MEDICATIONS: DECISION AIDS CAN HELP WOMEN LEARN ABOUT BREAST CANCER RISK AND TESTING, AND ASSIST IN CHOOSING AMONG TREATMENT OPTIONS

July 27, 2004 — An interactive computer program can help educate women about breast cancer risk and genetic testing, and a decision board offering information on treatment options can help breast cancer patients choose between mastectomy and breast-conserving therapy, according to articles in the July 28 issue of JAMA, the Journal of the American Medical Association.

In the first of two studies, Michael J. Green, M.D., M.S., of Penn State College of Medicine in Hershey, Pa., and colleagues compared the effectiveness of an interactive, multimedia CD ROM-based decision aid with standard genetic counseling for educating women about BRCA1 and BRCA2 genetic testing. BRCA1 and BRCA2 are genes that help control normal cell growth. People who inherit specific mutations in one or both of these genes have an increased risk of developing breast cancer. People who carry these mutations and have family members with breast cancer are more likely to develop the disease.

According to background information in the article, genetic testing for inherited cancer predisposition has become widely available. But as the availability of and demand for genetic testing for hereditary cancers increases in primary care and other clinical settings, alternative or adjunct educational methods to traditional genetic counseling will be needed.

The authors conducted a randomized controlled trial at outpatient clinics at six U.S. medical centers from May 2000 to September 2002. Among 211 women with personal or family histories of breast cancer, 105 received standard one-on-one genetic counseling, and 106 received education by a computer program, followed by genetic counseling. Both groups had comparable demographics, prior computer experience, medical literacy, and baseline knowledge of breast cancer and genetic testing. The authors looked at outcome measures that tested factual knowledge, assessed decision making, and measured emotional reactions — such as anxiety, conflict, and satisfaction.

"An interactive computer program was more effective than standard genetic counseling for increasing knowledge of breast cancer and genetic testing among women at low risk of carrying a BRCA1 or BRCA2 mutation," the authors report. "However, genetic counseling was more effective than the computer at reducing women's anxiety and facilitating more accurate risk perceptions."

The authors believe their findings support the use of an interactive computer program to educate women about breast cancer risk and genetic testing.

"For those at high risk of hereditary breast cancer, our computer program can effectively supplement standard genetic counseling by providing factual information before genetic counseling sessions," the authors conclude. "For women at low risk, the computer program has the potential to stand alone as an educational method when accompanied by appropriate follow-up with a qualified health care professional."

Editor's Note: Dr. Green has received royalty payments from sales of the CD-ROM decision aid. Dr. Green had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Decision Board Helps Improve Communication and Enables Women to Make Choice Regarding Treatment

In an accompanying study, Timothy Whelan, B.M., B.Ch., of McMaster University and the Juravinski Cancer Centre in Ottawa, Ontario, and colleagues evaluated the impact of a decision aid on patient decision making regarding different surgical treatment options. According to background information in the article, long-term results of randomized trials have demonstrated equivalent survival rates for mastectomy and breast-conserving therapy (BCT) for the treatment of early stage breast cancer. Consequently, the choice of treatment should be based on a patient's preferences.

The decision board is an aid that presents written and visual information to patients regarding their treatment options, the acute and long-term adverse effects associated with treatment, and the effects of treatment on a patient's breast, long-term survival, and quality of life. The authors conducted a cluster randomized trial in which general surgeons in central, eastern, and western Ontario were randomly assigned to use the decision board, or not, in surgical consultations.

Twenty surgeons took part in the study, and 201 women with newly diagnosed clinical stage I or II breast cancer agreed to be evaluated. Patients received the decision board, or not, based on which surgeon they saw; 94 were assigned to the decision board, and 107 to usual practice. Immediately following counseling, at six months, and at 12 months, patients were questioned about their choices of therapy, conflict about their decision, satisfaction, anxiety, and depression.

"Patients in the decision board group had higher knowledge scores about their treatment options (66.9 vs. 58.7), had less decisional conflict (1.40 vs. 1.62), and were more satisfied with decision making (4.50 vs. 4.32) following the consultation," the authors write.

"Patients who used the decision board were more likely to choose BCT (94 percent vs. 76 percent)," they report.

"The results of this randomized trial demonstrate that the decision board not only improved patient knowledge about breast cancer and its treatment but also decreased their decisional conflict and increased their satisfaction with decision making following the consultation," the authors write.

"Such instruments should be considered by surgeons when communicating the different surgical options to women with breast cancer," they conclude.

Editor's Note: Dr. Whelan is a Canada Research Chair funded by Health Canada. The Canadian Breast Cancer Research Initiative and the Ontario Ministry of Health and Long-Term Care, Health System-Linked Research Programme provided funding support for the study. The study sponsors did not influence the design or conduct of the study; the collection, analysis, interpretation, or preparation of the data; or the preparation, review, or approval of the manuscript. Editorial: Long-Term Clinical Utility or Temporary Solution? In an accompanying editorial, Charis Eng, M.D., Ph.D., of the Ohio State University, in Columbus, Ohio, and the University of Cambridge, Cambridge, England, and Dirk Iglehart, M.D., of Harvard Medical School in Boston, assert that decision aids are useful only if they accurately reflect current and changing information and clinical practice. "New results and a changing art of practice continue to provide a moving target," they write. "Educational aids are helpful, but an experienced clinician, in touch with changing concepts and data, remains indispensable for integrating and explaining tests and treatments offered to patients." "Medicine, even 21st century genomic medicine, remains very much an art as well as a science," the authors conclude. (JAMA.2004; 292:496-498. Available post-embargo at JAMA.com)

Editor's Note: Dr. Eng is the Dorothy E. Klotz Professor of Cancer Research, is the recipient of a Doris Duke Distinguished Clinical Scientist Award, and is partially supported by the American Cancer Society, Department of Defense U.S. Army Breast and Prostate Research Programs, National Cancer Institute, National Institutes of Health, and V Foundation Jimmy V. Golf Classic Translational Cancer Research Award. Dr. Iglehart is the Anne E. Dyson Professor of Women's Cancer and is supported by a National Cancer Institute SPORE in Breast Cancer at Harvard University and the Breast Cancer Research Foundation.