What Drives Patient Choice: Preferences for Approaches to Surgical Treatments for Breast Cancer Beyond Traditional Clinical Benchmarks

Importance: Understanding what drives breast cancer (BC) patient's surgical decision-making and why, as survival continues to improve, are women continuing to choose mastectomy in increasing numbers. Objective: We sought to understand better what drives patient choice in surgical decision-making regarding BC treatment options. Design: We used a dynamic model, adaptive conjoint–based survey experiment, to assess multiple factors concurrently impacting patient choice, conducted from December 2016 to January 2017 using the Army of Women. Setting: Army of Women, is a U.S.–based nation-wide registry of women, both healthy and previous BC patients. Participants: An e-mail invitation was sent to the AWOL's 108,933 members, with 1,233 signing up to participate and 858 responding (548 healthy, 310 previous BC). Two hundred thirty-nine BC patients who underwent treatment > 5 years were excluded due to potential recall bias and changes in BC treatment paradigms. All subjects who did not complete the adaptive conjoint–based survey were also excluded due to inability to calculate preferences. The final sample consisted of 522 healthy women and 71 previous BC patients. Interventions or Exposures: Study of patient preference and decision drivers, without, interventions or exposures. Main Outcome(s) and Measure(s): Shares of preferences for various surgical treatment options were calculated using the highest-ranked factors, by the importance that drove patient decision-making. Results: Survey response rate was 69.5%. Among healthy women, the most important of the 9 factors in making a surgical choice were doctor's recommendation at 21.4% (SD, 13.6%) and overall survival (OS) at 20.5% (SD, 9.8%) while among previous BC patients, the most important factor was OS at 19% (SD, 9%) and doctor's recommendation at 17.2% (SD, 10.3%). Conclusion and Relevance: While OS accounted for the largest single driver of patient choice at ~20 %, it is notable that 80% of patient decision-making was driven by factors unrelated to survival such as cost, intensity and recovery time, and breast image. By understanding what drives choice, we can provide better patient-centric education and treatments. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Published online 20 April 2018. Received for publication November 19, 2017; accepted February 12, 2018. Disclosure: This study was sponsored by LifeCell Corporation (an Allergan affiliate), Bridgewater, N.J. All authors met the ICMJE authorship criteria. Neither honoraria nor payments were made for authorship. Dr. Toni Storm-Dickerson is a speaker for Allergan and a consultant for Invuity. Dr. Allen Gabriel is a consultant for Allergan and Acelity. Dave Macarios is an employee of Allergan and owns stock or stock options. Lopamudra Das, Matthew Gitlin, and Jorge Farias received research funding from LifeCell Corporation (an Allergan affiliate). The Article Processing Charge was paid for by the authors. Supplemental digital content is available for this ­article. Clickable URL citations appear in the text. Allen Gabriel, MD, FACS, Department of Plastic Surgery, 505 NE, 87th Avenue, Suite 250, Vancouver, WA 98664, E-mail: gabrielallen@yahoo.com Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.

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