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 by surgeons issuitable 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)

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

・・・・・・・・・・・・・5

・・・・・・・・・・・・・・・・・・11

Step 4: Clarify what is important to you ・・・・・・・・・・・・・・・・・・・17

Step 5: Make your own decision ・・・ ・・・・・・・・・・・・・・・・・・23

Conclusion ・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・25

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 decide convincingly
which breast-conserving and mastectomy options is appropriate for them, whether to undergo breastreconstruction after mastectomy, and to understand why the surgical options proposed by their surgeon isappropriate for them Created for. It is designed to assist those who want to gain a better 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

•

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

•

By compare medical knowledge of surgical options forbreast cancer. you can have a better understanding of
which aspects are similar and which 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 adecision.

•

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

Learn to make an informed
and values-based decision
P1～

Step

2

Know your options(medical knowledge ofbreast cancer surgery)

P5～

Step

3

Know your options(impact on lifestyle and daily life)
P11～

Step

4

Clarify what is important to you
P17～

Step

5

Make your own decision
P23～

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 bestfor you. It is designed to help you choose an option that is appropriate for you and that you are comfortable with, byreading the information included, comprehending accurate information, and examining what is important to you when
making a decision, and by facilitating communication with doctors, nurses, and other 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 to undergo
mastectomy, but are reconsider whether to have reconstruction.
◼ The surgeon has recommended breast-conserving surgery or mastectomy, but you would like toknow why the doctor recommended that method and whether it is suitable for you.

However, it does not contain information for those who, should be informed and are discussing their individual
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 of anti-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 anduse 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 to have 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 a second 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 are feeling distressed, you
may not be able to comprehend the information well, it may take you a long time 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 your surgeons andnurses.

4

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 the surgicalmethod and whether to undergo breast reconstruction. The decision aid is designed to be used for patientsdiagnosed with cancer and required to undergo surgery.
Breast cancer treatment flow

diagnosis

Ductal Carcinoma In Situ

(In addition to the flow described here, treatment may be carried out
according to an individual patient's specific needs. )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 suspicion ofmetastasis,
cancer cells
considered tohave been
completely
removed bysurgery,

follow-up

Breast-conserving
surgery

Breastreconstru
ction

breast-conserving
surgery fails to
remove all thetumourRadiation therapy（If post-operative
chemotherapy is given,
chemotherapy is given
first）

additional excisionor mastectomy

Drug therapy（Hormone therapy/Chemotherapy/Targeted terapy）
7）Page 71 Partially modified.
5

Step
2

Know your options (medical knowledge of breast cancer surgery)

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

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

milk, the ducts that carry the milk and the fat that supports

Breast cancer
development

lobulethem. Each mammary gland is divided into lobules, which
Breast cancer

are connected by duct-like structures called milk ducts.
About 90% of breast cancers originate from these ducts
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 and drug therapy (e.g.,
hormone therapy, targeted therapy and chemotherapy).

lactiferous duct

intraductal spreadinterstitial
infiltration（invasive
carcinoma）● Basic knowledge about surgery■ Breast-conserving surgery

Removal site

incision site

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

（drain）■ Modified ladical mastectomy
the extent of resection（ Mastectomy )dermal incision line

The breast is removed, leaving the pectoralis
muscle, including part of the skin4). Mastectomy
is a surgical procedure in which the nipple,
nipple areola and breast bulge are generally（drain）

removed in their entirety. It is also called a total
mastectomy.

6

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 thefollowing two methods are also being increasingly used. However, there are conditions for the indications. If
you want reconstruction after surgery, you may consult your doctor to see if this type of surgery is possible7）.

Skin-sparing mastectomy

The nipple areola andmammary gland are removed,
leaving as much skin as
possible. The extent of theresection is determinedaccording to the spread of thecancer7).

Nipple-sparing mastectomy
Incision along
the nipple.

The nipple areola is left intact
and the mammary gland isremoved. It is not yet a standard
treatment as it has not yet been
fully evaluated for safety andlong-term survival. Indications
7)
need to 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 frombreast cancer. Sentinel lymph node biopsy is a surgical procedure inwhich only these sentinel lymph nodes are removed to check for thesentinel lymph nodepresence of metastatic cancer cells. If there are no cancer cells in theBreast cancer

sentinel node, it is assumed that no other lymph nodes havemetastasized, and lymph nodes other than the sentinel node are notremoved. Sentinel lymph node biopsy is 95–97% accurate in identifying

regional
lymph node
lymphatic vessel

metastases5).

