BREAST CANCER: DECISION MAKING, COSTS, AND POLICY
* Finalists for the Lee B. Lusted Student Prize
Method: Using Medicare claims data for 47,869 beneficiaries undergoing RT after lumpectomy from 2005-2007, we estimated RT-specific and one-year total costs for inpatient, outpatient and physician services using generalized linear models with log link and gamma distribution. In multivariable analyses, we accounted for RT complications, race, rural residence, age, comorbidities, and censoring from death.
Result: Unadjusted average payment for radiation treatment was $6,260 for whole breast RT vs. $10,470 for brachytherapy-based RT (difference: $4200,p<0.0001), while unadjusted one-year total payment was $9,460 for whole breast RT and $12,180 for brachytherapy=based RT (difference: $2720,p<0.0001). Multivariable analyses indicate that brachytherapy treatment cost 1.66 times more than whole-breast RT (95%CI:1.62-1.70). Adjusted one-year total payments were 31% higher for those receiving brachytherapy (95%CI:1.23-1.39), 45% higher for subjects experiencing complications (95%CI:1.4-1.51)(interaction of brachytherapy*complications, N.S.), and increasingly higher with number of comorbidities (cost ratios: 1.20, 1.54, and 2.35 for 1, 2, and 2+ comorbidities, respectively, p<0.0001). For every 10,000 women undergoing brachytherapy-based RT instead of whole breast RT, we could expect an additional $40million in treatment costs, or an additional $29million in overall 1-year costs.
Conclusion: This new treatment modality increased healthcare costs before long-term evidence proved its effectiveness. These funds could have been used instead to develop additional RT treatment registries to gather sufficient evidence of effectiveness and to create appropriate financial payment models to curb use outside of research studies.
Methods: Newly diagnosed breast cancer patients identified from Los Angeles and Georgia SEER registries were surveyed approximately 5 months after diagnosis. Patients were asked about their surgical treatment (lumpectomy-L, unilateral mastectomy-UM, CPM), and if they had a genetic test. Factors contributing to decision making, including knowledge about the benefit of CPM and values important to patients’ surgical decisions, were compared with surgery type using chi-square tests. Multinomal logistic regression (MNL) was ussed to assess factors associated with CPM compared to UM and L.
Results: 509 responses have been received to date (anticipated N of 1,000). Of these, 62.5% received lumpectomy, 15% UM and 22.6% CPM. Of women who had CPM, 43.4% did not have a genetic test, 45.2% had a negative test, and 11.3% had a genetic mutation. Of women without a mutation who got CPM, 36.5% thought CPM improved survival in all women with breast cancer, and 19.8% thought it would reduce risk of cancer coming back. These women more often reported it was very important to reduce worry about recurrence when choosing their surgery than did patients who got UM or L (78.4% vs. 62.5%, 55.9%, P<0.010) but were no more likely to indicate they wanted to do everything possible. Women who were incorrect regarding survival benefit of CPM were significantly more likely than those who were correct (RRR 4.88; 95% CI 2.37-10.21) to receive CPM vs. lumpectomy.
Conclusions: In this population-based sample, rates of CPM were high and it was most often received by women without a genetic mutation. CPM decisions appear driven by a desire to reduce worry about recurrence, while also being made with low knowledge about the impact of CPM on survival and recurrence. Further work to understand decision-making for CPM in the absence of clinical indications is warranted.
Purpose: Previous experiments demonstrated the efficacy of the BRCA Gist Intelligent Tutoring System (ITS) in helping women understand and make decisions about genetic testing for breast-cancer risk. The purpose of this experiment was to understand which aspects of BRCA Gist are responsible for particular outcomes, shedding light on cognitive mechanisms.
Methods: BRCA Gist avatars presented information orally, in writing, and through graphics and video clips designed following Fuzzy-Trace Theory (FTT). Interactive dialogues between user and avatar addressed questions such as, "How do genes affect breast-cancer risk?" Using "expectations texts" and Latent Semantic Analysis, BRCA Gist "understands" and responds to participants' typed statements helping them form good gist explanations of five aspects of BRCA1/2 testing. Women (N=206) were randomly assigned to BRCA Gist, a control ITS, or selectively reduced versions of BRCA Gist. The No-Tutorial-Dialogues condition was the same as BRCA Gist except it omitted dialogues that guide gist explanations. The No-FTT-Images condition was the same as BRCA Gist except 10 images designed following FTT that help users form gist representations (example below) were removed. Theory-guided images included figures that communicated base rates of genetic mutation and of breast cancer, ordinal gist of survival rates at different stages, and conditional probabilities (e.g., of breast cancer given BRCA mutation). We assessed declarative knowledge, gist comprehension, and genetic decision-making. Dialogues were subjected to fine-grained analyses of gist-level understanding.
