Smitt M C, Heltzel M
Department of Radiation Oncology, Stanford University Medical Center, California, USA.
Ann Surg Oncol. 1997 Oct-Nov;4(7):564-9. doi: 10.1007/BF02305537.
The majority of women with stage I/II breast cancer may choose between mastectomy and breast-conserving therapy (BCT). A survey was designed to examine the resources women used in making this decision.
From 1990 to 1994, 261 patients were diagnosed with or treated for stage I/II breast cancer at Washington Hospital (Fremont, CA). One-hundred seventy-six surviving patients received a questionnaire asking them to anonymously rank various medical and nonmedical persons, audio and visual materials, and decision criteria on a 5-point scale with regard to their influence on that individual's choice to undergo BCT or mastectomy. The BCT and mastectomy groups were similar demographically; approximately 50% were college-educated. Statistical significance of the difference in means between groups was assessed with the t test. The response rate to the survey was 65%.
The average survey ranking was > 1.0 for the following: surgeon (4.5), primary care physician (2.8), spouse (2.4), radiation oncologist (1.7), medical oncologist (1.5), American Cancer Society brochure (1.4), and children (1.2). The ranking of children (p = 0.08), friends (p = 0.08), parents (p = 0.09), and spouse (p = 0.13) was higher in the mastectomy group; the ranking of the radiation oncologist (p = 0.001) and ACS brochure (p = 0.03) was higher in the BCT group. The majority of patients consulted only with the surgeon (96%), primary care physician (64%), and spouse (55% overall, 75% among married patients) before making a treatment choice. Decision criteria were ranked as follows: chance for cure (4.5), physician recommendation (3.7), potential side effects (1.7), cosmetic appearance (1.3), sexual attractiveness (1.1), treatment convenience (1.0), and desire to avoid mastectomy (1.5). Desire to avoid mastectomy was higher in the BCT group (p < 0.0001); ranking of chance for cure was higher in the mastectomy group (p = 0.12). Overall satisfaction was higher in the BCT group; 87% of these patients were "very satisfied" with their decision versus 68% for the mastectomy group (p = 0.005). Review of the admitting records for 125 patients treated with mastectomy indicated that 46% had clear medical or personal contra-indications to BCT, but that the remainder might have benefitted from specialty consultation.
The surgeon's recommendation and the patient's perception of chance for cure were the most influential factors affecting treatment decision. There was a limited use of specialty consultation or written and audiovisual materials in this educated patient population. The survey results suggest potential areas of intervention to improve rates of BCT, namely use of up-front multidisciplinary evaluation, further education of primary care physicians, and greater attention to concerns of family members.
大多数I/II期乳腺癌女性可在乳房切除术和保乳治疗（BCT）之间做出选择。设计了一项调查以研究女性在做出该决定时所利用的资源。
1990年至1994年期间，261例患者在华盛顿医院（加利福尼亚州弗里蒙特）被诊断为I/II期乳腺癌或接受相关治疗。176例存活患者收到一份问卷，要求他们就各种医学和非医学人员、视听材料以及决策标准对其接受BCT或乳房切除术选择的影响，以5分制进行匿名排序。BCT组和乳房切除术组在人口统计学上相似；约50%接受过大学教育。采用t检验评估两组均值差异的统计学显著性。调查的回复率为65%。
以下各项的平均调查排名大于1.0：外科医生（4.5）、初级保健医生（2.8）、配偶（2.4）、放射肿瘤学家（1.7）、肿瘤内科医生（1.5）、美国癌症协会手册（1.4）和子女（1.2）。乳房切除术组中子女（p = 0.08）、朋友（p = 0.08）、父母（p = 0.09）和配偶（p = 0.13）的排名更高；放射肿瘤学家（p = 0.001）和美国癌症协会手册（p = 0.03）在BCT组中的排名更高。大多数患者在做出治疗选择前仅咨询了外科医生（96%）、初级保健医生（64%）和配偶（总体为55%，已婚患者中为75%）。决策标准的排名如下：治愈机会（4.5）、医生建议（3.7）、潜在副作用（1.7）、外观（1.3）、性吸引力（1.1）、治疗便利性（1.0）以及避免乳房切除术的意愿（1.5）。BCT组中避免乳房切除术的意愿更高（p < 0.0001）；乳房切除术组中治愈机会的排名更高（p = 0.12）。BCT组的总体满意度更高；这些患者中有87%对其决定“非常满意”，而乳房切除术组为68%（p = 0.005）。对125例行乳房切除术患者的入院记录审查表明，46%有明确的医学或个人BCT禁忌证，但其余患者可能会从专科会诊中受益。
外科医生的建议和患者对治愈机会的认知是影响治疗决策的最具影响力因素。在这个受过教育的患者群体中，专科会诊或书面及视听材料的使用有限。调查结果提示了可能提高BCT率的干预领域，即采用前期多学科评估、对初级保健医生进行进一步教育以及更多关注家庭成员的担忧。
