|Year : 2012 | Volume
| Issue : 2 | Page : 222-225
Participation in decision making regarding type of surgery and treatment-related satisfaction in North Indian women with early breast cancer
Sushma Agrawal, Anshu Kumar Goel, Punita Lal
Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
|Date of Web Publication||26-Jul-2012|
Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow
Source of Support: None, Conflict of Interest: None
Introduction: Breast conserving surgery followed by radiotherapy is an established modality of treatment in early breast cancer patients since three decades, but yet it has not been adopted worldwide.
Purpose: The aim of this study is to investigate the factors affecting decision making regarding type of surgery and satisfaction with type of surgery in North Indian women with early breast cancer.
Materials and Methods: A questionnaire was prepared to assess the factors responsible for decision making regarding type of surgery (breast conserving surgery (BCS) versus modified radical mastectomy (MRM) and to evaluate involvement of patient in decision making regarding the type of surgery. 47 women with early breast cancer on radiotherapy or on follow-up were interviewed by the resident doctors.
Results: Out of 47 patients, 28 underwent BCS and 19 MRM. Women undergoing BCS were younger, more literate than in those undergoing MRM. In the two arms (BCS versus MRM), decision for surgery was made by surgeon alone in 53% versus 73%, along with patient in 42% versus 6%, and only 10% women participated in decision making in each arm. Only 50% versus 30% patients had a clear understanding of the risks and benefits of both procedures in the two arms.
Conclusion: North Indian women do not independently take decision regarding any type of surgery. The reason for opting for either kind of surgery was based on surgeon's recommendation or concern about recurrence. Body image was not an issue amongst majority.
Keywords: Early breast cancer, patient involvement, patient satisfaction, type of surgery
|How to cite this article:|
Agrawal S, Goel AK, Lal P. Participation in decision making regarding type of surgery and treatment-related satisfaction in North Indian women with early breast cancer. J Can Res Ther 2012;8:222-5
|How to cite this URL:|
Agrawal S, Goel AK, Lal P. Participation in decision making regarding type of surgery and treatment-related satisfaction in North Indian women with early breast cancer. J Can Res Ther [serial online] 2012 [cited 2020 Apr 6];8:222-5. Available from: http://www.cancerjournal.net/text.asp?2012/8/2/222/98974
| > Introduction|| |
Breast cancer is the most common cancer in urban Indian females, and the second most common in the rural Indian women.  About a third belongs to the operable subgroup. Studies revealing equivalent results of breast conserving surgery (BCS) followed by radiotherapy to the whole breast as compared to mastectomy were published in 1991. Despite ample evidence, it has not been widely adopted in our country yet.  Only 10% of diagnosed patients undergo breast conserving surgery in India as compared to 70% in United States.  Low rates of BCS in our country may be due to several reasons such as advanced presentation, lack of surgical skills required for BCS and breast reconstruction, lack of radiotherapy facilities in rural region, lack of adequate expertise for radiotherapy to intact breast from the point of view of cosmesis, lack of awareness amongst patients, their providers and family members about availability of equivalent treatment options, absence of any law in our country mandating BCS as the standard procedure in early breast cancers and provision of information about the surgical options to patients with early breast cancer. Mastectomy in early breast cancers is considered as overtreatment and is a matter of concern.  There is evidence to the fact that 25% of women who undergo mastectomy are depressed, anxious, have sexual problems, have poor body image.  Several observers have suggested that large variation in patterns of surgical treatment for breast cancer is evidence of failure to involve women in making the decision about the treatment they prefer.  In response to concerns about overtreatment and lack of patient involvement, 20 states in United States have passed laws mandating that surgeons provide information about the surgical treatment options for breast cancer.  India has a long-standing tradition of paternalism with regard to patient-physician encounter and the general indifference toward health of women and insensitivity toward her sentiments for breast conservation in our society might also be the reason for prevailing mastectomy rates in our country. 