Results: Participants in all BRCA Gist conditions scored significantly higher on key outcomes, demonstrating the efficacy of BRCA Gist. BRCA Gist scored higher than both No-Tutorial Dialogues and No-FTT-Images groups on two tests of declarative knowledge. Detailed analyses indicate that removing dialogues and FTT images reduced performance on knowledge of mutations and genetic testing. Regarding genetic testing decisions, generating explanations and FTT images increased the weight participants gave to the number of relatives with cancer, improving concordance with testing recommendations. Generating explanations also improved genetic risk categorization. Fine-grained content analysis of verbal responses in dialogues further explicated underlying mechanisms.
Conclusions: Evidence of BRCA Gist efficacy replicated key findings from laboratory, web, and community studies, consistent with mechanisms of FTT. Images created using FTT principles and generating gist explanations each appears to enhance mental representations of base rates of BRCA mutations and breast cancer, recommendations for testing, and consequences of testing.
Method: We audiotaped and transcribed consultations with oncologists in which hormonal and/or chemotherapy was discussed. Based on these transcripts, two researchers independently assessed the patient’s level of involvement using the CPS categories. Within three days after the consultation patients were interviewed by telephone and asked whom they felt had made the final treatment decision (open-ended question). Two other researchers independently coded the patient’s answer using the CPS categories.
Result: We included 67 patients, involved in a total of 84 decisions about hormonal and/or chemotherapy. On average they were 61 years (range: 38-87) and 30% was highly educated. Overall, agreement between patients and observers about who had made the final treatment decision was 49% with a Kappa of 0.16 (95% CI 0 – 0.33). According to both patients (chemotherapy 6% and hormonal therapy 14%) and observers (chemotherapy 8% and hormonal therapy 2%) few decisions were shared. For both hormonal (68% vs. 26%) and chemotherapy (72% vs. 41%) decisions, patients more often indicated that they had made the final decision themselves than the observers. However, irrespective of assessor, patients seem to be more involved in chemotherapy than in hormonal therapy decisions.
Conclusion: The observers’ assessment of patients’ actual involvement in decision-making differed from the patients’ assessment, with patients experiencing a higher level of involvement. According to the observers’ assessment, patients were rarely involved in hormonal therapy decisions. Results suggest that observers are less lenient when it comes to judging behavior as participation than patients.
Breast cancer awareness advertisements (BCAAs) often contain sexualized images of women and sexually provocative terms. While these provocative images and terms may draw attention to breast cancer awareness, they may also have unanticipated consequences for women who view them. One of these includes self-objectification, whereby women place greater value on their physical appearance than their overall health. Having a close relative with breast cancer, however, may reduce the impact that BCAAs have on women’s self-objectification. The purpose of this research is to determine whether objectifying BCAAs increase women’s self-objectification, whether this is influenced by a family history of breast cancer, and whether self-objectification impacts women’s own health behavior.
Female participants (N = 604; recruited from Amazon Mechanical Turk) were randomly assigned to view either: 1) BCAAs that are sexually provocative, 2) BCAAs that are not sexually provocative, or 3) advertisements unrelated to breast cancer. Participants then completed a measure of self-objectification in which they rank-ordered the personal importance of traits ranging from physical appearance (e.g., physical attractiveness) to physical ability (e.g., physical coordination). Participants then completed several measures including their desire to keep their breast if diagnosed with breast cancer and their desire to learn more about their personal breast cancer risk. Finally, we asked participants whether they had a close relative who had breast cancer.
Analyses revealed that viewing sexually provocative BCAAs caused women who did not have a relative with breast cancer to self-objectify more than women who viewed neutral BCAAs and women who viewed ads unrelated to breast cancer, p = .029. Further, greater self-objectification was associated with 1) a decreased desire to learn more about personal breast cancer risk, p < .001 and 2) an increased desire to keep their breast if diagnosed with breast cancer, p= .02.
BCAAs that contain sexualized images may have the unintended consequence of increasing women’s self-objectification, which can make women less interested in learning about their personal breast cancer risk—an outcome that is actually in opposition to the objectives of BCAAs. However, women with a family history of breast cancer may be buffered from the effects of objectifying BCAAs. Considering these results, organizations should consider their specific goals (e.g., raise money, encourage breast cancer screening) when creating BCAAs.