Decisions about neoadjuvant systemic therapy for breast cancer: a survey of Australian and New Zealand specialists

Women with operable breast cancer who receive neoadjuvant systemic therapy (NAST) followed by optimal locoregional therapy have equivalent disease-free and overall survival outcomes to those who receive adjuvant systemic therapy. For women with larger tumours, NAST has some advantages over traditional sequencing including allowing breast conserving surgery for some women who would otherwise have required a mastectomy; reducing the resected volume; and providing information on prognosis. Clinical trials using NAST can identify treatment strategies for early breast cancer using pathological complete response (pCR) as an end point for provisional drug approval. The option of NAST for operable breast cancer is endorsed by international guidelines and by patients. Read et al. make a reasonable case that any woman who is clearly a chemotherapy candidate should have the option to receive it before surgery, particularly those with tumour subtypes, such as triple negative or HER2 positive, that are most likely to respond well. However, the rate of NAST use in Australian and New Zealand women with operable breast cancer was found to be only 2.75%, based on unpublished data from the BreastSurgANZ Quality Audit. Using a cross-sectional cohort design, we sought to understand how NAST is currently used in Australia and New Zealand in order to inform strategies to optimize its appropriate use. Here, we report results of survey questions about decision-making control to determine how involved patients are in the decision to receive NAST. Clinician members of major professional organizations representing Australian and New Zealand breast cancer specialists were invited to participate by email. This study received ethics committee approval and is registered on the Australia and New Zealand Clinical Trials Registry (www.anzctr.org.au, ACTRN1261 3000658718). Control over typical NAST decisions was measured using an adaptation of the control preferences scale, a 5-point scale developed to describe typical decision-making agency for a medical decision. Of 77 respondents, 37 were surgeons and 40 were nonsurgeons. Two (3%) felt that the doctor should decide, 38 (49%) felt that the doctor should decide, taking the patients view into account and 37 (48%) felt that the decision should be shared equally. No respondents reported that patients had more than equal control over the final decision about whether or not they received NAST. There was no difference in the level of decisional control between surgeons and non-surgeons. The decision about whether to have NAST was typically made at the time of the initial specialist consultation (56%) or at the multidisciplinary team meeting (31%). Decision-making control over the decision about NAST was skewed towards clinician-directed care, indicating that most respondents felt the need to direct patients in their decision about NAST. An Australian study found that breast cancer patients typically want to share decisions about their treatment, particularly in the early stages. In this study, around one quarter of patients preferred greater than equal control over treatment options, and patients who were involved in decision making experienced greater satisfaction and lower decisional conflict. Decision aids in other areas have been associated with decreased decisional conflict, a more active role in the decision and greater satisfaction with the decision. Clinicians who responded to our survey indicated that they would offer a patient decision aid for women who have been offered NAST, which may allow women to become more involved in the decision and to achieve better decision-related outcomes. A shared decision represents the patient and clinician reaching a decision based on the available evidence, after informed consideration of the options. Ideally, patients would be offered options where they are available and be allowed to make voluntary choices within the bounds of their ability to make such choices. Shared decision making involves a trusting patient–doctor relationship where autonomy is respected, but the decision is still supported by the doctor. We do not advocate that patients should bear all responsibility for their decisions, as this can actually undermine autonomy in situations where interdependence is part of effective decision making. Much of the responsibility for initiating the discussion about NAST lies with the surgeon, who has several complex issues to present to their patient in a limited period of time. This type of complex decision making is influenced by both evidence and a patient’s intuition, feelings and communication with trusted others. The generalizability of this study is limited by a low response rate; however, the denominator is likely to have been overestimated. Reasons for this include recipients who are members of more than one organization being counted more than once; and non-response from clinicians who do not treat breast cancer. Reliance on clinicians’ retrospective estimates of their practice may bias results. Interpretation of the control preferences scale may have differed between clinicians. In conclusion, this group of experienced and engaged Australian and New Zealand breast cancer specialists tended to exert control over the decision about NAST, rather than allowing some patients to make the final decision. Strategies to increase patient involvement, such as a decision aid, and greater awareness about NAST, may improve decision-related outcomes and give more patients access to a treatment strategy that they may prefer. The authors are evaluating PERSPECTIVES