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

7

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 yourpreference, 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 the same
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 have radiotherapy
 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.

8

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.
Breast-conserving surgery
followed by radiation
therapy

Survival rate

Mastectomy

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

Risk of cancer
being left
behindMarginally higher than with

Marginally lower compared

The risk of recurrence in themastectomy (about 10%

to breast-conserving

breast is the same as forover a 10-year period５）.

surgery (around 3% over a

those who undergo

10-year period).

mastectomy only.

There is a minor risk of the

There is little risk of leaving

There is little risk of leaving

cancer being left behind. In

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 of thecomplications fromfive consecutive weekdays

surgery,

reconstruction may require

this case, the surgery is
performed again.

Treatment
required inaddition tosurgery

for five minutes eachsurgery.

session for three to five
weeks.

Need forchemotherapy
or other drug
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 of recurrence.

A comparison helps to understand which of the benefits and risks of each are the same and which are
different.
9

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 your healthcare
professionals. If you feel the need to gather information on your own, you can do so through 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?

10

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 your treatment wisely.

For early-stage breast cancer, the medical outcome (outcome regarding survival) is the same regardless ofwhich surgical procedure you choose２）. It is important to learn about both the effects of surgery and theimpact on quality of life after surgery.

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

shape of Breast
nipples, areola
size of scars location ofscars sensation ofbreast skin

Time and effort
spent on surgery
and recuperation(length of hospitalizationand hospital visits)

Page 12Page 13What may affect yourlifestyle and quality oflife after surgery

Other
Costs during and after
treatmentPainpossible problems effecton posture

Page 14

Page 15

11

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 of shapeof 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 the breast
may be the same as before
surgery or it may be
deformed due to the location,
size and spread of the cancer.

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

Breast reconstruction can createa breast shape. If you have had
your nipple or areola removed,reconstruction can also 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 thetiming/method of reconstruction
using autologous tissue (usingpart of the fat or muscle fromthe patient'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–rightdifference in the position ororientation of 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
location

The size and location of thescar will depend on thelocation, size, and spread of
the cancer.

The size and location of the scar
will depend on the method used
to perform the mastectomy.

The size and location of the scar
will differ depending on themethod of reconstruction. In thecase of reconstruction using
autologous tissue, the scar islarger than that of an artificial
breast, and it is located where
the skin, muscle, and fat areremoved.

post-operative
breast skinsensation

There will still be sensation of
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.

12

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 and recuperation bydifferent 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 andon your progress after the surgery.

The length of hospitalization
depends on the institution where
the patient is treated and thecourse of the post-operative
period.

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

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

A relativery longer stay than forbreast-conserving surgery iscommon.

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

As a rough guide only, it can takefrom a day to a few days for
artificial breasts (implants) andfrom about two weeks to amonth for autologous tissue.
Consult your doctor or plastic
surgeon about the length of
hospitalization due toreconstruction, regular visits tothe 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 areable to do your original activities
may vary greatly from person toperson.

Recovery time after surgery may
be shorter than with mastectomy
or mastectomy plus breastreconstruction, if the patient isdoing well after surgery.

Recovery time after surgery is
generally somewhat longer thanwith breast-conserving surgery,even if the postoperative course
is favorable.

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

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

13

Consult your surgeon or plastic
surgeon for recovery time afterreconstruction.

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 health insurance(public medical insurance).
In some cases, a high-cost medical care reimbursement system may also be available. Some coveragedepends on the type of medical insurance that an individual has. If you have chemotherapy 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 be costs
for pads and bras to compensate
for the appearance of the breasts(if the breasts retain their shape,
there is no need to be purchasenew ones).

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

You will have to pay for transport
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 some time).
Some methods are covered byhealth insurance and some arenot.
Before reconstruction, talk to
your plastic surgeon or surgeon
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 specifically the besttreatment options, together with the effects of the treatment and your life after treatment.

14

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.

Pain

Breast-conserving surgery
followed by radiation therapy

Mastectomy

Mastectomy
with reconstruction

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.

In the immediate post-operative
period, you may experience painat the surgical site, which can berelieved with painkillers.

In the early post-operative period,
pain at the surgical site may be
experienced, but can be relieved
with painkillers.

After some time, discomfort
may still be experienced.

For reconstruction with an artificial
breast, pain may occur while theexpander is creating a bulge.

