A decision aid for choice
regarding surgical treatment

to help patients diagnosed with breast cancer

make an informed and values-based decision

There are various options for breast cancer surgery, and each carries its own
benefits and risks.
This decision aid seeks to help women diagnosed with breast cancer decide
whether to undergo breast-conserving surgery or mastectomy, and whether or
not to undergo breast reconstruction after undergoing mastectomy.
It also helps them understand why the surgical method proposed bysurgeons is suitable for them.

Contents

Step 1: Learn to make an informed and values-based decision ・・・・・・・・・1

Step 2: Know your options(medical knowledge of breast cancer surgery)・・・・・・・・・・・・7

Step 3: Know your options(impact on lifestyle and daily life) ・・・・・・・・・・・・・・・・・・15

Step 4: Clarify what is important to you ・・・・・・・・・・・・・・・・・・・21

Step 5: Make your own decision ・・・ ・・・・・・・・・・・・・・・・・・・27

To make the steps work: Using information from testimonials ・・・・・・・・・29

Conclusion ・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・33

Step
1

Learn to make an informed and values-based decision●What is the decision aid for choice regarding surgical treatment for breast cancer?
There are benefits and risks associated with breast cancer surgery.
This decision aid is for people who have been diagnosed with breast cancer and want to decideconvincingly which breast-conserving and mastectomy options is appropriate for them, whether toundergo breast reconstruction after mastectomy, and to understand why the surgical options proposedby their surgeon is appropriate for them Created for. It is designed to assist those who want to gain abetter understanding of why the surgical procedure proposed by their doctor is appropriate for them.
The steps in this decision aid are as follows. When you first read it, follow the order of the steps.

Step

1

Learn to make an informed
and values-based decision•

Understand how to use the decision aid. Make
sure this decision aid is appropriate for yoursituation and your decision-making preferences.

•

By compare medical knowledge of surgicaloptions for breast cancer. you can have a better
understanding of which aspects are similar andwhich are different.

•

Compare the impact of breast cancer surgery
options on your lifestyle and daily life for a better
understanding of which aspects are the same andwhich are different.

•

Let's examine four perspectives regarding what
you want to consider when making a decision. It
will help clarify what is important to you while
making a decision.

•

Make sure you are ready to make a decision.
If you feel you are not yet ready, organize what to
do next (you can go back to the previous steps if
necessary).

•

Understand how to use other patients' experiences
as information.

P1～
Step

2

Step

3

Know your options(medical knowledge ofbreast cancer surgery)

P7～

Know your options(impact on lifestyle and daily life)
P15～

Step

4

Clarify what is important to you
P21～

Step

5

Make your own decision＋
To makethe steps
work:

P27～

Using information from testimonials
P29～

This decision aid includes stories from people who have undergone surgery for breast cancer(experiences of decision making process and making a decision) at each step of the process.
1

Step
1

Learn to make an informed and values-based decision●How to use the decision aid for choice regarding surgical treatment of breast cancer■ Make sure this decision aid is useful to you.
The decision aid for choosing a breast cancer surgery procedure is not intended to recommend which
option is best for you. It is designed to help you choose an option that is appropriate for you and that you are
comfortable with, by reading the information included, comprehending accurate information, and examining
what is important to you when making a decision, and by facilitating communication with doctors, nurses, andother medical professionals, family members, acquaintances, and breast cancer survivors.
This decision aid is designed for people mentioned below

Who can use this decision aid?
◼ Those who have been diagnosed with breast cancer and are planning to undergo breastconserving surgery or mastectomy.
◼ Those who have been diagnosed with breast cancer and have almost decided toundergo mastectomy, but are reconsider whether to have reconstruction.
◼ The surgeon has recommended breast-conserving surgery or mastectomy, but you
would like to know why the doctor recommended that method and whether it is suitablefor you.
However, it does not contain information for those who, should be informed and are discussing theirindividual situations with their doctor.

You need to discuss your individual situation with your doctor if(You need more information other than what is in this decision aid)
◼ You found out that you have breast cancer during your pregnancy◼ You have a strong genetic background◼ Your doctor has recommended treatment options other than surgery(e.g., Stage IV breast cancer).
＊If you are planning your pregnancy, inform and discuss with your healthcare professionals about your desire to
become pregnant or have a baby before starting treatment. You may be able to obtain information about the effects ofanti-cancer drug treatment and hormone therapy on pregnancy ahead of starting treatment, so that your doctor can
decide your treatment plan.

2

Step
1

Learn to make an informed and values-based decision■Identify what role you would like to play in your treatment decisions.
You have identified that this decision support tool is suitable for your breast cancer situation.
Another important thing to consider is what decision-making role you prefer.
There are three main types of roles in decision-making.

I want to make informed
decisions myself

I want to share my decisions
with healthcare professionals
and family members

I want others, such as
doctors and family
members, to makedecisions for me.

When deciding, check what role you prefer.
□You want to “make an informed decision for yourself”□You want to “share your decision with your healthcare professionals and family”

If either or both of the above apply to you, you may find this decision aid helpful.
If you would prefer someone else, such as a doctor or a family member, to make the decision for you,
you may not find the information in this section useful. For example, you could read this decision aid
with your family and use it to check whether your doctor has made the right decision for you.

■ You can use this decision aid to read, write and discuss the contents.

Read

Write

(Check or tick)3

Use fordiscussion

Step
1

Learn to make an informed and values-based decision●Preparing for informed values-based choice■You need time to think about your surgical options.
When you are diagnosed with breast cancer, it is natural to want to eliminate the cancer as soon as
possible. However, if you are diagnosed with early-stage breast cancer, there is no medical urgency tohave imediate surgery. Time is also needed to carry out a full examination to decide the appropriate
surgical procedure. It may take between one and three months from the time of diagnosis to surgery(depending on the medical facility).
Talk to your doctor about the time you have to think about your surgical options. This will give you
sufficient time to calm down, obtain information and consider the best option.

It is crucial to know how much time you have to think carefully.

If the doctor suggests that you have to decide immediately or that this is definitely the better
option, there must be a reason. Ask your doctor why you need to do so. If you wish, you can get asecond opinion.

■ You are not alone.
Your surgeons and nurses can help you to better understand your medical condition and assist you
to consider carefully about what is important for you before you take any decision. When you arefeeling distressed, you may not be able to comprehend the information well, it may take you a longtime to understand it or you may not be able to think clearly.
Don't put up with the hard feelings. Emotional support is also important for you. Talk to yoursurgeons and nurses.

