Making Good Decisions about Breast Cancer Chemoprevention
Harvard University, Cambridge, Massachusetts, United States Annals of internal medicine
(Impact Factor: 17.81).
08/2002; 137(1):52-4. DOI: 10.7326/0003-4819-137-1-200207020-00014
The U.S. Preventive Services Task Force recommendations on chemoprevention of breast cancer, which appear in this issue with a supporting evidence review by Kinsinger and colleagues, present two serious challenges for clinicians. First, clinicians must respond to misinformed patients and mitigate the worry that may cloud perspective and create demand for chemoprevention when the potential harms far exceed the benefits. Second, clinicians must identify and engage uninformed persons for whom chemoprevention holds potential promise.
Available from: Ilona Juraskova
- "Our findings echo those from an interview study with 27 women most of whom were considering tamoxifen in a primary care setting , where the issue of side effects and the association with ' chemotherapy ' were identified as barriers to uptake ( Heisey et al , 2006 ) . Previous research has indicated that the decision to engage in chemoprevention of breast cancer is a preference - sensitive decision ( Mulley and Sepucha , 2002 ; Lippman , 2006 ; Ropka et al , 2010 ) that asks the woman to explore her own needs and values , how she perceives her own risk of developing the disease ( Altschuler and Somkin , 2005 ) , and to anticipate how the drug will impact on her both physically , emotionally , and on her life in general . Indeed , Bastian et al ( 2001 ) and Bober et al ( 2004 ) report that increased cancer risk perceptions and anxiety are integral to whether a woman will engage with chemoprevention . "
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Randomised trials of tamoxifen versus placebo indicate that tamoxifen reduces breast cancer risk by approximately 33%, yet uptake is low. Approximately 10% of women in our clinic entered the IBIS-I prevention trial. We assess the uptake of tamoxifen in a consecutive series of premenopausal women not in a trial and explore the reasons for uptake through interviews.
All eligible women between 33 and 46 years at ⩾17% lifetime risk of breast cancer and undergoing annual mammography in our service were invited to take a 5-year course of tamoxifen. Reasons for accepting (n=15) or declining (n=15) were explored using semi-structured interviews.
Of 1279 eligible women, 136 (10.6%) decided to take tamoxifen. Women >40 years (74 out of 553 (13.4%)) and those at higher non-BRCA-associated risk were more likely to accept tamoxifen (129 out of 1109 (11.6%)). Interviews highlighted four themes surrounding decision making: perceived impact of side effects, the impact of others' experience on beliefs about tamoxifen, tamoxifen as a ‘cancer drug', and daily reminder of cancer risk.
Tamoxifen uptake was similar to previously ascertained uptake in a randomised controlled trial (IBIS-I). Concerns were similar in women who did or did not accept tamoxifen. Decision making appeared to be embedded in the experience of significant others.
Available from: onlinelibrary.wiley.com
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ABSTRACT: Little is known about patients' preferences for discussing cancer risks and risk management with primary care physicians. We sought to determine whether patients want to discuss such topics and what factors are associated with this interest. Participants (375 patients ages 40-85, of diverse race and education level) completed a telephone survey prior to scheduled physician visits. Survey included items on perceived health, perceived cancer risk, education level, and whether participants would like to discuss with a physician their breast, ovarian or colon cancer risk, tamoxifen, cancer genetic counseling, and colon cancer screening. Greater proportions were interested in discussing risks for each cancer, compared with those who were not (P < 0.0001). More participants were interested in discussing mammograms (80%) and cancer genetic counseling (60%) than tamoxifen (49%) or colon cancer screening modalities (43-53%). For many topics, poorer perceived health was associated with greater interest in future discussion; higher education level was associated with less interest.
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