Physician‐related facilitators and barriers to patient involvement in treatment decision making in early stage breast cancer: perspectives of physicians and patients

Objective To identify patients’ and physicians’ perceptions of physician‐related verbal and nonverbal facilitators and barriers to patient involvement in treatment decision making (TDM) occurring during clinical encounters for women with early stage breast cancer (ESBC). Methods Eligible women were offered treatment options including surgery and adjuvant therapy. Eligible physicians provided care for women with ESBC in either a teaching hospital or an academic cancer centre. In Phase 1, women were interviewed 1–2 weeks after their initial consultation. In Phase 2, women and their physicians were interviewed separately while watching their own consultation on a digital video disk. All interviews were audiotaped, transcribed and analysed. Results Forty women with ESBC and six physicians participated. Patients and physicians identified thirteen categories of physician facilitators of women’s involvement. Of these, seven categories were frequently identified by women: conveyed a rationale for patient involvement in TDM; explained the risk of cancer recurrence; explained treatment options; enhanced patient understanding of information; gave time for TDM; offered a treatment recommendation; and made women feel comfortable. Physicians described similar information‐giving facilitators but less often mentioned other facilitators. Few physician barriers to women’s involvement in TDM were identified. Conclusions Women with ESBC and cancer physicians shared some views of how physicians involve patients in TDM, although there were important differences. Physicians may underestimate the importance that women’s place on understanding the rationale for their involvement in TDM and on feeling comfortable during the consultation.     

Physicians' and Women's Views on Hormone Therapy and Breast Cancer Risk After the WHI: A Qualitative Study

Background: The use of menopausal hormone therapy (HT) has significantly declined since the release of the Women's Health Initiative findings, but to what extent physicians' and women's concerns about breast cancer contributed to this change is unknown. Our study explored physicians' and women's beliefs about hormone therapy and breast cancer risk.

Methods: We conducted qualitative in-depth interviews with 22 primary care physicians and 45 female patients at two large integrated health care delivery systems in Washington State and Massachusetts.

Results: Concerns about breast cancer risk weighed into the decision-making process for physicians and women in initiating and continuing hormone therapy. For women, control of menopausal symptoms was important and possibly outweighed their concerns about the potential risks of breast cancer. Though concerned about its association with increasing breast cancer risk, physicians were willing to consider hormone therapy to manage women's menopausal symptoms but were frustrated about the lack of available non-hormone therapy alternatives. Most physicians and some women were aware of the Women's Health Initiative, and its findings appeared to influence their beliefs about hormone therapy and breast cancer risk, though doubts remained among both groups about the study findings and implications.

Conclusions: Our qualitative study suggests that after the Women's Health Initiative, concerns about breast cancer risk weighed into decisions to initiate and continue hormone therapy for both physicians and women, but menopausal symptoms often directed use.     

The presentation and management of female breast symptoms in general practice in Sheffield.

BACKGROUND: Relatively little is known about the incidence of breast symptoms in primary care consultations and GPs' patterns of referral to secondary care. OBJECTIVE: We aimed to identify the consultation rate for breast symptoms in general practice and to describe the management of those symptoms, including patterns of referral to secondary care. METHOD: Prospective data were collected by 248 GPs concerning 508 women consulting for breast symptoms. A verification study was carried out in nine practices to compare the data collected prospectively with information recorded contemporaneously in the same patients' notes. Main outcome measures were number of patients with lump, pain, nipple discharge, skin or nipple problems, family history or other symptoms at first or subsequent consultation, management action, age of patient and number of patients meeting study criteria for whom GPs did not record information in the prospective study. RESULTS: The mean number of consultations per GP over the 4-week recording period was 2.05. However, examination of a patient's notes from a sample of nine practices participating in the verification study suggested that GPs recorded only slightly over half of the consultations for breast symptoms on the study pro forma. At their first consultation, 40% of women presented with a breast lump and 40% with breast pain. Fifty-eight per cent of women with lumps were referred for specialist evaluation after a first or subsequent consultation, whereas the comparable percentage for women referred for pain was 17%. CONCLUSIONS: At an initial consultation for breast symptoms, GPs refer approximately one-third of women to secondary care. Women are most likely to be referred for a lump or for a family history of breast cancer and least likely to be referred for breast pain. The verification study suggests that relying on GPs to collect data on a specific group of patients may produce an underestimate of the consultation rates for a specified condition.     