Little is known about how surgical decisions about breast cancer treatment are made in our country. Surgical treatment decision making for breast cancer involves an interplay between patients, their providers, and family members. ,, Surgeons may recommend mastectomy because of a clinical contraindication to BCS, such as multicentric or multifocal disease, or because the removal of a large tumor would result in poor cosmesis. Additionally, some surgeons may continue to harbor the opinion that mastectomy is clinically superior to BCS particularly because of the lower risk of local disease recurrence. Patient preferences also play an important role in surgical treatment decisions. Patients may prefer mastectomy over BCS because of concerns about recurrence of disease, recovery from surgery, or side effects of radiation treatment. , Factors responsible for decision making regarding the type of surgery in early breast cancer have been analyzed considerably in many developed countries but not in our country. We undertook a study to evaluate the factors responsible for decision making regarding the type of surgery in early breast cancers. The aim of this study is to explore patient perceptions about their involvement in the decision making regarding surgical treatment.
| > Materials and Methods|| |
Patients with stage I or II breast cancer, who underwent a definitive surgical procedure (BCS or mastectomy) and were either receiving adjuvant treatment or on follow up (after a complete treatment), were eligible for this study. A self-designed questionnaire was prepared to assess various factors responsible for decision making regarding type of surgery which were categorized into patient dependant variables, tumor-related variables, interaction between surgeon and patient-related variables and patient satisfaction variables. The patient-dependant variables evaluated were age category (less than or more than 50 years age), patient background (rural, urban), literacy status of the woman (literate or illiterate), employment status (employed or unemployed), sponsor for treatment (self, husband), knowledge of BSE(breast self examination), and whether treatment was reimbursable or not. The tumor-related variables evaluated were stage of cancer (I or II), maximum tumor size (clinical or pathological), and quadrant of the breast involved by the tumor, tumor belonging to right or left breast. The surgeon- and patient-related variables evaluated were decision making for type of surgery (made by surgeon alone, surgeon and husband together, patient alone), time spent by patient with surgeon (less than 15 min, 15-30 min, 30-60 min), satisfaction with the time spent with surgeon (yes or no), clear understanding of the treatment options, why they opted for BCS (concern for body image, equivalent results with both types of surgery, based on treating surgeon's preference, surgery carried out in a private setup, district hospital, medical college/ institute, number of surgeons consulted before surgery and number of visits made to surgeon prior to surgery. The patient satisfaction related variables evaluated were satisfaction with cosmesis, body image, sexual activities after surgery, presence of postoperative pain, and overall satisfaction with the outcome of treatment.
Analysis: Analyses was restricted to patients with stage 0, I, and II disease. We calculated the significance of the differences in responses between the two arms by paired t test.
| > Results|| |
47 women of early breast cancer on radiotherapy or on follow-up after completion of treatment were interviewed by a resident in training in radiation oncology (AG) or consultant radiation oncologist (SA). The study was carried out over a period of three months. The median age of patients was 47 years.7% had stage I disease and 93% had stage II disease. 38% tumors were right sided and the rest belonged to left side. Overall 46% women were illiterate, 25.5% were of rural origin, 12.8% were employed. Husbands were funding the treatment in 89.4% cases. Treatment was reimbursable in 40.4% patients. The results pertaining to patient-dependant variables, tumor-related variables, interaction between surgeon and patient-related variables and patient satisfaction variables are listed in [Table 1].
