What Is Important When Making Treatment Decisions in Metastatic Breast Cancer? A Qualitative Analysis of Decision-Making in Patients and Oncologists

Abstract

Background Metastatic breast cancer (MBC) is an ideal environment for shared decision‐making because of the large number of guideline‐based treatment options with similar efficacy but different toxicity profiles. This qualitative analysis describes patient and provider factors that influence decision‐making in treatment of MBC. Materials and Methods Patients and community oncologists completed in‐person interviews. Academic medical oncologists participated in focus groups. Interviews and focus groups were audio‐recorded, transcribed, and analyzed using NVivo. Using an a priori model based on the Ottawa Framework, two independent coders analyzed transcripts using a constant comparative method. Major themes and exemplary quotes were extracted. Results Participants included 20 patients with MBC, 6 community oncologists, and 5 academic oncologists. Analysis of patient interviews revealed a decision‐making process characterized by the following themes: decision‐making style, contextual factors, and preferences. Patient preference subthemes include treatment efficacy, physical side effects of treatment, emotional side effects of treatment, cognitive side effects of treatment, cost and financial toxicity, salience of cutting‐edge treatment options (clinical trial or newly approved medication), treatment logistics and convenience, personal and family responsibilities, treatment impact on daily activities, participation in self‐defining endeavors, attending important events, and pursuing important goals. Physician decisions emphasized drug‐specific characteristics (treatment efficacy, side effects, cost) rather than patient preferences, which might impact treatment choice. Conclusion Although both patients with MBC and oncologists considered treatment characteristics when making decisions, patients’ considerations were broader than oncologists’, incorporating contextual factors such as the innovative value of the treatment and life responsibilities. Differences in perspectives between patients and oncologists suggests the value of tools to facilitate systematic communication of preferences in the setting of MBC. Implications for Practice Both patients with metastatic breast cancer (MBC) and oncologists emphasized importance of efficacy and physical side effects when making treatment decisions. However, other patient considerations for making treatment decisions were broader, incorporating contextual factors such as the logistics of treatments, personal and family responsibilities, and ability to attend important events. Furthermore, individual patients varied substantially in priorities that they want considered in treatment decisions. Differences in perspectives between patients and oncologists suggest the value of tools to facilitate systematic elicitation of preferences and communication of those preferences to oncologists for integration into decision‐making in MBC.

Tailoring chemotherapy supply according to patients’ preferences: a quantitative method in colorectal cancer care

“…Results on interpersonal skills are in line with the literature, where understanding, empathy and relational versatility have been identified as relevant [44,45]. Desire for substantial engagement in decision-making has previously been demonstrated among breast cancer patients [46,47]. Furthermore, Schmidt and colleagues [2016], observed that preferences were not homogenous among lung cancer patients, and some subjects seemed to prefer a passive rather than an active role in decision-making [48].…”

Challenges Conveying Clinical Equipoise and Exploring Patient Treatment Preferences in an Oncology Trial Comparing Active Monitoring with Radiotherapy (ROAM/EORTC 1308)

“…This led them to largely accept patient treatment preferences at face value and avoid providing information to balance preferences. This is especially pertinent because the priorities that inform patients' deliberations about treatments are rather different to those that inform the deliberations of oncologists and other practitioners [34]. Practitioner reluctance to explore patient treatment preferences seemed to reflect the belief that doing so is inconsistent with patient voluntariness, founded on an assumption that voluntariness depends on independent choice [35].…”

Patient-reported factors that influence the vestibular schwannoma treatment decision: a qualitative study

“…Other patient-related factors identified in this study have not been previously reported for VS, but have been investigated in other diseases. For example, personal characteristics, such as decision-making style and a patient's trust in the physician have been reported to influence treatment decisions in metastatic breast cancer [18]. The patient's cognitions about therapy and their own past experiences have been shown to influence management decisions in diabetes mellitus type II and lumbar disc herniation [19,20].…”