Breast Cancer Survivorship—Intersecting Gendered Discourses in a 5-Year Follow-Up Study

In this article the authors present a follow-up study of women's interview narratives about life 5 to 7 years after a breast cancer operation. The women had taken part in a study during the 6-month postoperation period. Art therapy contributed to well-being, including strengthening personal boundaries. In the new study, interview analysis informed by critical discursive psychology indicated three problematic discourses that the women still struggled with several years after the operation: the female survivor, the “good woman,” and individual responsibility. We concluded that many women with a history of breast cancer need support several years after their medical treatment is finished.     

The Effects of Experienced Uncertainty and Patients’ Assessments of Cancer-Related Information-Seeking Experiences on Fatalistic Beliefs and Trust in Physicians

Using the 2013 HINTS 4 Cycle 2 data representing a general population sample, this study investigates the effects of patients’ experiences of uncertainty about prostate cancer during doctor–patient communication, as well as patients’ positive assessments of their cancer-related information-seeking experiences, on their fatalistic beliefs regarding cancer and their trust in physicians. Our tests show significant differences in trust in physicians among men who do and do not experience uncertainty about the prostate-specific antigen (PSA) test during doctor–patient communication. The analysis also indicates that individuals with experiences of uncertainty about the PSA test are more likely than those without such experiences of uncertainty to place their trust in doctors. However, no apparent difference or association exists when there are uncertainties relating to treatment choices regarding slow-growing cancer or treatment side effects. Nevertheless, as hypothesized, individuals who positively evaluate their cancer-related information-seeking experiences are less likely to have fatalistic beliefs about cancer. Furthermore, patients’ positive assessments are highly predictive of their levels of trust in their physicians. Additionally, tests of interaction effects show that individuals’ levels of education moderate the association between uncertainty experiences about the PSA test and both cancer fatalism and trust in physicians. Further implications and limitations of the study are discussed.     

136例早期乳腺癌保乳治疗的临床研究

目的:观察早期乳腺癌保乳手术治疗效果。方法:回顾性分析该院乳腺二科2000~2005年0~Ⅱb期女性乳腺癌患者136例行保乳手术的疗效。采用肿瘤局部扩大切除及腋淋巴结清扫,术后辅以化疗、放疗或内分泌治疗。残留腺体缝合或不缝合以保证乳腺外形。结果:保乳术后乳房外形总体满意。皮下积液发生率为7.3%。随访结果局部复发率为0.7%。无远处转移,无死亡病例。其中1例病人因心理因素于保乳术后1年自行在外院行全乳切除。结论:保乳手术具有创伤小,并发症少,外形改变小,疗效满意,生存质量高等优点。     

放疗网络社区的构建及临床应用

目的探讨放疗患者网络社区的构建与临床应用。方法网络社区设计采用ASP语言，以SQL Server 2000为数据库，使之具有界面友好、结构灵活、智能化、易交互等特点。结果所研制的网络社区系统包括七大模块：数据库管理模块、远程随访模块、放疗模块、检索模块、打印模块、信息发布模块、肿瘤社区模块。该社区能使患者及时了解最新的医疗动态以及自身的病情，并获得医生的帮助；同时也使医生能够随时掌握病人情况，获取第一手的临床资料。结论网络社区可使医患关系更加密切，随访更加便捷，医疗资源得以共享，有利于开展多中心的临床研究，提升肿瘤治疗水平。     

新辅助内分泌治疗高龄乳腺癌的临床观察

目的探讨术前新辅助内分泌治疗在老年乳腺癌治疗中的意义。方法 33例老年乳腺癌患者术前服用芳香化酶抑制剂3～9个月并观察疗效,手术后继续服用芳香化酶抑制剂,随访1～5年。结果 33例患者中,完全缓解2例,占6.06%;部分缓解19例,占57.58%;稳定7例,占21.21%;进展5例,占15.15%。全组随访1～5年,7例在随访期间因本病死亡,4例因其它合并症死亡。结论术前新辅助内分泌治疗高龄乳腺癌患者能达到原发病灶和区域淋巴结降期的目的 。     

新辅助内分泌治疗绝经后乳腺癌的临床疗效观察

目的 观察和探讨新辅助内分泌治疗绝经后乳腺癌的临床疗效和应用价值.方法 对56例绝经后乳腺癌患者应用新辅助内分泌治疗,疗效达CR（完全缓解）、PR（部分缓解）或SD（稳定）则继续进行治疗,直至病情出现PD（进展）或主动提出终止内分泌治疗,再给予手术治疗.结果 所有患者中CR 6例,PR 29例,总有效率（CR＋PR）为62.5%;不同受体阳性患者中,以ER、PR双阳性疗效最好,有效率为78.38%.结论 新辅助内分泌治疗用于治疗绝经后激素受体阳性的乳腺癌患者有明显疗效,副作用小,具有在临床上推广的价值.     

