Research carried out at the Ulleval University Hospital in Oslo, Norway, has revealed that breast cancer surgeons do not always offer a choice between mastectomy and breast-conserving surgery to women with early stage breast cancer, even when either option is medically appropriate.
Mrs. Inger Schou Bredal told the 3rd European Breast Cancer Conference in Barcelona today (Wednesday 22 March) that, in addition, the women’s perceptions of when they had been offered a choice by the surgeon differed significantly from the surgeons’ perceptions of when they had offered a choice. The sex of the surgeon also made a difference, with female surgeons basing their recommendations on their assessment of the women’s need for security, while male surgeons put more emphasis on how important they felt the breast was for the women’s feelings of femininity.
Mrs. Schou Bredal, a doctoral student in nursing science at the hospital, asked 194 women with early stage breast cancer and 25 surgeons to complete questionnaires. The aim was to discover whether women’s perceptions of receiving a choice between mastectomy (MAS) and breast-conserving surgery (BCS) matched the surgeons’ perceptions of giving a choice, and to assess if factors influencing the women’s choice of surgery were the same as the factors which influenced the surgeons’ recommendations.
She found that even when surgeons considered that it was medically appropriate to give 81% of women a choice, they only offered a choice in 62% of cases. Amongst the patients, 59% of the women felt they had been offered a choice between MAS and BCS. In only 38% of cases was there complete agreement between the women’s assessment of receiving a choice and the surgeons’ of giving a choice.
Factors that most influenced the women’s choices were fear of cancer recurrence (in 89% of cases), the necessity of further treatment (72%) and the surgeons’ recommendations (70%). For surgeons, medical assessment (in 97% of cases) was the most important factor, followed by the breast appearance in relation to surgical outcome (82%). Women who were not given a specific recommendation tended to choose BCS (66%).
Mrs. Schou Bredal said: “From this research it is clear that factors influencing the women’s choice of surgery are not the same as the factors influencing the surgeons’ recommendations. Yet the most influential person for the woman in the decision-making process is the surgeon. The vast majority of women complied with their surgeon’s recommendation for a particular type of surgery – 91% of women followed the surgeon’s advice and when they didn’t it was usually because they chose to have a mastectomy rather than BCS because they were afraid of cancer recurrence.
“I have not asked the surgeons what reason they had for not giving a choice and I think it would be interesting to do a survey asking surgeons why they didn’t give a choice when either treatment was a medical possibility, and why they emphasise the factors they do when giving a recommendation.
“However, from my experience as a breast cancer nurse, I think there are several reasons why sometimes no choice is offered. The surgeons may assess that the woman doesn’t want to make the choice, or they evaluate that the woman 's capacity for enduring further treatment is poor (because BCS is followed by radiotherapy) and therefore decide on mastectomy. My study supports this possibility because women who had BCS were given a choice more often than women who had mastectomies. The surgeons may have felt that the cosmetic outcome after surgery would be poor if the women choose BCS and therefore recommended mastectomy.
Other explanations could be that some surgeons may have felt that, regardless of the information given, the women could never completely comprehend the information because of their lack of medical knowledge, or that the time they spent with each woman was too brief to fully outline and discuss all treatment options, or the surgeon felt a genuine dilemma about sharing too much information and making patients assume more responsibility for treatment decision.”
Although there was total agreement in only 38% of cases between the women’s and the surgeons’ perceptions of a choice being offered, Mrs Schou Bredal explained that the questionnaire used a four-point scale from “not at all” to “very much”. Therefore women could answer that they felt they had been offered “a little” choice, while the surgeon might answer that he or she had offered “a lot” of choice. She said: “The low percentage mainly shows how differently two people can perceive the same encounter.”
The study also showed that not all women want to participate in decision-making. “This finding is of interest in the current health care delivery climate in Norway, where active participation is being encouraged,” she said. “We also found that demographic variables such as age and education had no impact on women’s preferences for participation in treatment decision-making. This suggests that health care professionals should be cautious about stereotyping women and should be systematic in assessing each woman’s preference for participation in decision-making.
“Also, this research proved how vital it is for the women to receive adequate information for making a choice of treatment, and how important it is that women are followed up to check that they have received and understood the information given. Therefore, it has been decided that that all women receiving diagnosis of breast cancer at our hospital will be contacted by our breast cancer nurse.
“The finding that the gender of the surgeon affected their recommendations to patients underlines the rather subjective nature of breast cancer treatment,” continued Mrs Schou Bredal. “The important point here is that surgeons should be aware of this fact, and that they should try to assess the needs of the women individually before giving a recommendation. It could be argued that female surgeons have more empathy with their patients and therefore more female surgeons should be recruited. However I also know that some women prefer male surgeons, so it is not a straightforward issue.”
Mrs. Schou Bredal concluded: “This research has not been released yet at our hospital, however I have discussed my findings with some of our surgeons and they were not aware that their gender had any influence on their recommendation. Also they found the result that not all women wanted to participate in treatment-making decisions interesting. They acknowledge that more time is needed for consultations, and that all women should be given the opportunity to contact our breast cancer nurse for further consultation.”
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