4

Step
1

Learn to make an informed and values-based decision● How long did other breast cancer survivors take to decide on the surgical procedure?
When I underwent a comprehensive medical e
examination, my breasts needed to be re-examined. I
then underwent a full breast examination. I was
informed that I have breast cancer by the doctor at
the hospital where I had the full breast examination.
The doctor referred me to a hospital where I could get
admitted and undergo surgery. It took about threemonths before I underwent surgery. (Ms. B)

My decision was made rather early on. I had preoperative chemotherapy, so I had enough time before
I underwent surgery for breast cancer. The surgicalmethod was going to change depending on how well
the pre-operative chemotherapy worked, so I tookcare to control my emotions so that I would be okaywith either surgical method. (Ms. F)

It was about a month-and-a-halffrom the diagnosis of breast
cancer to the surgery. It took amonth to make a definitive
diagnosis. When I was diagnosed
with breast cancer, I wanted tohave surgery immediately.
However, I contacted several
hospitals for a second opinion. I
underwent surgery at the hospitalwhere I got the second opinion.
(Ms. C)● Tell us about your feelings after the breast cancer diagnosis.
I behaved like a typical cancer patient. I
thought “No way, not me” when I was
diagnosed with breast cancer. I started tolearn about breast cancer soon after mydiagnosis and have collected informationfrom books and professionals. I was
extremely depressed soon after diagnosis
until my course of treatment was decided.
(Ms. G)

When I was diagnosed with breast cancer, I
was not shocked and I accepted it without
emotion.
I knew I was at a high risk of cancer because
I lost my mother to cancer.
(Ms. D)

The year I was diagnosed with breast cancer,
I had a lot of things to attend to at mychildren's wedding and at work.I had todeal selflessly with hospitalization andtreatment.

When I was diagnosed with breast cancer, I
couldn't believe what had happened to me.
I was really sad and felt miserable.
Naturally, I had no knowledge of breast
cancer. I could hardly understand what thedoctors were telling me. (Ms. J)

I read many books and used the internet togather information. Before the surgery, I
was imagining what would happen after
surgical procedure. (Ms. H)

5

Step
1

Learn to make an informed and values-based decision● How did other breast cancer survivors decide?

I had sufficient time between diagnosis andsurgery. However, I was extremely scared tolearn about breast cancer.

I had early stage breast cancer, so I followed
my doctor's recommendations. I only had toread books about cancer. (Ms. B)

My surgeon explained about the treatment.
My husband accompanied me toappointments with my surgeon and didsome research about breast cancer andtreatment on the internet for me.
Subsequently I made a decision. (Ms. I)

Before I underwent surgery, I received asecond opinion.

When I was diagnosed with breast
cancer, I was single. My parents were
elderly and it was difficult to talk to them
about it.

I chose to have my surgery at the first
hospital because the explanation from thedoctor at the first hospital corresponded withthe explanation I received at the second
opinion, and also because it was easy toaccess post-operative treatment. (Ms. D)

I have always made my own decisions.
I used the internet to gather information
about breast cancer treatment on myown. I visited other hospitals because theprocedure I wanted (one-stage breastreconstruction) was not offered at thefirst hospital.
Although a lot of information wasavailable online, I was confused becauseof my lack of knowledge about thetreatment and the procedure. I asked thedoctors several questions about what I
did not know and what I did notunderstand.
Ultimately, I chose the surgical procedureand underwent treatment after
understanding the potential risks, withmy main concern being that I would not
feel any loss and that I would be able toreturn to my normal life as soon as
possible. (Ms. M)

From the diagnosis of breast cancer tosurgery and subsequent treatment, theschedule proposed by the surgeon was
followed. My surgeon seemed very busy, so I
gathered information from the internet andbooks. I approached my treatment
considering what was best for me.
(Ms. E)

6

Step
2

Know your options (medical knowledge of breast cancer surgery)● Breast cancer treatment flow
This decision aid focuses on the treatment flow for breast cancer, particularly the decision on thesurgical method and whether to undergo breast reconstruction. The decision aid is designed to be used
for patients diagnosed with cancer and required to undergo surgery.
Breast cancer treatment flow

diagnosis(In addition to the flow described here, treatment may be carriedout according to an individual patient's specific needs. )Ductal Carcinoma In Situ Invasive ductal carcinoma
Timing of use of thisdecision aid

Tumor size is large, orsuspected lymph nodemetastasis.

Tumor size
Is smallDistant metastasis

neo-adjuvant
chemotherapy

information containedin this decision aid

Surgery（Breast-conserving surgery or Mastectomy ）no suspicionof metastasis,
cancer cells
considered tohave been
completely
removed bysurgery,

follow-up

Breast-conserving
surgery

Breastreconstr
uctionRadiationtherapy（If post-operative
chemotherapy isgiven, chemotherapy
is given first）

breast-conserving
surgery fails to
remove all thetumouradditional
excision or
mastectomy

Drug therapy（Hormone therapy/Chemotherapy/Targeted terapy）
文献7）p71より一部改変
7

Step
2

Know your options (medical knowledge of breast cancer surgery)

Choosing an appropriate treatment requires a proper understanding of the medical characteristics ofthe options. Learn about the options from a medical point of view. Then compare the different types ofsurgical procedures and the differences between them.

● What is breast cancer?
The breast consists of mammary glands that
adipose tissue

produce milk, the ducts that carry the milk and the fatthat supports them. Each mammary gland is divided

lobuleBreast cancer

into lobules, which are connected by duct-like

Breast cancer
development

structures called milk ducts.
About 90% of breast cancers originate from theseducts and are called ductal carcinomas. About 5–10%
of breast cancers arise from the lobules and are called
lobular carcinomas3). Treatment of breast cancer
includes surgery (surgical treatment), radiotherapy
lactiferous ductand drug therapy (e.g., hormone therapy, targeted

intraductal spreadinterstitial
infiltration（invasive
carcinoma）

therapy and chemotherapy).

● Basic knowledge about surgery■ Breast-conserving surgery

Removal site

incision site

(Partial mastectomy)
Breast-conserving surgery (partial
mastectomy) is a procedure in which only
the part of the breast which is cancerous isremoved7）.

（drain）■ Modified ladical mastectomy

the extent of resection（ Mastectomy )The breast is removed, leaving thedermal incision line

pectoralis muscle, including part of the skin4).
Mastectomy is a surgical procedure in which
the nipple, nipple areola and breast bulge
are generally removed in their entirety. It isalso called a total mastectomy.

（drain）

8

Step
2

Know your options (medical knowledge of breast cancer surgery)■ Subcutaneous mastectomy
The two methods listed on the previous page are the most commonly performed procedures, but
the following two methods are also being increasingly used. However, there are conditions for theindications. If you want reconstruction after surgery, you may consult your doctor to see if this typeof surgery is possible7）.

