SDM POSSIBLE - Shared Decision Making For People Over Seventy With Stage I Breast Cancer To Learn And Engage Trial
Surgeon talking points
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How to engage women age 70 and older with small (<2cm), ER+, HER2-, breast cancers in shared decision-making around breast cancer treatment
Make clear:​​
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There’s a decision to make
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There are no “right” or “wrong” answers
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Women’s values and preferences matter in the decision
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That you have the patient’s best interest at heart
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That the patient has time to think about her treatment options and does not have to decide right now.
Communication pearls (from Fagerlin et al. JNCI 2011)
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Acknowledge the complexity in the decision
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Speak slowly and avoid medical jargon
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Provide information in small segments
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Pause to allow patient participation
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Assess what your patient already knows
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Periodically check with your patient for understanding
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Communicate numbers in a way that your patient may understand (frequencies, pictographs)
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Summarize
Example language for inviting patients to participate in the decision making
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‘My job is to make sure I support you in getting to an understanding of your treatment options so that we can compare them and work out what is best for you.’
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‘Regardless of what treatment we choose most people with your type of breast cancer do very well. For this reason, there is not one right treatment pathway for all people. There are different options with different benefits and risks that we must weigh.’
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‘I’d like to take some time to talk with you about the different treatment options for your breast cancer. There’s more than one reasonable path we can take, and each option has pros and cons based on your health, your lifestyle, and what matters most to you.’
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‘My role is to help you understand the choices and what to expect with each option, and your role is to share with me what’s important to you – like how you feel about certain treatments, your daily routines, and your preferences.’
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‘We’ll make this decision together and we can include your daughter or anyone else you would like.
Sentinel Lymph Node Biopsy (SLNB)
Example language for discussing omitting a SLNB
‘We used to think that taking out lymph nodes under the armpit near the breast to see if breast cancer was there would help us decide how best to treat women. However, more recent studies have found that for women with your type of breast cancer that taking out and testing lymph nodes for breast cancer rarely changes treatment. In addition studies do not show any survival benefit for testing the lymph nodes for breast cancer in women with your type of breast cancer. This is because most women do very well with your type of breast cancer either way’.
‘Meanwhile, a lymph node biopsy may cause some women, around 5 out of 100, to have trouble with arm swelling.’
‘Some guidelines do not recommend lymph node testing for women aged 70 and older with your type of breast cancer who plan to take anti-estrogen pills’.
Language for discussing that lymph node biopsies leads to more testing:
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‘A lymph node biopsy may also lead people to get tests and treatments that they do not need. The likelihood that a lymph node biopsy would find breast cancer is low (<15%) in women your age with your type of breast cancer. But if the biopsy does show breast cancer, people sometimes feel that they must have more tests, procedures, and treatments.’
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‘But these additional treatments may not actually help them live longer since most people with your type of breast cancer do well either way. Therefore, getting more information from the biopsy could lead to more medical interventions that may not help you live longer or better.’
Omitting Radiation Therapy:
Example language for discussing omitting radiation therapy:
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‘Having radiation treatment after a lumpectomy can lower your chances of having breast cancer come back in your breast or chest wall over the next 10 years, from 10 women out of 100 to 2 women out of 100. So 8 fewer women out of 100 who have radiation treatment will avoid their breast cancer coming back in their breast or chest. These numbers assume that women take anti-estrogen pills for 5 years. Also, radiation treatment has not been shown to improve survival in women age 70 and older with your type of breast cancer since most women with your type of breast cancer do very well either way.'
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‘There are some downsides to radiation treatment. While most women do very well some feel very tired during treatment. Radiation treatment may also cause pain or swelling in the breast that can take a while to go away. Some women experience long-term changes to their breast. Having radiation may also slightly increase your long-term risk of heart or lung disease, but this is extremely rare.’
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‘Also, some women find it difficult or burdensome to travel to a medical facility for radiation treatments’.
Radiation therapy vs. Endocrine therapy
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Women who do not have radiation treatment and do not take anti-estrogen pills have a higher chance of having their breast cancer come back in their breast or chest. Therefore, women with your type of breast cancer are increasingly being given a choice of having radiation after a lumpectomy or to take anti-hormone (or anti-estrogen pills). Both treatments lower the chance of breast cancer coming back in the breast or chest wall. Some women prefer getting treated with radiation for a few weeks rather than taking a pill for 5 years but the decision really comes down to how you weigh the different benefits and downsides of each option.
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Anti-hormone pills may cause some women to experience fatigue, insomnia, headaches, weight gain, hot flashes and sexual problems. The anti-hormone pill most commonly given to women with your type of breast cancer (called aromatase inhibitors), may cause muscle or joint pain and possibly increase the risk of bone fractures. The other medication often given, called tamoxifen, can slightly increase the chance of blood clots or uterine cancer.
Primary endocrine therapy (PET)
Example language for discussing primary endocrine therapy:
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‘As we get older, it can take longer to recover or bounce back from some treatments for breast cancer, like surgery. While breast surgery is generally very safe there are side effects that can be burdensome. For women who do not want surgery or who have some significant health issues, taking an anti-hormone (or anti-estrogen) pill for 5 years is an option.”
