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.