Breast Cancer Research and Treatment

, Volume 129, Issue 1, pp 79–87 | Cite as

The benefits of discussing adjuvant therapies one at a time instead of all at once

  • Brian J. Zikmund-Fisher
  • Andrea M. Angott
  • Peter A. Ubel
Preclinical study


Breast cancer patients must often decide between multiple adjuvant therapy options to prevent cancer recurrence. Standard practice, as implemented in current decision support tools, is to present information about all options simultaneously, but psychology research suggests that sequential decision processes might improve decision making. We tested whether asking women to consider hormonal therapy and chemotherapy separately would improve women’s risk knowledge and/or affect treatment intentions. We conducted an Internet-administered experimental survey of a demographically diverse sample of 1,781 women ages 40–74. Participants were randomized to experience a standard, comprehensive decision process versus sequential (one at a time) decisions regarding adjuvant therapy options for a hypothetical breast cancer patient with an estrogen receptor-positive (ER+) tumor. We assessed comprehension of key statistics, perceptions of treatment effectiveness, and perceived interest in adjuvant chemotherapy, as well as participants’ numeracy levels. When participants made sequential decisions, they demonstrated greater comprehension of decision-relevant risk statistics, as compared to when they made decisions all at once (all P’s < 0.001). Among higher-numeracy participants, those making sequential decisions were less interested in chemotherapy (P < 0.001). Lower-numeracy participants who considered all options simultaneously were insensitive to the degree of risk reduction, but those who made sequential decisions were sensitive (P = 0.03). In conclusion, presenting adjuvant therapy options sequentially improves women’s comprehension of incremental treatment benefit and increases less numerate women’s sensitivity to the magnitude of the achievable risk reduction over standard, all at once approaches. Sequential approaches to adjuvant therapy decisions may reduce use of chemotherapy among those at low risk for recurrence.


Risk Patient education as topic Patient-provider communication Adjuvant therapies 



Financial support for this study was provided by the National Institutes for Health (R01 CA87595). Dr. Zikmund-Fisher is supported by a career development award from the American Cancer Society (MRSG-06-130-01-CPPB). Dr. Angott was supported by a National Science Foundation Graduate Research Fellowship. The funding agreements ensured the authors’ independence in designing the study, interpreting the data, and publishing the report. The authors would like to thank Mark Dickson for creating the risk graphics and for programming, testing and implementing the survey and Nicole Exe for her project management.

Conflicts of interest

The authors have no conflicts of interest to report.


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Copyright information

© Springer Science+Business Media, LLC. 2010

Authors and Affiliations

  • Brian J. Zikmund-Fisher
    • 1
    • 2
    • 3
  • Andrea M. Angott
    • 4
  • Peter A. Ubel
    • 4
    • 5
  1. 1.Department of Health Behavior and Health EducationUniversity of MichiganAnn ArborUSA
  2. 2.Center for Behavioral and Decision Sciences in MedicineAnn ArborUSA
  3. 3.Division of General Internal MedicineUniversity of MichiganAnn ArborUSA
  4. 4.Fuqua School of BusinessDuke UniversityDurhamUSA
  5. 5.Sanford School of Public PolicyDuke UniversityDurhamUSA

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