Reducing Decisional Conflict and Enhancing Satisfaction with Information among Women Considering Breast Reconstruction following Mastectomy: Results from the BRECONDA Randomized Controlled Trial.
BACKGROUND
Deciding whether or not to have breast reconstruction following breast cancer diagnosis is a complex decision process. This randomized controlled trial assessed the impact of an online decision aid [Breast RECONstruction Decision Aid (BRECONDA)] on breast reconstruction decision-making.


METHODS
Women (n = 222) diagnosed with breast cancer or ductal carcinoma in situ, and eligible for reconstruction following mastectomy, completed an online baseline questionnaire. They were then assigned randomly to receive either standard online information about breast reconstruction (control) or standard information plus access to BRECONDA (intervention). Participants then completed questionnaires at 1 and 6 months after randomization. The primary outcome was participants' decisional conflict 1 month after exposure to the intervention. Secondary outcomes included decisional conflict at 6 months, satisfaction with information at 1 and 6 months, and 6-month decisional regret.


RESULTS
Linear mixed-model analyses revealed that 1-month decisional conflict was significantly lower in the intervention group (27.18) compared with the control group (35.5). This difference was also sustained at the 6-month follow-up. Intervention participants reported greater satisfaction with information at 1- and 6-month follow-up, and there was a nonsignificant trend for lower decisional regret in the intervention group at 6-month follow-up. Intervention participants' ratings for BRECONDA demonstrated high user acceptability and overall satisfaction.


CONCLUSIONS
Women who accessed BRECONDA benefited by experiencing significantly less decisional conflict and being more satisfied with information regarding the reconstruction decisional process than women receiving standard care alone. These findings support the efficacy of BRECONDA in helping women to arrive at their breast reconstruction decision.
Sydney, Australia; Bristol, United Kingdom; and Merced, Calif.|From the Centre for Emotional Health, Macquarie University; the Westmead Breast Cancer Institute, Westmead Hospital; the Macquarie University Cancer Institute, Australian School of Advanced Medicine, Macquarie University; The Poche Centre, Mater Hospital; the Centre for Appearance Research, University of West of England; and the University of California, Merced.
Kerry A
KA
Sherman
Sydney, Australia; Bristol, United Kingdom; and Merced, Calif.|From the Centre for Emotional Health, Macquarie University; the Westmead Breast Cancer Institute, Westmead Hospital; the Macquarie University Cancer Institute, Australian School of Advanced Medicine, Macquarie University; The Poche Centre, Mater Hospital; the Centre for Appearance Research, University of West of England; and the University of California, Merced.
Laura-Kate E
LE
Shaw
Sydney, Australia; Bristol, United Kingdom; and Merced, Calif.|From the Centre for Emotional Health, Macquarie University; the Westmead Breast Cancer Institute, Westmead Hospital; the Macquarie University Cancer Institute, Australian School of Advanced Medicine, Macquarie University; The Poche Centre, Mater Hospital; the Centre for Appearance Research, University of West of England; and the University of California, Merced.
Caleb J
CJ
Winch
Sydney, Australia; Bristol, United Kingdom; and Merced, Calif.|From the Centre for Emotional Health, Macquarie University; the Westmead Breast Cancer Institute, Westmead Hospital; the Macquarie University Cancer Institute, Australian School of Advanced Medicine, Macquarie University; The Poche Centre, Mater Hospital; the Centre for Appearance Research, University of West of England; and the University of California, Merced.
Diana
D
Harcourt
Sydney, Australia; Bristol, United Kingdom; and Merced, Calif.|From the Centre for Emotional Health, Macquarie University; the Westmead Breast Cancer Institute, Westmead Hospital; the Macquarie University Cancer Institute, Australian School of Advanced Medicine, Macquarie University; The Poche Centre, Mater Hospital; the Centre for Appearance Research, University of West of England; and the University of California, Merced.
John
J
Boyages
Sydney, Australia; Bristol, United Kingdom; and Merced, Calif.|From the Centre for Emotional Health, Macquarie University; the Westmead Breast Cancer Institute, Westmead Hospital; the Macquarie University Cancer Institute, Australian School of Advanced Medicine, Macquarie University; The Poche Centre, Mater Hospital; the Centre for Appearance Research, University of West of England; and the University of California, Merced.
