Presenting on day 3 of of Miami Breast Cancer Conference, Jean L. Wright, MD, Chair of the Department of Radiation Oncology at UNC Medical School, described an important trend from the last few years: More and more patients aim to take an active role in their care plan, aligning with the growing awareness among patients and physicians on the importance of shared decision-making.

Many patients prefer a more active role

Sometimes, however, patients make a choice that MDs, or their treatment guidelines, do not support. Dr. Wright considered data from the International Journal of Radiation Oncology, Biology, and Physics, which found that 30% of cases saw patients receiving radiation therapy alone without endocrine therapy—something she thinks could have been driven by patient choice.

Gerber NK, Shao H, Cadha M, et al. Radiation Without Endocrine Therapy in Older Women With Stage I Estrogen-Receptor-Positive Breast Cancer is Not Associated With a Higher Risk of Second Breast Cancer Events. Int. J. Radiat. Oncol. Biol. Phys. January 1, 2022.

“RT alone is becoming a reasonable option as data matures,” Dr. Wright said, “and our patients are choosing that. So we need to be patient and courteous when we have these conversations. But short of asking their intentions, there’s not a great way to know what a patient is gonna do with endocrine therapy.”

The spectrum of patient choices is wide-ranging, she says. “Patients can be coming from very very different places,” she says. “But many want comprehensive information provided to them and then to engage in a shared process.”

Here's what physicians can do

She pointed to an investigation published in JAMA

Joshi S, Ramarajan L, Ramarajan N, et al. Effectiveness of a Decision Aid Plus Standard Care in Surgical Management Among Patients With Early Breast Cancer: A Randomised Clinical Trial. JAMA Netw Open. 2023;6(10):e2335941. doi:10.1001/jamanetworkopen.2023.35941

which looked at a decision-making aid for breast cancer patients. It offered an online, self-administered survey used outside of the clinician encounter. “It guides a patient through scenarios, between lumpectomy and mastectomy…and they answer it with a clear mind, at home,” Dr. Wright said. “Decisional conflict was reduced when the survey was used. It helps make patients feel comfortable and confident. It’s relatively easy to do.”

She also discussed utilising a single-item questionnaire, which asks patients how they prefer decisions made about which post-surgical treatment to have for their breast cancer. They could select answers ranging from “the doctor should make the decision with little input from me” to “I should make the decision with little input from my doctor.”

The Medical Minimiser-Maximiser scale is another tool, allowing patients to select on a scale of 1-10 how much care they want to take action vs how much they want to wait and see. The American Psychological Association says preferences may be predictive of health care utilisation and treatment preferences across a range of healthcare contexts.

Scherer LD, Caverly TJ, Burke J, et al, (2016). Development of the Medical Maximiser-Minimiser Scale. Health Psychology, 35(11), 1276–1287. doi.org/10.1037/hea0000417.