Breast Cancer Research and Treatment

, Volume 143, Issue 1, pp 135–140

Patient preferences regarding intraoperative versus external beam radiotherapy following breast-conserving surgery

  • Michael D. Alvarado
  • Jay Conolly
  • Catherine Park
  • Theadora Sakata
  • Aron J. Mohan
  • Brittany L. Harrison
  • Mitchell Hayes
  • Laura J. Esserman
  • Elissa M. Ozanne
Clinical Trial

Abstract

The TARGIT-A Trial is an international randomized, prospective trial comparing intraoperative radiotherapy (IORT) for equivalence to external beam radiotherapy (EBRT) following lumpectomy for invasive breast cancer in selected low-risk patients; early results suggest that outcomes are similar. In addition to effectiveness data and cost considerations, the preferences of patients should help inform practice. This study was undertaken to explore and quantify preference in choosing between IORT and the current standard, EBRT. Eligible subjects were current or past candidates for breast-conserving surgery and radiation being seen at the University of California, San Francisco Breast Care Center. A trade-off technique varying the risk of local recurrence for IORT was used to quantify any additional accepted risk that these patients would accept to receive either treatment. Patients were first presented with a slideshow comparing EBRT with the experimental IORT option before being asked their preferences given hypothetical 10-year local recurrence risks. Patients were then given a questionnaire on demographic, social and clinical factors. Data from 81 patients were analyzed. The median additional accepted risk to have IORT was 2.3 % (−9 to 39 %), mean 3.2 %. Only 7 patients chose to accept additional risk for EBRT; 22 accepted IORT at no additional risk; and the remaining 52 chose IORT with some additional risk. Patients weigh trade-offs of risks and benefits when presented with medical treatment choices. Our results show that the majority of breast cancer patients will accept a small increment of local risk for a simpler delivery of radiation. Further studies that incorporate outcome and side effect data from the TARGIT-A trial clarify the expected consequences of a local recurrence, and include an expanded range of radiation options that could help guide clinical decision making in this area.

Keywords

Breast-conserving surgery Radiation Adjuvant radiation Intraoperative radiation IORT Patient preference 

