Locoregional Treatment Decision-making in Older Adults with Early-Stage, Hormone Receptor-Positive Breast Cancer
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Project Summary/Abstract Over 83,000 new breast cancer cases are diagnosed annually in the U.S in women >70 years, and most of these women have early-stage, hormone receptor-positive (HR+) disease. Overtreatment of these women is a growing concern, as existing data demonstrate that less-intense locoregional therapy (i.e. de-escalated therapy) does not decrease overall survival. It is well-established that mastectomy does not confer a survival benefit over breast-conserving surgery (BCS), and emerging trial data also support safe omission of radiation therapy (RT) and axillary lymph node evaluation. Proceeding with RT and axillary lymph node evaluation comes with an increased risk of surgical site infection, bleeding, chronic pain, lymphedema, and radiation-induced malignancy. Omitting these treatments, however, may be associated with a small increase in locoregional recurrence. These women thus face complex treatment decisions, which can be further complicated by the presence of geriatric-specific concerns, such as frailty, life expectancy, functional status, and competing risks. Though oncologic professional societies endorse integration of geriatric-specific concerns into treatment decision-making, it is unclear to what extent physicians heed this recommendation. Shared decision making (SDM) reinforces the importance of patient autonomy, can facilitate high-quality decisions (defined as knowledgeable decisions that are concordant with patient values), and can help to reduce overtreatment. SDM, however, can also be a difficult and time-consuming process, and existing data hold that few physicians consistently attempt to involve patients in decision making, and even fewer adjust care to patient concerns and preferences. Given the observed decisional difficulty faced by older adults with early-stage HR+ breast cancer, there is a critical need to understand how SDM can be improved in this population. This GEMSSTAR application seeks support for preliminary work aimed at understanding how geriatric-specific concerns are integrated into treatment decision-making, both on a population-level and at the level of patient-physician conversations. My research aims are to: 1) determine factors associated with physician-level and regional variation in the receipt of de-escalated locoregional treatment of older adults with early-stage HR+ breast cancer using SEER-Medicare data, and 2) detail how geriatric-specific concerns (e.g. frailty, life expectancy, functional status, and competing risks) are currently integrated into treatment conversations and to create patient-physician interaction typologies by using discourse analysis to analyze audio-recorded clinical encounters between older adults with early-stage, HR+ breast cancer and surgical, medical, and radiation oncologists. Completion of these aims will set a strong foundation for future studies exploring the complex interplay of patient and physician factors in effective SDM and for targeted interventions aimed at modulating patient-physician interactions to improve decisional quality for older women with early stage breast cancer. This work will, in turn, reduce overtreatment and improve patient care. In addition, this award would provide me with the support, mentorship, training, and networking I need to become a national leader in the study and improvement of treatment decision-making, clinical outcomes, and oncologic outcomes, in older adults with breast cancer.
