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A Bedside Decision Instrument To Elicit a Patient's Preference Concerning Adjuvant Chemotherapy for Breast Cancer

Mark N. Levine, MD; Amiram Gafni, PhD; Barbara Markham, MBA; and Dawn MacFarlane, BSc, RN
[+] Article, Author, and Disclosure Information

Grant Support: By the Ontario Ministry of Health. Dr. Levine is a scientist of the Medical Research Council of Canada.

Requests for Reprints: Mark Levine, MD, OCTRF, Hamilton Regional Cancer Centre, 699 Concession Street, Hamilton, Ontario L8V 5C3, Canada.

Current Author Addresses: Dr. Levine: OCTRF, Hamilton Regional Cancer Centre, 699 Concession Street, Hamilton, Ontario L8V 5C3, Canada.

Dr. Gafni and Ms. Markham: Centre for Health Economics & Policy Analysis, Department of Clinical Epidemiology & Biostatistics, McMaster University, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada.

Ms. MacFarlane: Ontario Cancer Foundation, Ottawa Regional Centre, 190 Melrose Avenue, Ottawa, Ontario K1Y 4K7, Canada.

© 1992 American College of PhysiciansAmerican College of Physicians

Ann Intern Med. 1992;117(1):53-58. doi:10.7326/0003-4819-117-1-53
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▪ The objective of this study was to develop an instrument to help clinicians inform patients with breast cancer of risks and benefits of adjuvant chemotherapy as derived from clinical trials and to help the informed patient decide whether she prefers treatment or no treatment. The instrument consists of a visual aid (called the decision board) and written material. It provides detailed information on a patient's choices (chemotherapy or no chemotherapy), outcomes (recurrence or not), probabilities of outcomes and their meaning, and quality of life associated with treatment choice and outcome. The validity and reliability of the instrument were evaluated in 30 healthy female volunteers. It was first administered using standard estimates of recurrence for node-negative breast cancer (15% risk of recurrence without treatment, which is reduced to 10% with chemotherapy). A preference for treatment (or no treatment) was then elicited. The validity was evaluated by changing the information provided on risks and benefits and determining whether the preference changed in a predictable manner. To test for reliability, the instrument was administered 2 weeks later. Seventeen women chose chemotherapy and 13 chose no chemotherapy. In the former group, 14 women (82%) switched preference when the magnitude of benefit was reduced, and 16 (94%) switched when the toxicity of treatment was increased. For those women who chose not to receive chemotherapy, 12 (92%) switched when the benefit was increased and 100% switched when toxicity was eliminated. The reliability was excellent (κ = 0.86). The instrument has been used to elicit treatment preferences in 37 newly presenting patients with high-risk, node-negative breast cancer and has been found to be acceptable and helpful to the patient.





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