Elicit values and preferences
Example language for eliciting patients’ values and preferences:
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‘Some women tell me they want ‘everything done’ to feel safe, while others feel that avoiding the fatigue or stress of extra procedures is more important for their quality of life. Where do you fall on that spectrum?’
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‘Knowing that your type of breast cancer is unlikely to affect how long you live, tell me what matters most to you. For example, how important is it to you to avoid the side effects of treatment? How important is it to you the peace of mind that may come from more invasive options to treat your breast cancer?’
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‘Given that this breast cancer is very slow-growing, how do you feel about the trade-off between the ‘peace of mind’ of x breast cancer treatment versus the risk of side effects that might impact your daily independence?’
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‘If we chose a path with less treatment—like just the hormone pill instead of surgery – how would you feel about knowing the tumor is still there but is being managed and kept ‘asleep’ ?’
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‘What is a ‘typical good day’ for you right now, and how much are you willing to disrupt that routine for medical appointments or recovery time?’
​To elicit patient preferences:
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Acknowledge the values and preferences that matter to your patient and her goals for treatment.
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Agree on what is important to your patient (e.g., recovery time, out-of-pocket costs, being pain free, maintain independence, maximizing survival).
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‘As you think about your options, what’s important to you?’
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‘So, if I can summarize you think option A is better for you because of X, is that right? I want to be sure I’ve understood your preferences and priorities.’
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‘What major concern or fear do you have about having breast surgery?’
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‘What major concern or fear do you have about NOT having breast surgery?’
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‘People have different goals and concerns. As you think about your options, what’s important to you?’
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‘Discuss likelihood of surgery or PET or cryotherapy addressing patient’s greatest concerns and the patient’s goals.
How to respond to ‘Doctor, what would you do?’
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‘I’m happy to make a recommendation for you. But, before I do, I would like to just understand a little more about what is important to you. Would that be okay?’
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‘Before I make a recommendation for you, are there questions about the options I can help to address?’
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May help confirm patient understanding of the key elements of the decision but respects patient’s preferred decisional role.
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Inviting family to participate
Example language for inviting family to participate:
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‘I want to make sure we’re making decisions that fit your health, your values, and your preferences. There’s a lot to consider. I’d also like to invite your daughter to be part of this conversation, if that feels comfortable to you. Sometimes it helps to have someone you trust hear the options with you, ask questions, and think through the pros and cons together.’
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‘Would it be okay if we all talk together about the treatment options and what matters most to you?’
Deliberation
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‘Tell me what you are thinking about your treatment options, what is your understanding of the benefits and risks.’
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‘What did you think of the options? Did some aspect of them worry or appeal to you?’
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‘I want to be sure I have explained things well. Please tell me what you heard.’​​
Example language for giving patients time to deliberate:
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‘It’s fine to take more time to think about the treatment choices. Would you like some more time, or are you ready to decide?’
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‘We do not have to decide today about the different breast cancer treatment options. We can think more about it. I will send you home with a patient handout with some of the information we discussed today, in case you want to think about it more.
How to discuss 10-year life expectancy with women ages 75 and older who are interested in this information
Health / Life expectancy
Example language for discussing overall health or life expectancy:
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‘A woman’s overall health may affect her chance of benefitting from breast cancer treatment. Since your type of breast cancer tends to be slow growing, it can take years before it may affect your health or quality of life. Meanwhile, the side effects of treatment can affect the quality of your life right now.’
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‘Since information on your overall health may be helpful to us in deciding on breast cancer treatment and planning for the future, I would like to use a calculator to estimate your overall health.’
Ask patients if they are interested in discussing their life expectancy:
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‘Would it be helpful to talk about how much longer you are likely to live to help us decide together about breast cancer treatment?’
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Note: Older adults tend to prefer hearing their prognosis (e.g., you have a 50% chance of living 10 more years) than their life expectancy (your life expectancy is approximately 10 years), since prognosis better communicates the uncertainty in these estimates.
When sharing prognosis information or Life expectancy remind patients:
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Everyone is different, and it is impossible to know the future, the information obtained is from women the same age and in similar health.
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You will do everything you can to help the woman live comfortably for as long as possible.
Talking points for patients interested in learning their 10-year life expectancy/prognosis.
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Life expectancy: ‘Since information on how long you may have to live would be helpful to you in deciding on breast cancer treatment and planning for your future, based on information from others your age and in similar health (and based on available risk calculators), I would estimate that your life expectancy is around 5-10 years. Of course, everyone is different, and it is impossible to know the future.’
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Prognosis: ‘Since information on how long you may have to live would be helpful to you in deciding on breast cancer treatment and for planning for your future, based on risk calculators, out of 100 adults your age with similar health problems, around 50 would be alive in 10 years while 50 would not (OR you have a 50% chance of living 10 years). Regardless, I will do everything I can to help you live comfortably for as long as possible.’
‘Based on this risk calculator, out of 100 women your age with similar health problems, around 50 would be alive in 5 years, 50 would not.’
Section references​
​(Jindal, S. K., et al. (2022); Schoenborn, N. L., et al. (2017))
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