1997

28. Beisecker AE: Aging and the desire for information and input in medical decisions: Patient consumerism in medical encounters. Gerontologist 28:330-335, 1988[Medline]

29. Turk-Charles S, Meyerowitz BE, Gatz M: Age differences in information-seeking among cancer patients. Int J Aging Hum Dev 45:85-98, 1997[Medline]

30. Bruera E, Willey JS, Palmer JL, et al: Treatment decisions for breast carcinoma: Patient preferences and physician perceptions. Cancer 94:2076-2080, 2002[CrossRef][Medline]

31. Janz NK, Wren PA, Copeland LA, et al: Patient-physician concordance: Preferences, perceptions, and factors influencing the breast cancer surgical decision. J Clin Oncol 22:3091-3098, 2004[Abstract/Free Full Text]

32. Lantz PM, Ubel PA: The use of life expectancy in cancer screening guidelines: Moving with caution from model-based evidence to evidence-based guidelines. J Gen Intern Med 20:552-553, 2005[CrossRef][Medline]

33. Moyer A, Salovey P: Patient participation in treatment decision making and the psychological consequences of breast cancer surgery. Womens Health 4:103-116, 1998[Medline]

34. Gattellari M, Butow PN, Tattersall MH: Sharing decisions in cancer care. Soc Sci Med 52:1865-1878, 2001[CrossRef][Medline]

35. Jansen SJ, Otten W, Stiggelbout AM: Factors affecting patients' perceptions of choice regarding adjuvant chemotherapy for breast cancer. Breast Cancer Res Treat 99:35-45, 2006[CrossRef][Medline]

36. Keating NL, Weeks J, Borbas C, et al: Treatment of early stage breast cancer: Do surgeons and patients agree regarding whether treatment alternatives were discussed? Br Cancer Res Treat 79:225-231, 2003[CrossRef][Medline]

37. Maly RC, Leake B, Silliman RA: Breast cancer treatment in older women: Impact of the patient-physician interaction. J Am Geriatr Soc 52:1138-1145, 2004[CrossRef][Medline]

Submitted April 26, 2006; accepted July 21, 2006.

CiteULike    Complore    Connotea    Del.icio.us    Digg    Facebook    Reddit    Technorati    Twitter    What's this?

This article has been cited by other articles:

				M. Morrow, R. Jagsi, A. K. Alderman, J. J. Griggs, S. T. Hawley, A. S. Hamilton, J. J. Graff, and S. J. Katz Surgeon Recommendations and Receipt of Mastectomy for Treatment of Breast Cancer JAMA, October 14, 2009; 302(14): 1551 - 1556. [Abstract] [Full Text] [PDF]

				S. T. Hawley, J. J. Griggs, A. S. Hamilton, J. J. Graff, N. K. Janz, M. Morrow, R. Jagsi, B. Salem, and S. J. Katz Decision Involvement and Receipt of Mastectomy Among Racially and Ethnically Diverse Breast Cancer Patients J Natl Cancer Inst, October 7, 2009; 101(19): 1337 - 1347. [Abstract] [Full Text] [PDF]

				C. Braddock III, P. L. Hudak, J. J. Feldman, S. Bereknyei, R. M. Frankel, and W. Levinson "Surgery Is Certainly One Good Option": Quality and Time-Efficiency of Informed Decision-Making in Surgery J. Bone Joint Surg. Am., September 1, 2008; 90(9): 1830 - 1838. [Abstract] [Full Text] [PDF]

				E. B. Elkin, S. H.M. Kim, E. S. Casper, D. W. Kissane, and D. Schrag Desire for Information and Involvement in Treatment Decisions: Elderly Cancer Patients' Preferences and Their Physicians' Perceptions J. Clin. Oncol., November 20, 2007; 25(33): 5275 - 5280. [Abstract] [Full Text] [PDF]

				A. D. Naik, T. T. Issac, R. L. Street Jr, and M. E. Kunik Understanding the Quality Chasm for Hypertension Control in Diabetes: A Structured Review of "Co-maneuvers" Used in Clinical Trials J Am Board Fam Med, September 1, 2007; 20(5): 469 - 478. [Abstract] [Full Text] [PDF]

				S. J. Katz and S. T. Hawley From Policy To Patients And Back: Surgical Treatment Decision Making For Patients With Breast Cancer Health Aff., May 1, 2007; 26(3): 761 - 769. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mandelblatt, J. Articles by Feng, S. Search for Related Content PubMed PubMed Citation Articles by Mandelblatt, J. Articles by Feng, S. Social Bookmarking                            What's this?