What drives patient choice: Preferences for approaches to surgical treatments for breast cancer beyond traditional clinical benchmarks

Abstract

Importance: Understanding what drives breast cancer (BC) patient's surgical decision-making and why, as survival continues to improve, are women continuing to choose mastectomy in increasing numbers. Objective: We sought to understand better what drives patient choice in surgical decision-making regarding BC treatment options. Design: We used a dynamic model, adaptive choice-based conjoint survey experiment, to assess multiple factors concurrently impacting patient choice, conducted from December 2016 to January 2017 using the Army of Women. Setting: Army of Women is a U.S.-based nationwide registry of women, both healthy and previous BC patients. Participants: An e-mail invitation was sent to the AWOL's 108,933 members, with 1,233 signing up to participate and 858 responding (548 healthy, 310 previous BC). Two hundred thirty-nine BC patients who underwent treatment > 5 years were excluded due to potential recall bias and changes in BC treatment paradigms. All subjects who did not complete the adaptive choice-based conjoint survey were also excluded due to inability to calculate preferences. The final sample consisted of 522 healthy women and 71 previous BC patients. Interventions or Exposures: Study of patient preference and decision drivers without interventions or exposures. Main Outcome(s) and Measure(s): Shares of preferences for various surgical treatment options were calculated using the highest-ranked factors by the importance that drove patient decision-making. Results: Survey response rate was 69.5%. Among healthy women, the most important of the 9 factors in making a surgical choice were doctor's recommendation at 21.4% (SD, 13.6%) and 20-year survival at 20.5% (SD, 9.8%) while among previous BC patients, the most important factor was 20-year survival at 19.0% (SD, 9.0%) and doctor's recommendation at 17.2% (SD, 10.3%). Conclusion and Relevance: While 20-year survival accounted for the largest single driver of patient choice at ∼20 %, it is notable that 80% of patient decision-making was driven by factors unrelated to survival such as cost, intensity and recovery time, and breast image. By understanding what drives choice, we can provide better patient-centric education and treatments.