Linda D
LD
Cameron
Sydney, Australia; Bristol, United Kingdom; and Merced, Calif.|From the Centre for Emotional Health, Macquarie University; the Westmead Breast Cancer Institute, Westmead Hospital; the Macquarie University Cancer Institute, Australian School of Advanced Medicine, Macquarie University; The Poche Centre, Mater Hospital; the Centre for Appearance Research, University of West of England; and the University of California, Merced.
Paul
P
Brown
Sydney, Australia; Bristol, United Kingdom; and Merced, Calif.|From the Centre for Emotional Health, Macquarie University; the Westmead Breast Cancer Institute, Westmead Hospital; the Macquarie University Cancer Institute, Australian School of Advanced Medicine, Macquarie University; The Poche Centre, Mater Hospital; the Centre for Appearance Research, University of West of England; and the University of California, Merced.
Thomas
T
Lam
Sydney, Australia; Bristol, United Kingdom; and Merced, Calif.|From the Centre for Emotional Health, Macquarie University; the Westmead Breast Cancer Institute, Westmead Hospital; the Macquarie University Cancer Institute, Australian School of Advanced Medicine, Macquarie University; The Poche Centre, Mater Hospital; the Centre for Appearance Research, University of West of England; and the University of California, Merced.
Elisabeth
E
Elder
Sydney, Australia; Bristol, United Kingdom; and Merced, Calif.|From the Centre for Emotional Health, Macquarie University; the Westmead Breast Cancer Institute, Westmead Hospital; the Macquarie University Cancer Institute, Australian School of Advanced Medicine, Macquarie University; The Poche Centre, Mater Hospital; the Centre for Appearance Research, University of West of England; and the University of California, Merced.
James
J
French
Sydney, Australia; Bristol, United Kingdom; and Merced, Calif.|From the Centre for Emotional Health, Macquarie University; the Westmead Breast Cancer Institute, Westmead Hospital; the Macquarie University Cancer Institute, Australian School of Advanced Medicine, Macquarie University; The Poche Centre, Mater Hospital; the Centre for Appearance Research, University of West of England; and the University of California, Merced.
Andrew
A
Spillane
D000328:Adult; D000368:Aged; D003657:Decision Making; D003661:Decision Support Techniques; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D020407:Internet; D016462:Mammaplasty / Q000523:psychology*; D008408:Mastectomy; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010353:Patient Education as Topic; D010358:Patient Participation / Q000379:methods* / Q000523:psychology; D017060:Patient Satisfaction / Q000706:statistics & numerical data*; D016037:Single-Blind Method
Cancer Australia. Breast cancer statistics. Available at: http://canceraustralia.gov.au/affected-cancer/cancer-types/breast-cancer/breast-cancer-statistics. Accessed March 11, 2015.
National Health Service. Breast cancer (female). Available at: http://www.nhs.uk/conditions/cancer-of-the-breast-female/pages/introduction.aspx. Accessed March 11, 2015.
Canadian Cancer Society. Breast cancer statistics. Available at: http://www.cancer.ca/en/cancer-information/cancer-type/breast/statistics/?region=bc. Accessed March 11, 2015.
International Agency for Research on Cancer and World Health Organization. GLOBOCAN 2012: Estimated cancer incidence, mortality and prevalence worldwide in 2012. Available at: http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx. Accessed October 1, 2014.
Agarwal J, Agarwal S, Pappas L, Neumayer L. A population-based study of breast cancer-specific survival following mastectomy and immediate or early-delayed breast reconstruction. Breast J. 2012;18:226232.
Lee BT, Chen C, Yueh JH, Nguyen MD, Lin SJ, Tobias AM. Computer-based learning module increases shared decision making in breast reconstruction. Ann Surg Oncol. 2010;17:738743.
Sivell S, Edwards A, Manstead AS, et al. Increasing readiness to decide and strengthening behavioral intentions: Evaluating the impact of a web-based patient decision aid for breast cancer treatment options (BresDex: www.bresdex.com). Patient Educ Couns. 2012;88:209217.
Lam WW, Chan M, Or A, Kwong A, Suen D, Fielding R. Reducing treatment decision conflict difficulties in breast cancer surgery: A randomized controlled trial. J Clin Oncol. 2013;31:28792885.
Power TE, Swartzman LC, Robinson JW. Cognitive-emotional decision making (CEDM): A framework of patient medical decision making. Patient Educ Couns. 2011;83:163169.
Sheehan J, Sherman KA, Lam T, Boyages J. Regret associated with the decision for breast reconstruction: The association of negative body image, distress and surgery characteristics with decision regret. Psychol Health 2008;23:207219.
