Decision Aid Improves Breast Cancer Patients’ Knowledge of Surgical Options

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A Web-based decision aid that allows women with early breast cancer to easily compare surgical treatment options helps them make more informed decisions, suggests a randomized trial reported at the 2017 Society of Surgical Oncology (SSO) Annual Cancer Symposium.1

Receipt of a preconsultation decision aid may decrease the urgency patients feel around decision-making, and this may ultimately increase the quality of the patient-surgeon consultation as well as patient decision-making.
— Heather B. Neuman, MD, MS

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“Having knowledge of surgical options is a prerequisite for active patient participation in breast cancer surgery decision-making,” commented senior author Heather B. Neuman, MD, MS, Associate Professor in the Division of Surgical Oncology at the University of Wisconsin School of Medicine and Public Health in Madison. “Prior research suggests that information can be most beneficial if patients receive it prior to the consultation. However, delivering it routinely in that narrow window between diagnosis and the consultation can be challenging.”

Preconsultation Information

In the trial, 309 women were sent an e-mail before their first visit with a breast surgeon that contained either a link to the decision aid—which included textual explanations, video vignettes, and comparison tools such as tables—or links to high-quality standard cancer websites.

Immediately before their visit, the decision-aid group correctly answered 80% of knowledge questions related to breast surgery, whereas the group sent links to standard websites answered 66% correctly. In particular, the former were more likely to know that waiting a few weeks to make a treatment decision would have minimal impact on their survival.

“Patients found receipt of any preconsultation information highly beneficial,” Dr. Neuman commented. “Receiving a decision aid resulted in improved knowledge over receiving selected standard websites, especially on that key concept of whether there was an impact on survival of waiting a few weeks. Receipt of a preconsultation decision aid may decrease the urgency patients feel around decision-making, and this may ultimately increase the quality of the patient-surgeon consultation as well as patient decision-making.”

Sorting out the impact of the decision aid on treatment preferences, such as among women who were candidates for breast conservation, has been more difficult, she noted. For example, many women were still uncertain about their preference after their visit because they often were waiting on information from the surgeon or needed magnetic resonance imaging or genetic testing.

“Knowledge is one piece, and knowledge is definitely a requirement for patients to be involved. But the really important thing is making a decision that’s going to align with their preferences,” she said.

Study Details

The investigators previously established the feasibility and acceptability to both patients and clinicians of using online preconsultation information to facilitate treatment decision-making, according to Dr. Neuman. But they felt those merits were not sufficient to justify its routine use.

“We thought it would be important to know what the impact on outcomes would be, specifically on patient knowledge of key concepts. We also wanted to have some insight into what format of information would be most beneficial,” she elaborated. “One option would be to send patients selected high-quality websites; they would be websites that would be available in an online search but that patients may or may not find on their own. The second option would be using a decision aid. Decision aids consistently improved patients’ knowledge in every study that has been done; however, many of them are commercially developed, and there’s a cost associated with their use.”

The investigators recruited to the trial women from one academic clinic and one community breast clinic in Madison, Wisconsin, who had early (stage 0–III) breast cancer, spoke English, and were seeing a breast surgeon for the first time.

They were randomized to receive by e-mail either links to standard high-quality websites (American Cancer Society [],, and the National Cancer Institute’s Breast Cancer Treatment PDQ []) or a link to an online decision aid developed by Health Dialog (a care management, employee wellness, and decision support provider owned by Rite Aid). The latter helped patients compare three surgical options: mastectomy alone, mastectomy with reconstruction, and lumpectomy with radiation therapy.

“The decision aid that we chose compares things in parallel,” Dr. Neuman commented. “It includes video vignettes where patients describe how they made their decision and then information that’s specific to the choices, such as local recurrence data after lumpectomy or what a breast prosthesis would be like. It also includes sections on how to compare the treatments and things like tables to facilitate that comparison.”

Before seeing the surgeon, women completed a survey that contained five knowledge questions from the Breast Cancer Decision Quality Instrument,2 as well as questions about perceived helpfulness of the information and sociodemographics.

Participants were about 60 years old on average, and nearly all were non-Hispanic white women. Most had at least some college education and an above-median socioeconomic status. About three-fourths used the Internet multiple times per day.

Key Findings

Results showed that the median percentage of knowledge questions answered correctly was higher in the decision-aid group than in the standard-websites group (80% vs 66%, P = .01).

The trial lacked a usual-care arm, Dr. Neuman acknowledged. However, in a separate cohort of 18 women who had received the clinics’ usual care—meaning no information was sent to them—the median percentage of correct answers was 60%.

When it came to individual concepts, the decision-aid group was more likely to correctly know that there was minimal survival impact of waiting a few weeks to make a treatment decision (72% vs 54%, P < .01). The value was sharply lower, at 24%, in the separate usual-care cohort.

The decision-aid and standard-websites groups were statistically indistinguishable with respect to correctly answering questions about relative survival for each surgical option (84% and 74%), likelihood of death from breast cancer (92% and 86%), the procedure with the highest risk of second surgery (70% and 70%), and the procedure with the highest risk of recurrence (50% and 46%).

Women in both groups similarly rated the information they found as helpful, giving it a mean score of 8 out of 10.

“This was a mostly white, fairly educated, and fairly affluent population. It’s possible that our findings would not be the same if we went to another center,” Dr. Neuman acknowledged. “Some of the prior work on decision aids has suggested that they actually have the biggest benefit in knowledge in patients who are starting out with the lowest baseline education level, so it’s possible that our findings would actually be accentuated in other settings.” ■

Disclosure: Dr. Neuman reported no potential conflicts of interest.


1. Steffens N, Tucholka JL, Yang D, et al: A randomized controlled trial evaluating the impact of web-based information on breast cancer patients’ knowledge of surgical treatment options. 2017 SSO Annual Cancer Symposium. Abstract 9. Presented March 16, 2017.

2. Sepucha KR, Belkora JK, Chang Y, et al: Measuring decision quality: Psychometric evaluation of a new instrument for breast cancer surgery. BMC Med Inform Decis Mak 12:51, 2012.

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“Their study demonstrates that the provision of high-quality information can...