Disparities in cancer outcomes exist due to many reasons across the cancer care trajectory. One factor is communication about treatment decision-making. A study recently published online ahead of print in the journal Cancer aimed to address this disparity by helping to better understand how to help women with lower incomes or less formal education make more well-informed choices about breast cancer surgery (2020; doi.org/10.1002/cncr.33248).
For the study, researchers compared usual care with two different types of paper decision aids (one included pictures and the other was text-only) to see if they changed measures of shared decision-making, coordinated care, and decision regret. The results showed that both tools helped improve measures of shared decision-making between women and their providers.
"[The work] has the potential to reduce disparities in knowledge and quality of life while improving other outcomes across socioeconomic strata," the study authors note in the paper. In an interview with Oncology Times, the study's lead author Marie-Anne Durand, PhD, health psychologist and Adjunct Associate Professor at the Dartmouth Institute for Health Policy and Clinical Practice at Dartmouth College, shared her thoughts about the research and its implications.
1 What led you and your colleagues to conduct this research now-and how do the conversation aids change the way these types of breast cancer treatment decisions are currently made?
"About one in eight women will develop breast cancer in their lifetime. While this diagnosis is traumatic and life-changing for all women, the impact and outcomes can be worse for women of lower socioeconomic status and lower health literacy. Research evidence shows that they are more likely than women of higher socioeconomic status to have lower knowledge of breast cancer surgery, higher uptake of mastectomy, increased decision regret, worse patient-centered health outcomes, and poorer care.
"These disparities are differences that are unlikely to be explained by the patient's preferences, but are partly explained by difficulties accessing and understanding information, doctor-patient communication, and lack of involvement in treatment decisions. For those reasons, and to address those disparities, we developed conversation aids. Our goal was to understand how best to help women of lower socioeconomic status make high-quality decisions about early-stage breast cancer treatments.
"The Option Grid is a one-page, text-based, evidence-based summary of available options presented in a table, listing the trade-offs that patients normally consider when making breast cancer surgery decisions. The Picture Option Grid uses the same evidence and table layout, but it is tailored to women of lower socioeconomic status and low health literacy by having simpler text and images. Both conversation aids have been developed, tested, and shown to be effective.
"Because conversation aids are not routinely available in real-world settings, usual care was a legitimate and reasonable comparator. Usual care included the provision of routinely available informational resources about breast cancer. Both conversation aids were available as paper versions only. The principal investigator trained surgeons in shared decision-making and how to use their assigned intervention prior to recruitment. Surgeons in the intervention arms introduced the paper-based conversation aids during the first surgical encounter."
2 What would you say are the key findings from your research and the implications of those findings?
"Compared to usual care, a conversation aid with pictures and text (Picture Option Grid) led to higher knowledge. It improved the decision process, self-reported and observed shared decision-making, and lowered decision regret compared to usual care. A text-only conversation aid (Option Grid) led to improved decision process, more coordinated care, and higher observed shared decision-making compared to usual care. The conversation aid with pictures was more helpful for women with lower income or less formal education.
"In brief, paper-based conversation aids with pictures and text used during the surgical consultation helped women make better breast cancer surgery choices.
"The Picture Option Grid may be most effective, especially for disadvantaged populations. It has the potential to reduce disparities in knowledge and quality of life, while improving other outcomes across socioeconomic strata. Significant variation between surgeons highlighted the importance of robust training for participating surgeons and evaluation of optimal training and implementation strategies.
"Embedding these conversation aids in busy clinic workflows and electronic health record systems is a challenge. Developing effective yet short training that is acceptable to surgeons and can be sustained in routine clinical practice is complex.
"We hope to conduct a larger implementation study to promote the wider rollout and dissemination of those conversation aids."
3 So what's the bottom-line message that practicing oncologists and cancer care providers should know about your work?
"When used by clinicians, paper-based conversation aids that pay attention to health literacy appeared effective across socioeconomic strata. They offer a practical, accessible, and inexpensive solution to promote patient participation in decision-making during clinical encounters without relying on high levels of health, textual, or computer literacy."