Skin-sparing mastectomy

The nipple areola andmammary gland areremoved, leaving as muchskin as possible. The extent
of the resection isdetermined according to
the spread of the cancer7).

Nipple-sparing mastectomy
Incisionalong thenipple.

The nipple areola is left intact
and the mammary gland isremoved. It is not yet astandard treatment as it has
not yet been fully evaluatedfor safety and long-term
survival. Indications need to7)
be carefully considered .

Incision under the breast.

■ Axillary lymph node surgery
Sentinel lymph node biopsy
The sentinel lymph node is where lymph is assumed to first arrive
from breast cancer. Sentinel lymph node biopsy is a surgicalprocedure in which only these sentinel lymph nodes are removed

sentinel lymph node

to check for the presence of metastatic cancer cells. If there are no

Breast cancer

cancer cells in the sentinel node, it is assumed that no other lymph

nodes have metastasized, and lymph nodes other than the sentinelnode are not removed. Sentinel lymph node biopsy is 95–97%

regional
lymph node
lymphatic vessel

accurate in identifying metastases5).

Axillary dissection
This is indicated for patients who have obvious metastases on pre-operative examination or who
have been found to have metastases on sentinel lymph node biopsy. The lymph nodes in the axilla
are buried in fatty tissue. The removal of these in one lump to a defined extent is called dissection5） .

9

ステップ
２

Know your options (medical knowledge of breast cancer surgery)■ Breast reconstruction
This is a surgical procedure to reconstruct a new breast that has been lost as a result of breast
cancer surgery. There are two types of reconstruction: an artificial breast implanted under the muscle(artificial breast reconstruction) or a portion of fat or muscle from the back or abdomen transplanted
into the breast (autologous tissue reconstruction). It can be performed following breast cancer
surgery (one-stage reconstruction) or again months or years later (two-stage reconstruction)5）.
If you are considering reconstruction, you should inform your surgeon and plastic surgeon about
your preference, gather information and discuss with them.

● When mastectomy is considered more suitable than breast-conserving surgery
In the case of early-stage breast cancer, the medical outcome (outcome in terms of survival) is thesame regardless of whether breast-conserving surgery or mastectomy is chosen２）.
However, mastectomy may be more appropriate in some cases considering following factors.

■ Mastectomy is more suitable than breast-conserving surgery.
The following are some reasons why mastectomy may be more suitable than breast-conserving
surgery If the lump is large compared to the size of the breast If the cancer has spread widely If there are two or more lumps separated by more than one in the breast If you are pregnant or for any reason it is considered inappropriate or unsafe to haveradiotherapy
 If the cancer is so close to the nipple that the nipple must also be partially or completely
removed.

There are other cases not listed here where the doctor considers a mastectomy to be suitable.

10

Step
2

Know your options (medical knowledge of breast cancer surgery)● Comparison of the benefits (pros) and risks (cons) of the surgical options
from a medical point of viewLet's compare the benefits and risks of each options from a medical point of view.
Depending on your medical condition, you may be able to compare all the options before you, or you
compare two options: mastectomy only or mastectomy plus breast reconstruction.

Mastectomy

Breast-conserving
surgery
followed by radiation
therapy

Survival rate

Mastectomy
with reconstruction

The survival rate remains the same regardless of which surgical procedure is chosen.
By undergoing surgery, one can live longer than if one does not undergo surgery.

Risk ofrecurrence inthe breast

Marginally higher thanMarginally lower

The risk of recurrence inwith mastectomy (aboutcompared to breast-

the breast is the same as

10% over a 10-year

conserving surgery

for those who undergo

period５）.

(around 3% over a 10-

mastectomy only.

year period).

Risk ofcancer being
left behind

There is a minor risk of

There is little risk of

There is little risk of leaving

the cancer being left

leaving behind cancer.

behind cancer.

Radiotherapy is usuallyRadiotherapy may not be

Same as for mastectomy.

required after breast-necessary in some cases.

conserving surgery.

If lymph node metastases

There is a risk thatRadiotherapy is given on

are found as a result ofcomplications fromfive consecutive weekdays

the surgery,reconstruction may require

behind. In this case, thesurgery is performed
again.

Treatment
required inaddition tosurgery

for five minutes eachsurgery.

session for three to five
weeks.

Need forchemotherapy or otherdrug therapy

This is not related to the different methods of surgery. The decision is made after
examining the characteristics of the cancer cells removed by surgery and the risk ofrecurrence.

A comparison helps to understand which of the benefits and risks of each are the same and which are
different.
11

Step
2

Know your options (medical knowledge of breast cancer surgery)

The decision aid contains basic medical information about surgery, but it is not all-inclusive. You
should understand the basics here and use it while discussing surgical procedures with yourhealthcare professionals. If you feel the need to gather information on your own, you can do sothrough books.
Whether or not you will be treated with medication after surgery, and what type of medication
will be used, will be determined by examining the characteristics of the breast cancer tissue
removed surgically, but we have not included information regarding this in this decision aid.

● Which option did you choose? What did you discuss with your surgeon?

When I had to make a decision about surgery,I told my surgeon “I would like to undergo
breast-conserving surgery if it can help
preserve my breast shape.” I underwent
breast-conserving surgery after I had
received an adequate explanation of not only
the advantages, but also risks involved frommy surgeon. (Ms. A)

My surgeon showed me MRI and CT images
and explained that breast-conserving
surgery was not possible because of thelarge size of the tumor and that amastectomy would be more suitable. (Ms. K)

The surgeon provided information about
the benefits and risks of both breastconserving surgery and mastectomy.
I chose breast-conserving surgery on myown after my surgeon explained to me that
there were two options—breast-conserving
surgery and mastectomy—and theirbenefits and risks. (Ms. D)

However, the surgeon recommended
mastectomy because it would be difficult
to preserve the shape of my breast
considering the number of lumps and thelocation of my cancer.
(Ms. I)For some breast cancer survivors who provided their stories, the doctor decided whether breastconserving surgery or mastectomy was appropriate and only one method was explained to them.
If the surgeon recommends one or the other to you, the best method in terms of medical andstandard of care is chosen and information provided.
If you feel that you are not convinced or do not understand, you can ask why that particular method
is suitable for you and why the other option is not.

12

Step
2

Know your options (medical knowledge of breast cancer surgery)● What did you think when comparing the benefits and risks of each option?

