Refusing Adjuvant Treatment
Through all the years of my practice, I have frequently had difficult conversations with women who are trying to make a decision about adjuvant chemotherapy. Most of the time, is is clear whether chemotherapy is a beneficial treatment in a particular situation. For the gray areas, the advent of the Oncotype DX test has been a big help; it suggests a recurrence risk (a number, falling into low, medium, or high risk groups) for women whose tumors are ER Positive and who have negative lymph nodes. Some women, regardless of their doctor's recommendations, feel very strongly one way or another. I think of a recent single mother of twins who was told by three medical oncologists that chemotherapy was not necessary or recommended for her, but she insisted on receiving it--feeling that she had to do absolutely everything possible to stay alive. On the other hand, I recently spoke with a woman who had been told by two medical oncologists that she should have chemotherapy, and she flatly refused.
Clearly, our own experiences, perspectives, attitudes, values, and life situations impact our thinking. I was very interested in this recent article by Leventhal et al from the Journal of Clinical Oncology. It describes the underuse of adjuvant therapy as related to patients' knowledge, beliefs, and medical mistrust. Here is a quote:
OncologyStat® One Source, Many Resources.® By Elsevier
Underuse of Breast Cancer Adjuvant Treatment: Patient Knowledge, Beliefs, and Medical Mistrust
J Clin Oncol. 2009 Sept 21; Epub ahead of print, NA Bickell, J Weidmann, K Fei, JJ Lin, H Leventhal
Supplementary editorial provided by OncologySTAT
Underuse of adjuvant therapy for breast cancer is more common among patients with certain knowledge, beliefs, and attitudes.
Improved communication with patients may influence their willingness to undergo adjuvant therapy.
STUDY IN CONTEXT
Approximately one-third of women eligible for adjuvant treatment of early-stage breast cancer refuse this treatment. Previous studies have shown that beliefs and attitudes play a large part in such decisions. Patients who have more positive beliefs about the benefits and risks of tamoxifen therapy, for instance, are more likely to adhere to therapy. Other studies have shown that patients' knowledge, as well as their beliefs and perceptions, influences treatment choice. This study surveyed patients' beliefs and knowledge on the use of adjuvant therapy for early-stage breast cancer. The objective was to identify remediable factors that, if addressed by physicians during patient encounters, may improve rates of adjuvant therapy use.
Patients were eligible for the study if they had new, primary stage I or II breast cancer, for which they underwent definitive surgery, and were participating in a physician-centered tracking and feedback intervention study. The patients were surveyed 6 months >postsurgery to assess their beliefs, attitudes, and knowledge about breast cancer, including its treatment. Patients were also surveyed regarding their experience with health care, perceived racism, instrumental and emotional support, and general and emotional health status.
A total of 401 women were eligible for the study, of whom 258 provided assessable data. Based upon treatment guidelines, 34 women who should have received adjuvant therapy did not, including 12.5% of the 64 women who should have received chemotherapy, 7.3% of the 150 women who should have received hormonal therapy, and 8.6% of the 174 women who should have received radiotherapy.
Underuse of adjuvant therapy was associated with older age, Medicare (vs commercial) insurance, greater comorbidities, and less instrumental social support. Factors that did not influence underuse included ethnicity, level of education, access to care, health status, emotional social support, or type of hospital. Women who were less likely to receive adjuvant therapy were those with lower levels of self-efficacy. In addition, patients who did not know that adjuvant therapies increased survival and those who believed that adjuvant therapies were harmful were less likely to agree to have therapy. Similarly, those who were less willing to undergo painful or unpleasant treatments, even though that might improve their chances of survival, were unlikely to undergo adjuvant therapy. Finally, women with greater mistrust of the medical system were also represented in the group of patients for whom adjuvant therapy was underutilized. On multivariate analysis, older age, comorbidity, knowledge and beliefs about treatment, and mistrust of the medical system were the factors most associated with underuse of adjuvant therapy.
Unlike age and comorbidities, knowledge and beliefs about adjuvant treatment and mistrust of the medical system are factors that are modifiable and could possibly be influenced by improved communication with patients. The authors suggested that a combined approach, involving both printed information and personal support, may improve communication. Personal support may be available through a patient assistance provider, who can offer educational information as well as emotional and practical support. Mistrust of the medical system may be addressed by fostering open communication.