| > Discussion|| |
In this hospital based study of north Indian women with early breast cancer, we found that only 10% women participated independently in the decision making regarding the type of surgery as compared to 41.0% women in the developed countries.  This low figure of patient alone involvement in our study can be attributed to the low literacy rate(46%), rural background (25.5%), employment status (12.8%) and funding by other than self (89.4%). All these factors also lead to under-confidence in a woman leading to difficulty in interaction with the surgeon directly, and inability to perceive the implications of benefits and risks of both surgical options in early breast cancer. Though knowledge about BSE was found in only 25.5% of all women, this was significantly higher in those undergoing BCS (35.7%) as compared to MRM (10.5%, P=0.05). The decision was made by the surgeon alone in 57.4% patients or shared by surgeon and husband and or patient in 27.7% in our study as compared to 21.9 and 37.1% (surgeon and patient) in the developed countries. Our findings show that surgeons play a central role in decision making process and that they preferred BCS in tumors lying in the upper outer quadrant, smaller tumors. Counseling by the surgeon for the type of surgery is usually to the husband as our society is patriarchal and women infrequently participate in the discussion regarding management of their illness. Counseling in our institute clearly involves discussing the issues of equivalence of results between both types of surgery and that of local recurrence (2% with MRM as compared to 4% in BCS) based on the data from breast conservation trials. , Despite this, the decisions for BCS was made based on the surgeon's preference in 70% patients, and equivalence of results of BCS and MRM was the reason for decision making in only 17% cases. This shows that higher local recurrence rates with BCS have serious implication for the patient or her caregivers/spouse. The exact import of equivalent survival figures was clearly lost out in the light of higher local recurrence in our patient population. The statistical implications of 2% versus 4% recurrence rates is complex and is difficult to assimilate by the husband or patient, as is also revealed by the finding that a clear understanding of the risks and benefits of the two procedures was evident to only 40 to 50% of patients or their husbands. Also the statistics of recurrence rate belong to studies conducted in 90's or before and the technology of radiotherapy of present era has changed dramatically changing the recurrence rates to less than 1%.  Therefore, we believe that counseling should involve stating equivalence of results with the two techniques with an additional benefit of having a conserved breast for the patient. Body image issue was a reason in all women who participated in the decision making. This implies that perhaps if women are involved in decision making they would like to opt for BCS as is evident from the data that 80% of women in MRM arm would have liked to conserve their breast.
The reason for surgeon preference for MRM in 60% of our patients was tumor in other quadrants than upper outer where the cosmesis due to BCS is suboptimal. Fear of recurrence of disease and of repeat surgery was responsible for MRM in the rest 40% cases. Perhaps non reimbursability of treatment costs in 40% cases also contributed to this decision. Data from developed countries reveal that the decision for surgery was based on surgeon recommendation alone, joint decision with surgeon or self decision by patient in 5.3, 16.8, and 27% in white women as compared to 22, 16 and 27% in African American women and the reasons for taking this decision were disease recurrence, recovery from surgery and side effects due to radiotherapy. 
The perception of cosmesis of the conserved breast was 75-100% satisfactory in more than 90% patients but this data reveals cosmesis due to surgery alone as many patients were questioned at the time of postoperative radiotherapy. BCS led to satisfaction of women with their body image in 90% patients which is comparable to available literature.  It was difficult to extract information regarding sexual satisfaction due to the difficulty faced while broaching personal questions regarding sex, some patients were on postoperative radiotherapy and sexual satisfaction did not have priority over recurrence due to BCS in elderly women. Social acceptance was 100% (BCS) and 89% (MRM) which is similar to the data published by Fallowfield. 
This study had several limitations. First, most patients underwent MRM due to a relative clinical contraindication for BCS (60%) as opposed to fear of recurrence (40%) which can create bias in the interpretation of results. Second, since most of the patients interviewed had undergone surgery in our institute which is a tertiary care academic hospital based in a city, where the surgical skills are optimal, facilities available for BCS are optimal and all surgeons routinely offer a choice for both surgeries, the generalizability of the findings of this study is limited. Despite these, we still believe that this study can offer several suggestions to increase patient involvement and patient satisfaction.
| > Conclusions|| |
To conclude, the decision of breast conservation versus mastectomy was based on various tumor, host and physician related factors. This study showed that the primary treating surgeon and the patient's spouse were the key persons in this decision making. One issue which swayed the decision in favor of mastectomy over breast conservation was higher local recurrence rate following breast conservation which was based on earlier reports mentioned in literature.