The surgical method was determined by the sizeof the tumor and other factors rather than acomparison of benefits and risks. (Ms. F)

Comparison of the benefits and risks helped
me choose my option.
Knowing the disadvantages of each option
allowed me to consider carefully about my
options. I will be satisfied with my decisioneven if something unexpected happens.
(Ms. M)

I chose breast-conserving surgery. I believe I
made a good choice because I did not feel thesense of loss of having lost a breast.
However, I have concerns about the risk ofcancer recurrence.
(Ms. E)

In order to make the best choice for me, I
made a comparison by writing down theadvantages and disadvantages of each option
in a notebook.

There are benefits and risks to both choices,and there is no right answer, but I think it was
important to spend time worrying (comparing)
until I was satisfied with my choice.
(Ms. A)By writing, rather than thinking about it in myhead, I was able to calmly sort out myfeelings and go into the surgery satisfied.
(Ms. J)

I attended a seminar on breast reconstruction
prior to my surgery. I was able to see picturesof breast-conserving surgery, mastectomy
only, mastectomy plus breast reconstruction
at the seminar.

I had to make my choice in a hurry. So I don't
think I was able to compare them properly.
(Ms.H)I was able to see pictures of both good andnot-so-good outcomes at the seminar andidentify the benefits and risks of each method.
(Ms. J)

13

14

Step
3

Know your options (impact on lifestyle and daily life)

Surgery to remove the cancer is not the end of the process. Life continues long after surgery.
It is important to revamp your lifestyle and the impact on your daily life and to choose yourtreatment wisely.
For early-stage breast cancer, the medical outcome (outcome regarding survival) is the same
regardless of which surgical procedure you choose２）. It is important to learn about both the effectsof surgery and the impact on quality of life after surgery.

Let's look at the similarities and differences between the surgical options in four points that may
affect your lifestyle and daily life.

Time and effort
spent on surgery
and recuperation(length of
hospitalization andhospital visits)

shape of Breast
nipples, areola
size of scars
location of scars
sensation of breast
skin
Page 16

What may affectyour lifestyle andquality of life after
surgery

Page 17

Other
Costs during andafter treatment

Pain
possible problems
effect on posture

Page 18

Page 19

15

Step
3

Know your options (impact on lifestyle and daily life)● Shape of breast, nipple/areola, scar size, location and post-operative breast skin sensation
The table below shows the similarities and differences between the different options in terms ofshape of breast, nipple/areola, scar size, location and post-operative breast skin sensation.

shape of breast, nipple/areola

Breast-conserving surgery
followed by radiation
therapy

Mastectomy

Mastectomy
with reconstruction

The appearance of thebreast may be the same as
before surgery or it may be
deformed due to thelocation, size and spread of
the cancer.

There are several types ofmastectomy.
●Removal of the entire breast,
nipple and areola.
●The nipple and areola areleft in place and the mammary
glands are removed.
●The nipple, areola, and the
mammary glands arehollowed out.

Breast reconstruction cancreate a breast shape. If you
have had your nipple or areola
removed, reconstruction canalso be used to create a nipple
or areola.
When and how to reconstruct-Timing●At the same time as breast
cancer surgery.
●After a period of time
following breast cancer
surgery.
-Methods●Reconstruction using an
artificial breast●There are advantages anddisadvantages depending on
the timing/method ofreconstruction using
autologous tissue (using partof the fat or muscle from thepatient's abdomen or back).
It is important to discuss thiswith your surgeon or plastic
surgeon.

Whether the breast
deformity is minor or major
depends on the balance
between the original breast
size and the size of thecancer.

A dimpling may occur after
the tumor has been
removed, or there may be
a left–right difference inthe position or orientationof the nipple.

You will have a flat chest after
your breast is removed. The
possible options depend on
individual' situations.
It is important to discuss thiswith your doctor.

scar size
locationpost-operative
breast skinsensation

The size and location of
the scar will depend on thelocation, size, and spreadof the cancer.

The size and location of thescar will depend on themethod used to perform themastectomy.

The size and location of thescar will differ depending on
the method of reconstruction.
In the case of reconstruction
using autologous tissue, thescar is larger than that of an
artificial breast, and it islocated where the skin, muscle,
and fat are removed.

There will still be sensationof the breast skin.

You may lose sensation of theskin in the area where thesurgery was performed.
Sensation may or may notrecover over a year or two.

This is similar to mastectomy.

16

Step
3

Know your options (impact on lifestyle and daily life)● Time and effort spent on surgery and recuperation
The table shows the similarities and differences in the time and effort spent on surgery andrecuperation by different surgical procedures.

Length of hospitalization

Breast-conserving surgery
followed by radiation therapy

Mastectomy

Mastectomy
with reconstruction

The length of hospitalization
depends on the medical
institution where you are being
treated and on your progress
after the surgery.

The length of hospitalization
depends on the institution
where the patient is treated
and the course of the postoperative period.

The length of hospitalization
depends on the treating
medical institution and thecourse of the post-operative
period.

If the post-operative course isfavorable, the patient may bedischarged within a few days toa week.

A relativery longer stay thanfor breast-conserving surgery
is common.

As a rough guide only, it cantake from a day to a few days
for artificial breasts (implants)
and from about two weeks toa month for autologous tissue.

If the post-operative course isfavorable, the hospital stay isusually shorter than formastectomy or mastectomy
plus breast reconstruction.

Consult your doctor or plastic
surgeon about the length of
hospitalization due toreconstruction, regular visits
to the hospital and how long
you will need to stay.

Length of time to recovery

The time it takes to be able toperform your original activities
may vary greatly from person toperson.

The length of time until thepatient is able to return tonormal activities may vary
greatly from person to person.

The length of time until you
are able to do your originalactivities may vary greatly
from person to person.

Recovery time after surgery
may be shorter than withmastectomy or mastectomy
plus breast reconstruction, if
the patient is doing well after
surgery.

Recovery time after surgery is
generally somewhat longer
than with breast-conserving
surgery, even if the
postoperative course isfavorable.

Your recovery time may varydepending on the different
methods of reconstruction.

The time and effort of daily
visits to the hospital forradiation therapy for 3 to 5
weeks are required.

17

Consult your surgeon or
plastic surgeon for recovery
time after reconstruction.

Step
3

Know your options (impact on lifestyle and daily life)● Costs
以下に、費用について、それぞれの手術の方法による違いを示しました。比較の参考にしてください。
The table shows the similarities and differences between the options about costs.
Breast-conserving surgery
followed by radiation therapy

Mastectomy

Mastectomy
with reconstruction

Costs

Costs related to standard treatment, including surgery for breast cancer, are covered by healthinsurance (public medical insurance).
In some cases, a high-cost medical care reimbursement system may also be available. Somecoverage depends on the type of medical insurance that an individual has. If you havechemotherapy after surgery,you will also have to pay for a wig. Wigs are not covered by health insurance and are self-paid.
After surgery, there may becosts for pads and bras tocompensate for theappearance of the breasts (ifthe breasts retain their shape,
there is no need to bepurchase new ones).

