Women's use of resources in decision-making for early-stage breast cancer: results of a community-based survey.

BACKGROUND: The majority of women with stage I/II breast cancer may choose between mastectomy and breast-conserving therapy (BCT). A survey was designed to examine the resources women used in making this decision.
METHODS: From 1990 to 1994, 261 patients were diagnosed with or treated for stage I/II breast cancer at Washington Hospital (Fremont, CA). One-hundred seventy-six surviving patients received a questionnaire asking them to anonymously rank various medical and nonmedical persons, audio and visual materials, and decision criteria on a 5-point scale with regard to their influence on that individual's choice to undergo BCT or mastectomy. The BCT and mastectomy groups were similar demographically; approximately 50% were college-educated. Statistical significance of the difference in means between groups was assessed with the t test. The response rate to the survey was 65%.
RESULTS: The average survey ranking was > 1.0 for the following: surgeon (4.5), primary care physician (2.8), spouse (2.4), radiation oncologist (1.7), medical oncologist (1.5), American Cancer Society brochure (1.4), and children (1.2). The ranking of children (p = 0.08), friends (p = 0.08), parents (p = 0.09), and spouse (p = 0.13) was higher in the mastectomy group; the ranking of the radiation oncologist (p = 0.001) and ACS brochure (p = 0.03) was higher in the BCT group. The majority of patients consulted only with the surgeon (96%), primary care physician (64%), and spouse (55% overall, 75% among married patients) before making a treatment choice. Decision criteria were ranked as follows: chance for cure (4.5), physician recommendation (3.7), potential side effects (1.7), cosmetic appearance (1.3), sexual attractiveness (1.1), treatment convenience (1.0), and desire to avoid mastectomy (1.5). Desire to avoid mastectomy was higher in the BCT group (p < 0.0001); ranking of chance for cure was higher in the mastectomy group (p = 0.12). Overall satisfaction was higher in the BCT group; 87% of these patients were "very satisfied" with their decision versus 68% for the mastectomy group (p = 0.005). Review of the admitting records for 125 patients treated with mastectomy indicated that 46% had clear medical or personal contra-indications to BCT, but that the remainder might have benefitted from specialty consultation.
CONCLUSIONS: The surgeon's recommendation and the patient's perception of chance for cure were the most influential factors affecting treatment decision. There was a limited use of specialty consultation or written and audiovisual materials in this educated patient population. The survey results suggest potential areas of intervention to improve rates of BCT, namely use of up-front multidisciplinary evaluation, further education of primary care physicians, and greater attention to concerns of family members.