Some people lose their breasts
and become depressed. If lymph
node metastases are present,
additional radiotherapy may berecommended.

-Reconstruction at the same time as
mastectomy● It may be burdensome to think
about both surgery andreconstruction.
● There is little or no loss of thebreast.
● You may not have time to thinkcarefully about reconstruction
options.

You may still experience discomfort
etc. after a period of time.
Mammography is required forregular check-ups after surgery.
Some pain may be felt during theseprocedures.

Other possible problems

Some people may feel depressed
because of the change in theappearance of their breasts.
Post-operative radiotherapy isrequired. Radiotherapy after
surgery causes skin changes.

You will need to ask yourdoctor's opinion on this.

If reconstruction is desired due tochanges in the appearance of thebreast, there is a risk that theradiotherapy will reduce theelasticity of the skin, making
reconstruction difficult or causing
problems after reconstruction.

-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 theirbreasts after reconstruction, others
are not. There is a risk of problems
associated with reconstruction.

Effect on Posture

Compared to a mastectomy, theeffect on postural balance may bemarginal, but some patients may
feel that their postural balance has
been compromised.
The extent to which posturalbalance is affected may vary fromperson to person.

Losing one breast to amastectomy can cause postural
imbalance and neck andshoulder pain in some patients.
The extent to which posturalbalance is affected may varyfrom person to person.

15

Compared to a mastectomy,
postural balance may be lessaffected, but some patients may feelthat their postural balance has been
compromised.
There are individual differences inthe effects of postural balance.

16

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 your surgeon.

Pages 18– 21 provide four perspectives to help you clarify what is most important to you, so you can weighup or check your concerns. As you gather information, talk to healthcare professionals and discuss with yourfamily, 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 to review and reevaluate what you have ticked off your list.

17

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 copewith and deal with successfully. Consider the table below to see how important each thing is to you, with0 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 5How important is it to you that you can feel the skin of yourbreast?

0 1 2 3 4 5

If you have a mastectomy, how important is it that the shapeof 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 tosurgery.
□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 this would besuitable in my case).
18

Step
4

Clarify what is important to you● Theriskriskof cancer
recurrencein theafter
breastafter surgery
risk ofbeing
tumorleft
being
left behind● Theof recurrencein breast
surgery
and theandrisk theof tumorbehindThe risk of cancer recurrence in the breast after surgery differs only marginally depending on thesurgical 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 therisk of cancer recurrence in breast due to different surgicalprocedures?

important

0 1 2 3 4 5How important to you is to reduce the chance of tumor being
left behind?

0 1 2 3 4 5How important is it to you to eliminate the risk of reoperation
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 the breast was
only slightly higher, would that be acceptable?
 Would I feel more comfortable having my entire breast removed?

19

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 of surgery.
Specifically, the length of hospitalization at the time of surgery, the time required for recovery after
surgery, and whether radiotherapy is necessary after surgery differ (the length of hospitalization at thetime 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 the amount 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 take off fromwork and whether you will be able to attend daily radiation therapy after breast-conserving 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 the higher thenumber, 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 toattend radiotherapy every weekday for approximately three tofive weeks, which would be necessary afterwards?

important

0 1 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 the hospital
visits and the time required for the surgery?

20

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 of breast
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 arecovered by health insurance (public medical insurance) and which are not. If you undergo nonsurgical treatment, you will have to pay for that treatment. If you have chemotherapy, you will needto buy a wig.

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

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

important

0 1 2 3 4 5Other 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?

21

22

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 readyyou 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 a decision yet.
Is there anything you would like to do before you decide? Check the items on the following page toorganize what you would like to do.

23

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 take action.

□ 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 the chapter onPage 5 – “Know your options (medical knowledge of breast cancer surgery)” in this decision 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 can re-readthe chapter “Clarify what is important to you” on Page 17, or talk to other people, such as nurses,
family members, or breast cancer survivors.

24

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 alongwith the professional opinion of your healthcare professionals, you can make a choice that is right for you.
Each choice has its benefits (pros) and risks (cons). To help you understand the benefits (pros) and risks (cons) ofeach choice from a medical perspective and to help you examine which benefits and risks you think are importantfrom 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 andmedical 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 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 checkthe date and time the information is updated.

The information provided here is intended to facilitate communication with your healthcare provider inmaking your decision and to help you organize the information you know.

(Content last updated June 16, 2014)25

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 institute randomized
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 for surgery
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.

26

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. ＞