After surgery, you may have to
pay for pads, artificial breasts
and bras to compensate forthe shape of your breasts.

You will have to pay fortransport to and from hospital(every weekday for 3–5 weeks)
while undergoing radiotherapy.

Since 2013, some methods ofreconstruction with artificial
breasts are being covered byhealth insurance (autologous
tissue has been covered byhealth insurance for sometime).
Some methods are covered byhealth insurance and some arenot.
Before reconstruction, talk to
your plastic surgeon orsurgeon about the costs as
well.

Inform your healthcare professionals regarding any concerns you may have about your life
after surgery.
By informing your healthcare professionals, you will be able to discuss with them specificallythe best treatment options, together with the effects of the treatment and your life after
treatment.

18

Step
3

Know your options (impact on lifestyle and daily life)● Other (pain, possible other problems, effect on posture)
The table also shows other similarities and differences between the options about pain, possible
problems and postural effects.
Breast-conserving surgery
followed by radiation therapy

Pain

You may experience pain at thesurgical site shortly after surgery,which can be relieved withpainkillers. You may experience
heat and pain due to postoperative radiotherapy.
You may still experience
discomfort etc. after a period oftime. Mammography is required
for regular check-ups after
surgery. Some pain may be felt
during these procedures.

Other possible problems

Some people may feeldepressed because of thechange in the appearance of
their breasts.
Post-operative radiotherapy isrequired. Radiotherapy after
surgery causes skin changes.
If reconstruction is desired due
to changes in the appearance ofthe breast, there is a risk that theradiotherapy will reduce theelasticity of the skin, making
reconstruction difficult or
causing problems afterreconstruction.

Mastectomy
In the immediate postoperative period, you may
experience pain at thesurgical site, which can berelieved with painkillers.
After some time, discomfort
may still be experienced.

Some people lose theirbreasts and become
depressed. If lymph nodemetastases are present,
additional radiotherapy may
be recommended.
You will need to ask yourdoctor's opinion on this.

Mastectomy
with reconstruction
In the early post-operative period,
pain at the surgical site may be
experienced, but can be relieved
with painkillers.
For reconstruction with anartificial breast, pain may occur
while the expander is creating abulge.

-Reconstruction at the same time
as mastectomy● It may be burdensome tothink about both surgery andreconstruction.
● There is little or no loss of thebreast.
● You may not have time tothink carefully aboutreconstruction options.
-Reconstruction afterwards●You may feel depressed by the
temporary loss of your breasts.
●You can consider aboutreconstruction more gradually.
● You will have more surgeries.
Some people are happy with
their breasts after reconstruction,others are not. There is a risk ofproblems associated withreconstruction.

Effect on Posture

Compared to a mastectomy, theeffect on postural balance may
be marginal, but some patients
may feel that their posturalbalance has been compromised.

Losing one breast to amastectomy can cause
postural imbalance and neckand shoulder pain in somepatients.

Compared to a mastectomy,
postural balance may be lessaffected, but some patients may
feel that their postural balancehas been compromised.

The extent to which posturalbalance is affected may varyfrom person to person.

The extent to which posturalbalance is affected may varyfrom person to person.

There are individual differences inthe effects of postural balance.

19

20

Step
4

Clarify what is important to you

You have learnt about your options from two aspects: the medical aspect and the impact on yourlifestyle/day-to-day life. It is important that your decision is well informed and based on your values.
Once you are clear about your values, you are more likely to discuss your surgical choices with yoursurgeon.

Pages 22– 25 provide four perspectives to help you clarify what is most important to you, so you

can weigh up or check your concerns. As you gather information, talk to healthcare professionals
and discuss with your family, your initial ideas about what you want to care for may change.

As long as you do not feel burdened, you may take some time in the run-up to your surgery toreview and re-evaluate what you have ticked off your list.

21

Step
4

Clarify what is important to you● Shape of breast, nipple/areola, scar size, location and post-operative breast skin sensation
Thinking about the shape of the breast and the scars helps to visualize the prospects for life
after surgery.
For example, will the appearance of the breast change, and- Will I lose my femininity?
- How will my children and grandchildren react? Will I be able to bathe with them?
- Will I be able to go to hot spring again? Will the pads I use to compensate become a nuisance?
- Will my relationship with my partner change?
You may feel worried about these things. But not all is lost. There are many things you can learn
to cope with and deal with successfully. Consider the table below to see how important eachthing is to you, with 0 meaning 'not important' and the higher the number, the more important it
is.
Circle the number that applies to how important it is to you. You can choose from the following
or examine each one individually.

not important

important

How important is it for you to keep your breasts?

0

1

2

3

4

5

How important is it to you that you can feel the skin ofyour breast?

0

1

2

3

4

5

If you have a mastectomy, how important is it that theshape of your breast is as close as possible to its
original shape?

0

1

2

3

4

5

If you were to have a mastectomy, how important
would it be for you to have breast reconstruction
simultaneously?

0

1

2

3

4

5

You may also want to examine, for example, if necessary, you can ask your doctor questions in the

run-up to surgery.
□How will the shape of my breasts change if I undergo surgery?
□Where and how long is the scar expected to remain?
(For example, do I still want to wear fashionable open-breasted dresses after the surgery?)(I would like to know if there is a way to make the scars as inconspicuous as possible and whether thiswould be suitable in my case).
22

Step
4

Clarify what is important to you● Theriskriskof cancer
recurrencein theafter
breastafter surgery
risk ofbeing
tumor
being
left behind● Theof recurrencein breast
surgery
and the andrisk theof tumorleftbehindThe risk of cancer recurrence in the breast after surgery differs only marginally depending on
the surgical method.

The risk of tumor being left behind also differs. It may be difficult to think about this before
surgery. However, thinking about this will help you envision how you feel after surgery.
In the table below, we can weigh the factors, with 0 meaning "not important" and a higher
number meaning "important". Circle the number that best describes how important it is to you.
You may choose from the following or consider them one by one.

not important
How important to you is a difference of a few percent in
the risk of cancer recurrence in breast due to different
surgical procedures?

important

0

1

2

3

4

5

How important to you is to reduce the chance of tumor
being left behind?