Doctor‐patient communication patterns in breast cancer adjuvant therapy discussions

Objective To identify variables within the patient‐oncologist communication pattern that impact overall patient comprehension and satisfaction within the breast cancer adjuvant therapy (AT) setting. Setting and participants Fifty patients were recruited from a number of academic and community‐based oncology practices. Fifteen oncologists participated. Main variables Three communication variables were identified: percentage of total utterances spoken by the patient, percentage of total physician utterances that were coded as affective (i.e. emotional), and total number of questions asked by the patient during the consultation. Knowledge and satisfaction were assessed by a variety of outcome measures, including knowledge items and satisfaction as measured by VASs, the satisfaction with decision scale and the decisional conflict scale. Results The level of patient knowledge about breast cancer and satisfaction with the clinical encounter showed a tendency to correlate with the variables measuring aspects of patient‐physician communication style. Patients who spoke more or asked more questions tended to be more knowledgeable whilst patients whose physicians used more affective language tended to know less but to be more satisfied with their clinical encounter. Conclusions In order to optimize patients’ degree of comprehension and satisfaction with their breast cancer adjuvant therapy, physicians need to increase their affective participation in clinical encounters whilst encouraging patients to ask questions and to actively participate in the decision‐making process.     

治疗及支持系统对罹患乳腺癌患者术后抑郁的影响

摘要:目的　探讨女性乳腺癌患者术后抑郁的发生状况及治疗及支持系统对抑郁的影响。方法　选取唐山市三级甲等医院就诊的 337例女性乳腺癌术后患者进行问卷调查。结果　女性乳腺癌患者术后抑郁患病率为38.58%,多重回归分析显示,放疗与否、内分泌治疗与否、疤痕疼痛与否及社会支持水平与乳腺癌患者术后抑郁相关,（P＜0.05）。结论　乳腺癌术后抑郁的患病率较高,应提高社会支持度,降低乳腺癌术后抑郁的发生。     

Patient delay in women presenting with advanced breast cancer: an Iranian study

INTRODUCTION: Due to the lack of systematic screening programmes for early detection of breast cancer in Iran and the predominance of advanced cases, we aimed to study the extent and determinants of patient delay in women with advanced breast cancer. MATERIALS AND METHODS: In this 1-year cross-sectional study, all consecutive women with advanced breast cancer (stages IIb, III or IV) who initially presented to a university hospital were studied. RESULTS: Sixty-eight percent (136/200) of cases had delayed their first visit by >1 month and 42.5% by >3 months. The median patient delay was 12 weeks. Delay was associated with: older age, being married, lower income, less education, place of residence (small cities), negative family history of breast cancer, belief in the fatality of breast cancer, lack of access to health care services, lack of knowledge of breast cancer symptoms, and denying the importance of breast self-examination. The main reasons given for the delay were: lack of knowledge regarding the necessity of such a visit, fear, negligence, lack of access to physicians, and poverty. DISCUSSION: In contrast to some other studies, this study found that married women and those with a negative family history of breast cancer waited longer than others before seeking care. Public education initiatives focused on encouraging women (especially high-risk groups such as older women, married women, and those living in small cities or villages) to see a doctor promptly for evaluation of breast symptoms can decrease delay and improve patient outcome.     

The risk of breast cancer associated with oral contraception and hormone replacement therapy.