References

  1. 1.
    Hughes KS, Schnaper LA, Bellon JR et al (2013) Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343. J Clin Oncol Off J Am Soc Clin Oncol 31:2382–2387. doi:10.1200/JCO.2012.45.2615 CrossRefGoogle Scholar
  2. 2.
    Clarke M, Collins R, Darby S et al (2005) Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet 366:2087–2106. doi:10.1016/S0140-6736(05)67887-7 PubMedGoogle Scholar
  3. 3.
    Alvarado MD, Mohan AJ, Esserman LJ et al (2013) Cost-effectiveness analysis of intraoperative radiation therapy for early-stage breast cancer. Ann Surg Oncol 20(9):2873–2880. doi:10.1245/s10434-013-2997-3 PubMedCrossRefGoogle Scholar
  4. 4.
    Hill-Kayser CE, Vachani C, Hampshire MK et al (2012) Cosmetic outcomes and complications reported by patients having undergone breast-conserving treatment. Int J Radiat Oncol Biol Phys 83:839–844. doi:10.1016/j.ijrobp.2011.08.013 PubMedCrossRefGoogle Scholar
  5. 5.
    Herzlinger R (2007) A bold new consumer-driven health care system. The laws and their legislators. Manag care 16:34–6, 39–40Google Scholar
  6. 6.
    Herzlinger RE, Falit BP (2009) Consumer-driven health care. JAMA J Am Med Assoc 301:2093–2094. doi:10.1001/jama.2009.699 author reply 2094CrossRefGoogle Scholar
  7. 7.
    Vaidya JS, Joseph DJ, Tobias JS et al (2010) Targeted intraoperative radiotherapy versus whole breast radiotherapy for breast cancer (TARGIT-A trial): an international, prospective, randomised, non-inferiority phase 3 trial. Lancet 376:91–102. doi:10.1016/S0140-6736(10)60837-9 PubMedCrossRefGoogle Scholar
  8. 8.
    Shah C, Khwaja S, Badiyan S et al (2013) Brachytherapy-based partial breast irradiation is associated with low rates of complications and excellent cosmesis. Brachytherapy 12:278–284PubMedCrossRefGoogle Scholar
  9. 9.
    Leonardi MC, Maisonneuve P, Mastropasqua MG et al (2013) Accelerated partial breast irradiation with intraoperative electrons: using GEC-ESTRO recommendations as guidance for patient selection. Radiother Oncol J Eur Soc Ther Radiol Oncol 106:21–27. doi:10.1016/j.radonc.2012.10.018 CrossRefGoogle Scholar
  10. 10.
    Stiggelbout AM, de Haes JCJM (2001) Patient preference for cancer therapy: an overview of measurement approaches. J Clin Oncol 19:220–230PubMedGoogle Scholar
  11. 11.
    Palda VA, Llewellyn-Thomas HA, Mackenzie RG et al (1997) Breast cancer patients’ attitudes about rationing postlumpectomy radiation therapy: applicability of trade-off methods to policy-making. J Clin Oncol Off J Am Soc Clin Oncol 15:3192–3200Google Scholar
  12. 12.
    Fagerlin A, Zikmund-Fisher BJ, Ubel PA (2011) Helping patients decide: ten steps to better risk communication. J Natl Cancer Inst 103:1436–1443. doi:10.1093/jnci/djr318 PubMedCrossRefGoogle Scholar
  13. 13.
    Brown SM, Culver JO, Osann KE et al (2011) Health literacy, numeracy, and interpretation of graphical breast cancer risk estimates. Patient Educ Couns 83:92–98. doi:10.1016/j.pec.2010.04.027 PubMedCrossRefGoogle Scholar
  14. 14.
    Llewellyn-Thomas HA (1997) Investigating patients’ preferences for different treatment options. Can J Nurs Res = Revue canadienne de recherche en sciences infirmières 29:45–64Google Scholar
  15. 15.
    Llewellyn-Thomas HA, Paterson JM, Carter JA et al (2002) Primary prevention drug therapy: can it meet patients’ requirements for reduced risk? Med Decis Mak 22:326–339. doi:10.1177/0272989X0202200411 CrossRefGoogle Scholar
  16. 16.
    Brownlee S (2007) Overtreated: why too much medicine is making us sicker and poorer. Bloomsbury, New YorkGoogle Scholar
  17. 17.
    Smith BD, Arthur DW, Buchholz TA et al (2009) Accelerated partial breast irradiation consensus statement from the American Society for Radiation Oncology (ASTRO). J Am Coll Surg 209:269–277. doi:10.1016/j.jamcollsurg.2009.02.066 PubMedCrossRefGoogle Scholar
  18. 18.
    Montgomery G, Kangas M, David D et al (2009) Fatigue during breast cancer radiotherapy: an initial randomized study of cognitive-behavioral therapy plus hypnosis. Health Psychol 28:317–322PubMedCrossRefGoogle Scholar
  19. 19.
    Lehman M, Jacob S, Delaney G et al (2004) Waiting times for radiotherapy—a survey of patients’ attitudes. Radiother Oncol J Eur Soc Ther Radiol Oncol 70:283–289. doi:10.1016/j.radonc.2004.01.012 CrossRefGoogle Scholar
  20. 20.
    Vaidya JS, Tobias JS, Baum M et al (2004) Intraoperative radiotherapy for breast cancer. Lancet 44:67–73Google Scholar
  21. 21.
    Mohammed R. S. Keshtgar, Norman R. Williams, Max Bulsara et al (2013) Objective assessment of cosmetic outcome after targeted intraoperative radiotherapy in breast cancer: results from a randomized controlled trial. Breast Cancer Res Treat 140:519–525Google Scholar
  22. 22.
    Hoopes DJ, Kaziska D, Chapin P et al (2012) Patient preferences and physician practice patterns regarding breast radiotherapy. Int J Radiat Oncol Biol Phys 82:674–681. doi:10.1016/j.ijrobp.2010.11.077 PubMedCrossRefGoogle Scholar
  23. 23.
    Corica T, Nowak A, Saunders C et al (2012) 482 patient preferences for adjuvant radiotherapy in early breast cancer—an Australian sub-study of the international TARGIT trial. Eur J Cancer 48:S187CrossRefGoogle Scholar
  24. 24.
    Bentzen SM, Agrawal RK, Aird EG et al (2008) The UK Standardisation of Breast Radiotherapy (START) Trial B of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial. Lancet 371:1098–1107. doi:10.1016/S0140-6736(08)60348-7 PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Michael D. Alvarado
    • 1
  • Jay Conolly
    • 1
  • Catherine Park
    • 2
  • Theadora Sakata
    • 3
  • Aron J. Mohan
    • 4
  • Brittany L. Harrison
    • 5
  • Mitchell Hayes
    • 1
  • Laura J. Esserman
    • 1
  • Elissa M. Ozanne
    • 6
  1. 1.Department of Surgery, UCSF Comprehensive Cancer CenterUniversity of CaliforniaSan FranciscoUSA
  2. 2.Department of Radiation OncologyUniversity of CaliforniaSan FranciscoUSA
  3. 3.Department of Family and Preventive MedicineUniversity of UtahSalt Lake CityUSA
  4. 4.Brown University Warren Alpert School of MedicineProvidenceUSA
  5. 5.UCSF School of MedicineSan FranciscoUSA
  6. 6.The Dartmouth Institute for Health Policy and Clinical PracticeLebanonUSA

Personalised recommendations