CHICAGO – By definition, all clinical care is – or should be – patient-centered care, and that is especially true for older women with early stage breast cancer.
“Older women need to be informed of the benefits and risks of their treatment options, including the option of omitting a treatment,” said Mara Schonberg, MD, MPH, of the division of general medicine and primary care at Beth Israel Deaconess Medical Center in Boston.
“High quality shared decision-making considers a woman’s risk of recurrence, her tumor characteristics, her overall prognosis based on her general health, the lag-time to benefit from the treatment – how long will it take for this treatment to likely have an effect or a real chance of having any benefit for her – and her values and preferences,” she explained. Dr. Schonberg was speaking at a session on the management of care for older women with breast cancer held during the recent American Society of Clinical Oncology (ASCO) annual meeting.
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For example, patients may need to choose between mastectomy or breast conserving surgery (BCS), whether to have radiotherapy after BCS, what type of radiotherapy (e.g., whole breast, partial breast, accelerated partial breast irradiation, boost dose) to have, whether to undergo a lymph node biopsy, and whether to opt for primary endocrine therapy instead of surgery or radiation.
“It is really important that we think about all these decisions that older women face in their preference-sensitive decisions and that we include them in the decision-making, probably even starting at the time of mammography,” Dr. Schonberg said.
Decision-making partnership
Doctor–patient shared decision making improves patient care by helping the patients understand the best available evidence on the risks and benefits of specific choices and their alternatives, Dr. Schonberg said. Discussing and considering all the available options allows the doctor and patient to arrive together at an informed decision based on the individual patient’s needs and preferences, she emphasized.
“It’s particularly useful when there are multiple treatment options, when there’s uncertainty regarding the evidence or uncertainty regarding which patients may benefit or on the outcome, when there are both treatment advantages and disadvantages that patients must weigh, and when the decision is high impact, like for breast cancer treatment,” she said.
Shared decision-making can be complicated by barriers of time, how care is organized, lack of clinician training in patient-centered communication, and mistaken assumptions on the part of clinicians about a particular patient’s preferences or willingness to participate in the process.
Dr. Schonberg and colleagues created the website ePrognosis to consolidate prognostic indices designed to aid clinical decision-making for older adults who do not have a dominant terminal diagnosis. The site contains links to prognostic calculators, information about time to benefit for various cancer screening programs based on life expectancy, and helpful information about communicating information about prognosis, risks, and benefits to patients.