Current epidemiologic data from research on the association between combined oral contraceptives (OCs) and breast cancer show that longterm OC use does not significantly increase the risk of developing breast cancer after age 45, but may indeed protect against postmenopausal breast cancer. Yet, older studies with high dose OCs demonstrate a somewhat increased risk (relative risk = 1.5) for young women who have used OCs early and for at least 4 years. Nevertheless, the lack of association even holds true for women with a family history of breast cancer or for those who have benign breast disease. Studies should continue, however, since the OC user cohort is aging and to increase the statistical power of current studies. Standard hormonal replacement therapy consists of a progestin and estrogen. Addition of progestin prevents the risk of endometrial cancer. Some research indicates that it may also protect against breast cancer. However, research from Uppsala, Sweden, suggests that combined estrogen-progestin treatment slightly, but not significantly, increases the breast cancer risk. Further research and longer duration of hormonal replacement therapy should provide clinicians with more information about the breast cancer risk. Individual physicians should inform their patients about concerns raised by the research about hormones and breast cancer, but should be optimistic since the possible risk has not been proven. Some medical associations have already developed guidelines for physicians and included them into continuing medical education programs.     

Knowledge,Attitudes and Practices of Breast Cancer Screening Among Women in Jordan

Enhancing breast cancer screening in developing countries is pivotal in improving women's health. We aimed at describing knowledge of and perceived reasons for performing breast cancer screening. We interviewed 1,549 population-based randomly selected women. We found that women share limited knowledge about breast cancer screening. Few women performed screening for early detection purposes. The influence of physicians was the main reason for performing mammography. Prevalence of breast cancer screening might be enhanced by integrating screening into other medical services. Health agencies need to invite women for screening and educate them regarding the importance of screening in the absence of symptoms.     

Treatment of metastatic breast cancer in women aged 65 years and older

Breast cancer is a disease of aging and the incidence of breast cancer increases dramatically with increasing age. In spite of major advances in prevention, screening and treatment approximately 40,000 Americans still die of metastatic breast cancer every year--the majority being women aged 65 years and older. Metastatic breast cancer remains incurable regardless of age and the goals of treatment are to reduce symptoms when present and to provide the patient with the best quality of life for as long as possible. Cornerstones of treatment to control metastases include endocrine therapy, chemotherapy and radiation therapy. Supportive care that includes psychosocial support and treatment of pain is also a key component of management. This review focuses on the issues related to the care of older women with metastatic breast cancer.     

1 251例重复人工流产术后落实不同避孕方法的效果评价

目的：评价重复人工流产术后即时落实不同避孕方法的效果。方法：1 251例重复人工流产者接受流产后服务（PAC）,自愿选择并即时落实避孕方法,随访不同避孕方法的使用情况及不良反应等。结果：所有重复流产者接受PAC后均即时落实避孕措施,其中复方口服避孕药（COC）组随访12个月续用率达31.2%;宫内节育系统（IUS）组随访12个月有3例因有生育要求取出,其余均坚持使用,另外有19例、13例和17例分别于随访3、6、12个月自COC组转入;宫内节育器（IUD）组随访12个月有1例异位妊娠,6例因有生育要求取出,其余均坚持使用,另外有23例、31例和19例分别于随访3、6、12个月自COC组转入。随访中发现部分人群有阴道点滴出血、经量减少、经量增多、闭经、节育环下移和腰酸不适等不良反应,给予处理并充分解释后均继续坚持使用。结论：科学有效的PAC能有效避免重复流产,保护女性生殖健康。     

The patient's right to information in Japan--legal rules and doctor's opinions

A questionnaire survey concerning informed consent was administered among Japanese physicians in Yamaguchi prefecture. The survey results showed that even though these Japanese physicians are willing to give their patients sufficient information to obtain informed consent, the discretion of the physician to provide information is still prevalent. The survey also revealed that Japanese physicians believe that information regarding the treatment to be administrated should be fully disclosed both in case when the treatment is still experimental and when it is established among specialists. Finally, the survey showed that despite the liberal attitude of the Japanese physicians toward informed consent, they are reluctant to make medical records accessible to the patients. It was found that when Japanese physicians were faced with special cases such as prior to administering high-risk diagnostic procedures, prior to disclosing the presence of cancer in their patients, or when faced with patients unwilling to receive treatment, the involvement of the patient's family members in the decision-making process was preferred so as not to aggravate the patient's emotional anxiety. With respect to cancer patients, the survey suggested that many Japanese physicians believe that cancer operations performed without informed consent from the patient should be legal. Finally, the survey concluded that, although the concept of individualized informed consent has been generally accepted among physicians, the involvement of family members in the decision-making process and a conservative attitude toward disclosure of information are still prevalent in Japan.