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Zikmund-Fisher BJ, Janz NK, Hawley ST, Griffith KA, Sabolch A, Jagsi R. Communication of Recurrence Risk Estimates to Patients Diagnosed With Breast Cancer . JAMA Oncol. 2016;2(5):684–686. doi:10.1001/jamaoncol.2015.6416
For patients with breast cancer to play active roles in treatment decisions, they must understand their risk of cancer recurrence and how that risk changes with different treatments. Such information is available to treating clinicians through tools such as AdjuvantOnline,1,2 and the use of such tools may reduce patient selection of treatments with low risk reduction.3,4 Our objective was to identify how often medical oncologists and surgeons use such tools or provide patients diagnosed as having breast cancer with detailed recurrence risk information, as well as to explore what clinician characteristics influence these behaviors.
After approval by the institutional review board of the University of Michigan, in 2012, we mailed a questionnaire and a $50 cash incentive to 750 medical oncologists and 750 surgeons randomly selected from the American Medical Association Physician Masterfile, a relatively comprehensive list of US physicians. We used a modified Dillman approach to maximize the response rate.
We presented a clinical vignette of a 45-year-old woman with estrogen receptor (ER) and prohesterone receptor (PR) positive, ERBB2-negative (referred to as HER2 or HER2/neu-negative in the vignette) breast cancer who chose to undergo lumpectomy for a pT1c, N0, grade 2 infiltrating ductal carcinoma with negative surgical margins. Participating surgeons then answered 4 questions about communication of risk information: “In a case like this, would you…” (A) “use an online calculator (like AdjuvantOnline) to help estimate the patient’s recurrence risks,” (B) “discuss recurrence risk using specific numerical risk estimates (eg, 10-year risk of recurrence) with the patient,” (C) “discuss recurrence risk using descriptive words such as “high risk” or “low chance” (regardless of whether you provide numerical estimates to patients),” and (D) “give patients a copy of recurrence risk numbers to take home”? Response options were “definitely yes,” “probably yes,” “probably no,” and “definitely no” and were dichotomized for analysis. Participating medical oncologists answered identical items but with the modifier “systemic” for recurrence risk in items B and C.
Respondents also reported their personal and practice characteristics: years since residency, sex, practice setting, whether their primary practice has residents and/or fellows (as a marker of academic contexts), number of new patients with breast cancer seen in the past 12 months, and availability of same-day multispecialty appointments for new patients with breast cancer. Race was self-reported and included in this study as a potentially relevant sociodemographic feature of the respondents.
Using SAS statistical software (version 9.2), we described responses regarding communication of risk information and then used logistic regression models with communication practices designated as the binary dependent variable and specialty and respondent personal and practice characteristics as the independent variables.
In total, 498 of 750 surgeons (66.4%) and 398 of 750 medical oncologists (53.0%) returned surveys. We excluded 95 surgeons and 35 medical oncologists who reported not having seen patients with breast cancer. Table 1 details the personal and practice characteristics of the physicians whose responses were analyzed.
Most medical oncologists (84% ) and surgeons (85% ) reported discussing recurrence using verbal terms such as high risk. Although 76% (269) of medical oncologists reported using online risk calculators, 88% (311), discussing numerical risk estimates, and 71% (253), giving patients a copy of risk numbers, rates of these behaviors reported among surgeons were dramatically lower (24% , 47% , and 17% , respectively; P < .001 for all comparisons after multivariable adjustment).
Multivariable analyses (Table 2) identified clinical specialty and whether the clinician’s practice offers same-day multispecialty appointments as the 2 primary predictors of recurrence risk communication practices. Clinicians whose practices offer same-day multispecialty appointments were more likely to use risk calculators or discuss numerical risk estimates with patients.
After controlling for demographics and other practice characteristics, medical oncologists were found to be far more likely than surgeons to quantify risk estimates for patients. As in any survey, biases due to nonresponse or misclassification are possible but are unlikely to be the sole explanation for the interspecialty differences observed. Patients who do not see a medical oncologist until after surgery, if at all, may make treatment decisions (including the increasingly common decision to remove the contralateral breast)5 without full understanding of relevant risk information. Ensuring that all patients with breast cancer have timely access to such data is essential to supporting shared and value-congruent decision-making.6
Corresponding Author: Reshma Jagsi, MD, DPhil, Department of Radiation Oncology, University of Michigan, UHB2C490, SPC 5010, 1500E Medical Center Dr, Ann Arbor, MI 48109-5010 (email@example.com).
Published Online: February 18, 2016. doi:10.1001/jamaoncol.2015.6416.
Author Contributions: Mr Griffith and Dr Jagsi had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Zikmund-Fisher, Hawley, Griffith, Jagsi.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Zikmund-Fisher, Sabolch, Jagsi.
Critical revision of the manuscript for important intellectual content: All authors.
Obtained funding: Jagsi.
Administrative, technical, or material support: Sabolch, Jagsi.
Study supervision: Janz, Jagsi.
Conflict of Interest Disclosures: None reported.
Funding/Support: This work was supported by a Young Investigator Award from the National Comprehensive Cancer Network Foundation to Dr Jagsi.
Role of the Funder/Sponsor: The funder played no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.
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