0

1

2

3

4

5

How important is it to you to eliminate the risk ofreoperation due to leftover cancer?

0

1

2

3

4

5

You may also consider the following If I chose breast-conserving surgery and the chance of cancer recurrence in thebreast was only slightly higher, would that be acceptable?
 Would I feel more comfortable having my entire breast removed?

23

Step
4

Clarify what is important to you● Time and effort spent on surgery and recuperation
The time and effort spent for treatment and recuperation differ depending on the method ofsurgery. Specifically, the length of hospitalization at the time of surgery, the time required forrecovery after surgery, and whether radiotherapy is necessary after surgery differ (the length of
hospitalization at the time of surgery varies depending on the facility where the patient receives
treatment. Recovery time also varies from person to person. Your lifestyle (work, housework,
taking care of family members such as childcare or nursing care, hobbies, etc.) may dictate theamount of time and effort you can spend on treatment and recuperation.
For example, if you wish to continue working, you will need to consider how long you can takeoff from work and whether you will be able to attend daily radiation therapy after breastconserving surgery. Considering the amount of time and effort involved will help you envision
your hospital stay for surgery, your hospital visits, and your outlook on daily life after surgery.
Examine how important the following points are to you. 0 means “not important" and thehigher the number, the more important it is. Circle the number that applies to how important it
is to you. How important is it to you that the recovery time and effort after surgery is minimal?

not important
If you have breast-conserving surgery, would you be able
to attend radiotherapy every weekday for approximately
three to five weeks, which would be necessary afterwards?

01

important

2

3

4

5

You may also want to consider the following If you have breast-conserving surgery, would you be able to attend radiotherapy every
weekday for approximately three to five weeks, which would be necessary afterwards?
 If you choose breast reconstruction using an implant, would you be able to afford thehospital visits and the time required for the surgery?

24

Step
4

Clarify what is important to you● Costs
The costs of surgery and post-operative costs can be discussed. In addition to the cost ofbreast cancer surgery, there are other costs such as hospitalization, transport costs for
hospital visits, pads, breast prosthesis and bras.

In addition, if you have reconstruction, you will need to gather information on which
methods are covered by health insurance (public medical insurance) and which are not. If you
undergo non-surgical treatment, you will have to pay for that treatment. If you havechemotherapy, you will need to buy a wig.

Examine how important the following points are to you: 0 means “not important” and thehigher the number, the more important it is. Circle the number that best describes how
important it is to you.

not important
How important is it to you that the cost of treatment andthe costs associated with treatment are as low as
possible?

01

important
2

3

4

5

Other things to consider include Which treatments are covered by my private medical insurance?
 Where can I buy artificial breasts and special innerwear that can also be used after
surgery? How much do they cost?

25

Step
4

Clarify what is important to you● What did other breast cancer survivors value in their choice of surgery? What did they think
about, what information did they gather and with whom did they discuss it, in order to be clear
about what they valued?
Retaining my breasts after surgery was very
important to me.

I have two boys. When I was having surgery,my older son was a junior high school student
and my younger son an elementary school
student. I wanted to live at least until myyounger son graduated from high school.
I therefore made up my mind to undergo
whatever treatment options were available.
My family believed the same as I did.

I couldn't imagine losing my breasts and I
wasn't confident that I would be able toovercome this mentally.

I was single at the time and wanted to getmarried. I was not confident that I could be
proactive looking for a life partner, with orwithout breasts.

When I told my sons about my breast cancer,
they told me “We don't want anyone to know
about your cancer. We don’t want you tochange because of cancer.” So I continued tolive as I had done before being diagnosed withcancer.(Ms. C)

I also felt that I needed to get back to my prebreast cancer self as soon as possible, so that I
could return to work and get back to my dailylife.

It was also important that there were no time
constraints. And the fact that it was only one
surgery was a major reason for my decision. I
wanted to avoid having more than one surgery,because I didn't want to miss work. I also
wanted to reduce the burden on my body forthe surgery and reduce the cost of
hospitalization. When thinking about what was
important to me, listening to other people's
experiences at the breast cancer self help
group was very helpful. (Ms. M)

I made a choice, with survival as my top priority.
(Ms. I)

I hope to have a child in the future. I chose toundergo mastectomy because I wanted to reduce
the risk of recurrence. I discussed my options withmy husband and my parents and was able to
make a decision after sharing my families’ and mypreferences. (Ms. J)

Immediately after I was informed of my breast
cancer diagnosis, I thought, "I don't care what
method is used as long as it saves my life."
However, when I found out that there arevarious methods of treatment for early-stage
breast cancer, I came to the conclusion: "If mybreasts can be left beautifully, I want to keep
them. If they are ruined, I will have amastectomy and breast reconstruction." I wasparticular about the shape of my breasts.
(Ms. A)I chose my hospital based on these priorities:
first, no local recurrence; second, satisfied withreconstruction; and third, shorter hospitalization
and recuperation days and less time off work.
I was thinking about the worst possibilities.
I didn't tell my husband any particular details anddidn't discuss it with anyone. (Ms. H)

26

Step
5

Make your own decision● Make sure you know how much you are ready to decide
You have the basic knowledge and have clarified what is important to you. Now let's see how
ready you are to decide.

Check the boxes that apply to you.

● Do you know the benefits and risks of each option?
□Yes

□No

● Are you clear about which benefits and risks matter most to you?
□Yes

□No

● Do you have enough support and advice to make a choice?
□Yes

□No

●Do you feel sure about the best choice for you?
（It is important that you feel well-informed and congruent with your values.）
□Yes

□No

The SURE Test ©

O’ Connor and Légaré, 2008８）

If you have a "No" to any one of the four above, you may not be fully prepared to make adecision yet. Is there anything you would like to do before you decide? Check the items on thefollowing page to organize what you would like to do.

27

Step
4

Make your own decision● Plan the next steps based on your needs.

You can also check the following items to prioritize what you would like to do next and takeaction.

□ Nothing. I am ready to make a decision.

□I need to discuss my options with.

□ I need to do more research on my options.
□I need to clarify which benefits (pros) and risks (cons) are most important to me.
□ In addition, I need to.

Many people are unsure of what to do and how to proceed until they decide. Once you
know what you want to do in the above, it will be easier to take the next steps.
If you still feel you don't have a good understanding of your options, you can re-read thechapter on Page 7 – “Know your options (medical knowledge of breast cancer surgery)” in thisdecision aid, or ask your doctor to explain it to you.
If you are still unclear about what is important to you and what you want to decide, you canre-read the chapter “Clarify what is important to you” on Page 21, or talk to other people, suchas nurses, family members, or breast cancer survivors.

