2012 Summer Medical Editors Meeting: Wendy Y. Chen, MD, MPH

1. Challenges in shared medical
decision making:
an oncologist’s perspective
Wendy Y. Chen, MD MPH

2. Breast cancer statistics - 2012
• 226,879 invasive breast cancer cases
• 39, 510 breast cancer deaths
– Prostate cancer: 241,740 cases + 28,170 deaths
=>2,971,610 breast cancer survivors
Siegel, CA Cancer J
Clin 2012

3. Breast Cancer Decision Aids
1. Ductal carcinoma in situ
2. Early stage: local treatments
3. Early stage: systemic therapy
4. Breast reconstruction
5. Metastatic breast cancer

4. Challenges to decision aids
Standardization Personalization

5. Standardization
• National Comprehensive Cancer Network
(NCCN) guidelines
• Quality Oncology Practice Initiative
– Part of ABIM recertfication process for Oncology

7. Breast QOPI module measures
• Chemotherapy recommended within 4 mths of
diagnosis for Stage I (T1c) – III ER negative
breast cancer
• Trastuzumab recommended for Stage I (T1c) -
III Her2+ breast cancer
• Hormonal Rx recommended within 1 yr of
diagnosis for patient with ER+ breast cancer

8. Breast cancer treatment trend - Personalization
• Old theory
– Stage major determinant of aggressiveness
of treatment
• More advanced stage => more chemotherapy
• New theory
– Stage still important, but underlying biology
of tumor may be equally important
• Makes standardization difficult

9. Oncotypedx
Available for ER positive tumors and mainly node negative

10. Chemo benefit as function of OncotypeDX score
Paik S,JCO 2006

11. Heuristics in oncology
• Frameworks people use for decision making
• Risk aversion
– Preference for smaller certain gain over larger but
more uncertain one
=> Patients focus on recurrence
• Anticipated regret
– Prospect of regret over omitting therapy if
recurrence were to occur
If remains cancer free, benefit ascribed to treatment
If cancer recurs, blame ascribed to omitting therapy
Katz & Morrow, JAMA 2012

12. Shared Decision Making in Oncology
Preference sensitivity – early stage breast cancer
Yes No Maybe
Mastectomy vs lumpectomy + radiation
Radiation after lumpectomy
Hormonal therapy for ER positive tumors
Adjuvant chemotherapy for early stage
breast cancer

13. Shared Decision Making in Oncology
Preference sensitivity – early stage breast cancer
Yes No Maybe
Mastectomy vs lumpectomy + radiation
Radiation after lumpectomy
Hormonal therapy for ER positive tumors
Adjuvant chemotherapy for early stage
breast cancer

14. Shared Decision Making in Oncology
• Mastectomy vs lumpectomy + RT
– No difference in overall survival
• Radiation after lumpectomy
– Often cited for quality of care/benchmarking
=> No survival benefit for older pts with early ER+ cancer
• Hormonal therapy for ER+ breast cancer
– Often cited for quality of care/benchmarking
=> Unclear survival benefit for older pts with early stage
ER+ cancer and comorbidities
• Adjuvant chemotherapy for early stage breast
cancer
– Relative benefit fixed, but absolute benefits vary

15. Challenges to decision aids
Standardization Personalization

16. Breast Cancer Decision Aids
1. Ductal carcinoma in situ
2. Early stage: local treatments
3. Early stage: systemic therapy
4. Breast reconstruction
5. Metastatic breast cancer