Breast conserved patients had a higher satisfaction scale in terms of breast size and shape, better body image and unchanged sexual life as compared to mastectomy. Lastly, one interesting observation was that most women following mastectomy felt that, they had been involved in decision making they would have opted for breast conservation.
Participation of women in decision making can be improved by increasing their awareness regarding BSE, involvement of patients while discussing the management options. Counseling should clearly involve stating equivalence of results with the two surgical techniques with an additional benefit of having a conserved breast.
| > References|| |
|1.||National Cancer Registry Programme. Three-Year Report of Population Based Cancer Registries 2006-2008. ICMR, Bangalore, p. 13. |
|2.||NIH Consensus Conference: Treatment of early-stage breast cancer. JAMA 1991;265:391-5. |
|3.||Agarwal G, Ramakant P, Forgach ER, Rendón JC, Chaparro JM, Basurto CS, et al. Breast cancer care in developing countries. World J Surg 2009;33:2069-76. |
|4.||Katz SJ, Lantz PM, Janz NK, Fagerlin A, Schwartz K, Liu L, et al. Patient involvement in surgery treatment decisions for breast cancer. J Clin Oncol 2005;23:5526-33. |
|5.||Fallowfield LJ, Hall A, Maguire GP, Baum M. Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial. BMJ 1990;301:575-80. |
|6.||Wennberg JE. Unwarranted variations in health care delivery: Implications for academic medical centres. BMJ 2002;325:961-4. |
|7.||Nayfield SG, Bongiovanni GC, Alciati MH, Fischer RA, Bergner L. Statutory requirements for disclosure of breast cancer treatment alternatives. J Natl Cancer Inst 1994;86:1202-8. |
|8.||Available from: http://www.history-world.org/mainmenu.htm [Last accessed on 2011 Jul 20]. |
|9.||Guadagnoli E, Ward P. Patient participation in decision-making. Soc Sci Med 1998;47:329-39. |
|10.||Keating NL, Weeks JC, Borbas C, Guadagnoli E. Treatment of early stage breast cancer: Do surgeons and patients agree regarding whether treatment alternatives were discussed? Breast Cancer Res Treat 2003;79:225-31. |
|11.||Katz SJ, Lantz P, Zemencuk J. Correlates of surgical treatment type for women with noninvasive and invasive breast cancer. J Womens Health Gend Based Med 2001;10:659-70. |
|12.||Mandelblatt JS, Berg CD, Meropol NJ, Edge SB, Gold K, Hwang YT, et al. Measuring and predicting surgeons' practice styles for breast cancer treatment in older women. Med Care 2001;39:228-42. |
|13.||Ganz PA, Schag CA, Lee JJ, Sim MS. The CARES: A generic measure of health related quality of life for patients with cancer. Qual Life Res 1992;1:19-29. |
|14.||Fisher ER, Dignam J, Tan-Chiu E, Costantino J, Fisher B, Paik S, et al. Pathologic Findings from the National Surgical Adjuvant Breast Project (NSABP) Eight-Year Update of ProtocolB-17: Intraductal Carcinoma. Cancer 1999;86:429-38. |
|15.||Treatment of Early-Stage Breast Cancer. NIH Consensus Statement Online 1990;8:1-19. |
|16.||Mannino M, Yarnold JR. Local relapse rates are falling after breast conserving surgery and systemic therapy for early breast cancer: Can radiotherapy ever be safely withheld? Radiother Oncol 2009;90:14-22. |
|17.||Ohsumi S, Shimozuma K, Morita S, Hara F, Takabatake D, Takashima S, et al. Factors Associated with Health-related Quality-of-life in Breast Cancer Survivors: Influence of the Type of Surgery. Jpn J Clin Oncol 2009;39:491-6. |