28

To makethe steps
work

Using information from testimonials● How to use other breast cancer survivors' stories as information
Knowing what other breast cancer survivors valued in their choice of surgery may be helpful whenclarifying what is important to you, and when having an outlook for the future. This decision aid also
includes testimonials from people who have already undergone surgery. You can choose whether or not
you would like to refer to the experiences of other people who have gone through more.

■ What are the benefits (advantages) of knowing other breast cancer survivors' stories?
Stories from other breast cancer survivors are “concrete and easy to understand” because they are told
in the words of those who have experienced it. You will learn the following from other breast cancer
survivors' experiences.
• An approximate idea of what is about to happen• Specific experiences (when, what, how long, etc.)• After the choice, what you think about it looking back on the journey to the choice• What life is like as a result of choosing to do this• (e.g., pain, size of wound, degree of distress, resume work)■ What do you need to consider when learning about other breast cancer survivors' stories?
Each person's experience has a story. They can help you understand what is about to happen to you.
However, it is important to bear in mind that “each person feels differently” after the same surgery.
•

Some breast cancer survivors may have experienced pain you cannot imagine. You may have many
concerns as you learn about their painful experiences. However, what one person experiences may
not necessarily happen to you always.

•

learning about the experiences of more than one breast cancer survivor will give you an insight into
the diversity of experiences. If you can see the diversity, you may be cable of imagining more thanwhat will actually happen and not feel more anxious.

•

Breast cancer treatment is ever-evolving. It is a good idea to check when you learn about yourexperience to find out when you were treated and when you are talking about it.

29

To makethe steps
work

Using information from testimonials● Did other breast cancer survivors use their stories? What aspects did they find useful?

There was no opportunity to hear or read patient
experiences of surgery before I had cancer.
I think that was the time when I wanted to know
the most about breast cancer survivors' stories.
(Ms. I)

I actively met with other women with breast
cancer who had joined a self-help group.

However, I was disappointed that I did not meet
women who had continued working during theirtreatment. I needed some advice from womenin the same situation as me before starting mytreatment. (Ms. F)

When I had my surgery, it was around the time
when breast cancer survivors' stories started
appearing on the internet, like blogs. I read them,but felt the information was biased. I attended aseminar and listened to a breast cancer survivor.
It was good because it encouraged me.. (Ms. C)

At the time, I was not aware that I could use
other breast cancer survivors' experiences as areference.
I wanted to make a decision based on my own
feelings. I thought that with all the informationon the internet, I would be even more confused.
Looking back, I think I should have referred tothe experiences of other breast cancer survivors
a little more... (Ms. J)

I used the experiences of other breast cancer
survivors to inform my choices. I attended
patient meetings and heard from breast cancer
survivors. They allowed me to see and touch
their breasts after surgery. I was very happy tohear from breast cancer survivors about myfears, pre- and post-operatively.
I was able to compare the feel of thereconstructed breasts with different techniques
and the scars, which helped dispel my concernsand helped me make a decision about mychoice. (Ms. M)

I researched on the internet and in books tofind out what surgical choices other breast
cancer patients had made.
Blogs and testimonials were particularly helpful
in understanding how they are spending theirtime now after making that choice (e.g.
satisfaction with the choice, regrets, etc.).
However, I was confused when I saw
information that I didn’t want to know anddidn’t need. (Ms. K)

30

To makethe steps
work

Using information from testimonials■ How to find out about other breast cancer survivors' experiences
There are several ways to find out about other breast cancer survivors' experiences.
This Decision aid includes information on how to talk to them in person and how to use the internet.

If you would like to find out about other breast cancer survivors' experiences, please refer to thissection.

Meet and talk to a breast cancer survivors in person.
⚫ Before undergoing surgery, you can meet directly with a breast cancer survivor and hear about

their experience.
⚫ In some patient groups, you can see and touch the breasts of people who have undergone
reconstruction.
⚫ You can also meet other people who have gone through the procedure at breast cancer self
help groups (where people have undergone surgery).

Benefits

Risks⚫ Meeting in person makes it easier to ask questions about theexperiences of others who have gone through the surgery.
⚫ Meeting directly with the patient makes it easier to imagine what daily
life will be like after the surgery.
⚫ It is easier to obtain information on what you want to know and what
you want to ask.
⚫ You can get not only information about their experiences, but also
emotional support.
⚫ The other party is also a patient, so medical questions are not very
suitable.
⚫ Not all of the experiences of the people you meet will be available.
⚫ If you narrow down the people you want to meet too much (forexample, people in their 〇〇 age group, people with 〇〇 and 〇〇,people undergoing 〇〇 treatment, etc.),<Tips to make good use of this information>⚫ Try to learn about the experiences of more than one person.
⚫ Bear in mind that each person has a different way of feeling and thinking.
⚫ Don't just listen to their stories, but also talk about your feelings andconcerns.

31

To makethe steps
work

Using information from testimonials

Use the internet to learn about other breast cancer survivors' experiences(blogs, online communities)⚫ Blogs are like personal diaries. Many people write about the progress of their breast cancer
treatment.
⚫ The purpose of blogging is different for each infibidual. Some people want to write about
their painful feelings, while others want to communicate with their friends.
⚫ Online communities come in a variety of forms, such as Yahoo Chiebukuro, which can beviewed by anyone, and social networking services (SNS), which are members-only.

⚫ Both blogs and online communities can be used for browsing and gaining information, or forcommunicating with bloggers and commenters on the internet.

Benefits⚫ If the information is written in concrete terms, it can be used as areference in the future.
⚫ If it contains specific information on how to deal with a problem, it
can be useful when you are in trouble.
⚫ You can use it at home in your spare time
⚫ A wide range of diverse information can be obtained.
⚫ Can be used anonymously

Risks⚫ Information is vast.
⚫ It can be difficult to sort out the information you want to know
from the information you don't want to know.
⚫ Information may not be up-to-date.
⚫ May contain incorrect medical information⚫ Not all of the experiences of the blogger or the person giving
advice.

