Patients Vary Widely on Adjuvant Chemo -- Critical to Ask

Fran Lowry

April 19, 2017

For patients with early-stage breast cancer, preferences differ regarding adjuvant chemotherapy. Some want it, even if it will confer a survival benefit of just 1 month; others do not want it at all, even if the survival benefit is considerably longer.

The finding, from a study published online March 21 in Cancer, highlights how important it is for physicians to discuss the risks and benefits of adjuvant therapy with their patients to help them make informed decisions about their care.

"This paper tells us that among patients with early breast cancer who received modern, contemporary adjuvant chemotherapy, there is a lot of variation regarding patient preferences, and also that there are differences between patient and physician choices," first author Ines Vaz-Luis, MD, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts, told Medscape Medical News.

"We need to pay attention to patients' preferences regarding the risks and the benefits of adjuvant chemotherapy," Dr Vaz-Luis said.

"It's very important to engage in conversations with patients at the time of treatment decision and clearly understand where the patient is regarding a specific treatment, taking into consideration the risks and the benefits and not assuming that we are all the same, because in fact, when you look at our paper in detail, what you see is that there is a lot of variation on how patients perceive the benefits of chemotherapy," she said.

There is a lot of variation on how patients perceive the benefits of chemotherapy. Dr Ines Vaz-Luis

Studies conducted almost 2 decades ago showed similar findings, Dr Vaz-Luis noted.

"Those studies suggested that most patients with early-stage breast cancer are willing, for modest survival benefits, to receive 6 months of adjuvant cyclophosphamide, methotrexate, and 5-fluorouracil, which is an older regimen that is used infrequently today," she said.

The researchers wanted to see whether things had changed, "because in fact, treatments now are different, patients are different, our society is different, so we wanted to see if the variations in preferences were still a reality or not."

The study included 519 patients who had participated in the Eastern Cooperative Oncology Group (ECOG) Protocol 5103 study, in which patients with breast cancer were randomly allocated to receive standard adjuvant doxorubicin, cyclophosphamide, and paclitaxel with either bevacizumab or placebo.

The patients were enrolled between January 1, 2010, and June 8, 2010, and agreed to participate in the decision making/quality of life component of the study.

Surveys about decision making and quality of life were administered at baseline and at 18 months after enrollment and were conducted by telephone 2 weeks after a copy of the survey was delivered to the patient.

A parallel survey was sent to 175 physicians who had enrolled their patients in the study.

Six questions asked whether 6 months of chemotherapy would be worthwhile for a 1-, 2-, 6-, 9-, 12-, and 24-month survival benefit.

There were three possible answers for each question: Yes, definitely worthwhile; yes, maybe worthwhile; and no, not worthwhile.

Considerable variation was found in patient preferences, particularly for modest survival benefits.

For 1-month survival, 24% of patients said yes to 6 months of chemotherapy.

"This is a substantial minority of patients who would consider chemotherapy for 1 month of benefit," Dr Vaz-Ruiz said.

On the other hand, 2% of patients said no to 24 months of benefit.

For 2 months of survival benefit, 57% of patients would consider 6 months of chemotherapy, whereas 96% of patients would consider 6 months of chemotherapy for 24 months.

Most Doctors Would Nix Chemo for Small Benefit

The physicians who responded were less likely to recommend chemotherapy for modest benefit.

Only 3% of physicians said yes to chemotherapy that would confer a 1-month survival benefit.

Female physicians and physicians who had fewer years in practice were more likely to recommend chemotherapy for less survival benefit.

We have to let patients be patients and doctors be doctors. Dr Ines Vaz-Luis

"We have to let patients be patients and doctors be doctors and allow people to tell us what they want when we are making decisions," Dr Vaz-Luis said.

"We have to be sure we communicate well. There is a need for more flexibility for clinicians to incorporate patients' preferences. We need to be better in developing methods that allow us to explain to patients what are the risks and the benefits and to be sure that we incorporate what they want. Having a trusting relationship with our patients is essential."

The study was supported by Public Health Service grants, the National Cancer Institute, and a Susan G. Komen Promise Award. Dr Vaz-Luis reports no relevant financial relationships.

Cancer. Published online March 21, 2017. Abstract

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