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Title: Patient and clinician factors influencing the choice of breast cancer surgery : a qualitative and quantitative study
Author: Caldon, Lisa Jane Marie
ISNI:       0000 0001 2414 6934
Awarding Body: University of Sheffield
Current Institution: University of Sheffield
Date of Award: 2013
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Background and aims: In women with breast cancers up to 5 cm diameter, breast conservation therapy (BCT) and mastectomy are equivalent for survival and morbidity, although recurrence and body image vary. This mixed-method study in a UK region (population 5 million) aims to identify reasons for mastectomy rate (MR) variation between units. Methods and findings: The study comprised five components; two in 14 units: (1) An audit of the NHS Breast Screening Programme (n=5060 cases from 11 screening units) established MR variation was not due to case-mix or caseload (P=O.OOl). (2) A Discrete Choice Experiment (n=68/93) employing multinomial logistic regression confirmed clinicians surgical preferences (25 scenarios, n=1695) vary based on cancer (size, site and centricitv, P < O.OOl){ patient (age and breast size, P < O.OOl) and clinician variables (gender and clinician role, P=0.015 and P < O.OOl respectively). Three within units representing hiqh, medium and low case-mix adjusted MRs: (3) A validated questionnaire established that patients (n=356) preferred and achieved more autonomy in treatment selection than before; particularly among those choosing mastectomy (P < O.OOl). (4) Interviews with clinicians (n=26; 13 nurses and 13 doctors) highlighted variation in local ethos. Clinicians' focus in the low MR unit was the promotion of BCT and in others, autonomous decision-making. Communication strategies and processes optimised this. (5) Interviews with patients (n=65) demonstrated varied experiences between breast units. While patient factors influenced decisions, breast team factors predominated. Patients from the high and medium MR units described more informed autonomous decision-making processes and support. Conclusions: In this study low MRs were associated with clinicians preferring BCT and higher MRs with clinicians supporting patients' decision-making. Clinician factors related to treatment preferences associated with high MRs were not identified. This does not preclude their existence in other regions. Understanding surgical variation factors could facilitate treatment decision- making equity, but is unlikely to reduce MRs.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available