＜Tips to make good use of this information＞⚫ Try to get to know the experiences of more than one person.
⚫ Be aware that each person has a different way of feeling and thinking.
⚫ Protect your own personal information.
⚫ When communicating with people you can't see make sure to begood mannered and engage in comfortable communication.
Other ways to find out about experiences on the internet (Health and Illness Narratives: Dipex Japan)➢ Health and Illness Narratives: Dipex Japan is a database of “narratives” of people's experiences.
➢ The narratives are verified by members of the public, including medical professionals, before they
are made public.
➢ As of March 2014, the narratives of 50 breast cancer patients are available to anyone on theinternet free of charge.
➢ Website address. http://www.dipex-j.org/
32

Conclusion● For informed and values-based choice
There is no right or wrong choice for early breast cancer surgery. If you share your values and preferences
along with the professional opinion of your healthcare professionals, you can make a choice that is right foryou.
Each choice has its benefits (pros) and risks (cons). To help you understand the benefits (pros) and risks(cons) of each choice from a medical perspective and to help you examine which benefits and risks you
think are important from your values and to make it easier to communicate with others, such as healthcare
professionals, family members and others who have been through it, this decision aid is designed to help
you do this.

● Development process of the decision aid
This decision aid is based on the opinions of breast cancer survivors, doctors, nurses and nursing
and medical informatics experts.
The medical information contained herein has been verified by experts specializing in breast
cancer treatment.
However, it does not cover all medical literature, but it does contain basic information. It also
includes testimonials from people who have undergone surgery for breast cancer (their experiences
during the decision-making process before and after the surgery) at each step of the process. We
have explained the purpose of the publication to those who have provided us with their stories andhave obtained their consent before publishing them. Although it is not possible to cover all
experiences, we have included a good balance of which surgeries were chosen.
It is not funded by any companies or other organisations related to medicine (no conflict ofinterest).

● Updated information in the decision aid
The content of this decision aid is reviewed and updated as needed. When using the decision aid,
please check the date and time the information is updated.

The information provided here is intended to facilitate communication with your healthcare
provider in making your decision and to help you organize the information you know.
(Content last updated June 16, 2014)33

● Tell us your experiences of life after surgery and now.

My life after surgery is much the same as it was

It has been several years since I underwent

before I had breast cancer. I lost my breasts

the surgery. My life is the same as it was

following mastectomy, but I had breast

before the surgery.

reconstruction.
I feel more “There is no time like the present”
Of course, there is no substitute for real breast,

than I used to be than ever before (work,and the pain of losing my breast will always

hobbies, exercise, etc. ) . (Ms. D)

remain in my heart. I thought at the time, "It'shopeless to lose my breasts!" . But I wish I
could say to myself back then that it was not

I had to have the silicon removed because

like that. Now I can live a normal life with aof an infection after I underwent

smile on my face. (Ms. A)

mastectomy with reconstruction. It is now ayear since I completed breast reconstruction
surgery. I have received only hormonal
therapy.

I try to lead a regular life and return to my life
before I had breast cancer. (Ms. L)

Sometimes, I feel some tingling pain, but I
can live a normal everyday life and I enjoy
participating in sports. (Ms. H)

Many changes have taken place.
Nevertheless, I have a busy but enjoyable life

It has been seven years since my surgery. I

with my family, work, hobbies and volunteering.

have also completed hormone therapy.

I am still thinking about the future, as I consider

I exercise regularly and maintain a healthy dietthe treatment completed when my left and rightand lifestyle to stay healthy. I was working

breasts are in contrast. (Ms. C)

during my treatment and was able to work
until retirement. Now I enjoy a comfortable
life. (Ms. C)

Even after breast cancer... life after breast cancer
is more exciting! (Ms. G)

34

This decision aid is based on four such aids developed in other countries on the choice of breast cancer
surgery.
＜List of decision aids developed in other countries as a reference＞
1. Breast Cancer: Early-Stage Breast Cancer: Choosing Your Surgery(Health crossroad ( Health Dialog ) )https://www.healthcrossroads.com/EXAMPLE/crossroad.aspx?contentGUID=c3c65b10-bd6f-409c-afd04bc15fec7145 [2014-01-10]
2. Breast cancer: Should I have breast-conserving surgery or a mastectomy for early-stage cancer?
(Healthwise)https://www.healthwise.net/cochranedecisionaid/Content/StdDocument.aspx?DOCHWID=tv6530#zx3718[2014-01-10]
3. Surgery Choices for Women with DCIS or Breast Cancer(National Cancer Institute)
http://www.cancer.gov/cancertopics/treatment/breast/surgerychoices[2014-01-10]
4. BresDex：Breast Cancer Decision Explorer
http://www.bresdex.com/surgery_options.html[2014-01-10]＜References＞
1.

Stacey, D., Sammant R, Benett C. (2008). Decision making in oncology: A review of patient decision aids
to support patient participation. CA: a cancer journal for clinicians, 58(5), 293-304.

2.

Simone, N. L., Dan, T., Shih J., et al.(2012). Twenty-five year results of the national cancer instituterandomized breast conservation trial, Breast cancer Research treatment, 132, 197-203.

3.

独立行政法人国立がん研究センターがん対策情報センター(2012)．がんの冊子 各種がんシリーズ

乳

がん 受診から診断、治療、経過観察への流れ．
4.

聖路加国際病院乳腺外科発行（2012）．乳がん患者のための冊子「乳がんの治療を受けられる方へ」.

5.

日本乳癌学会 編

6.

有森直子（2004）．オタワ個人意思決定ガイド．http://www.kango-net.jp/decisionaid/public/pdf/otawa
01.pdf

患者さんのための乳がん診療ガイドライン 2012年版 金原出版株式会社．

[2014-01-10]

7.

山内英子（2013）．よくわかる最新医学 乳がん，主婦の友社．

8.

Légaré F., Kearing S., O’Connor A.(2008). Are you SURE? Assessing patient decisional conflict with a 4-item screening
test, Canadian Family Fysician, 56, 308-314.

9.

中山和弘 岩本貴 編集（2012）．患者中心の意思決定支援 納得して決めるためのケア，中央法規．

10. W. Osaka, K. Nakayama. Effect of a decision aid with patient narratives in reducing decisional conflict in choice forsurgery among early-stage breast cancer: A three-arm randomized controlled trial. Patient Education and Counseling,

2016, DOI: http://dx.doi.org/10.1016/j.pec.2016.09.011.

35

A decision aid for choice regarding surgical treatment

to help patients diagnosed with breast cancer make an informed and values-based decision

Developers
Wakako Osaka
Doctor’s Program of Graduate School of Nursing, St. Luke’s College of Nursing
Kazuhiro Nakayama
Professor at the Department of Nursing informatics, St. Luke’s College of Nursing
Medical information supervision
Hideko Yamauchi
Director of the Department of Breast Surgical Oncology, St. Luke’s International HospitalContent last updated : June 16, 2014
This work was supported by JSPS KAKENHI Grant Number JP25670928. (Grant-in-Aid for Challenging
Exploratory Research, Principal Investigator Kazuhiro Nakayama)＜Please refrain from unauthorized copying or reproduction. ＞