Peate M, Meiser B, Cheah BC, et al. Making hard choices easier: A prospective, multicentre study to assess the efficacy of a fertility-related decision aid in young women with early-stage breast cancer. Br J Cancer 2012;106:10531061.
Janis IL, Mann L. Emergency decision making: A theoretical analysis of responses to disaster warnings. J Human Stress 1977;3:3545.
Belkora JK, Volz S, Teng AE, Moore DH, Loth MK, Sepucha KR. Impact of decision aids in a sustained implementation at a breast care center. Patient Educ Couns. 2012;86:195204.
Schonberg MA, Hamel MB, Davis RB, et al. Development and evaluation of a decision aid on mammography screening for women 75 years and older. JAMA Intern Med. 2014;174:417424.
Mathieu E, Barratt AL, McGeechan K, Davey HM, Howard K, Houssami N. Helping women make choices about mammography screening: An online randomized trial of a decision aid for 40-year-old women. Patient Educ Couns. 2010;81:6372.
Culver JO, MacDonald DJ, Thornton AA, et al. Development and evaluation of a decision aid for BRCA carriers with breast cancer. J Genet Couns. 2011;20:294307.
Banegas MP, McClure JB, Barlow WE, et al. Results from a randomized trial of a web-based, tailored decision aid for women at high risk for breast cancer. Patient Educ Couns. 2013;91:364371.
Vodermaier A, Caspari C, Wang L, Koehm J, Ditsch N, Untch M. How and for whom are decision aids effective? Long-term psychological outcome of a randomized controlled trial in women with newly diagnosed breast cancer. Health Psychol. 2011;30:1219.
Goel V, Sawka CA, Thiel EC, Gort EH, O’Connor AM. Randomized trial of a patient decision aid for choice of surgical treatment for breast cancer. Med Decis Making 2001;21:16.
Sheehan J, Sherman KA. Computerised decision aids: A systematic review of their effectiveness in facilitating high-quality decision-making in various health-related contexts. Patient Educ Couns. 2012;88:6986.
Heller L, Parker PA, Youssef A, Miller MJ. Interactive digital education aid in breast reconstruction. Plast Reconstr Surg. 2008;122:717724.
Elwyn G, Lloyd A, Joseph-Williams N, et al. Option grids: Shared decision making made easier. Patient Educ Couns. 2013;90:207212.
Sherman KA, Harcourt DM, Lam TC, Shaw LK, Boyages J. BRECONDA: Development and acceptability of an interactive decisional support tool for women considering breast reconstruction. Psychooncology 2014;23:835838.
O’Connor AM, Fiset V, DeGrasse C, et al. Decision aids for patients considering options affecting cancer outcomes: Evidence of efficacy and policy implications. J Natl Cancer Inst Monogr. 1999;25:6780.
Waljee JF, Rogers MA, Alderman AK. Decision aids and breast cancer: Do they influence choice for surgery and knowledge of treatment options? J Clin Oncol. 2007;25:10671073.
Miller SM. Monitoring versus blunting styles of coping with cancer influence the information patients want and need about their disease: Implications for cancer screening and management. Cancer 1995;76:167177.
National Breast and Ovarian Cancer Centre. Guide for Women with Early Breast Cancer. 2008: Strawberry Hills, New South Wales, Australia: National Breast and Ovarian Cancer Centre; Available at: http://canceraustralia.gov.au/sites/default/files/publications/ebc-guide-for-women-with-early-breast-cancer_2_505aa94010a14.pdf. Accessed January 20, 2015.
Koedoot N, Molenaar S, Oosterveld P, et al. The decisional conflict scale: Further validation in two samples of Dutch oncology patients. Patient Educ Couns. 2001;45:187193.
O’Connor AM. Validation of a decisional conflict scale. Med Decis Making 1995;15:2530.
Loblaw DA, Bezjak A, Bunston T. Development and testing of a visit-specific patient satisfaction questionnaire: The Princess Margaret Hospital Satisfaction With Doctor Questionnaire. J Clin Oncol. 1999;17:19311938.
Wakefield CE, Meiser B, Homewood J, et al. Development and pilot testing of two decision aids for individuals considering genetic testing for cancer risk. J Genet Couns. 2007;16:325339.
Brehaut JC, O’Connor AM, Wood TJ, et al. Validation of a decision regret scale. Med Decis Making 2003;23:281292.
Cranney A, O’Connor AM, Jacobsen MJ, et al. Development and pilot testing of a decision aid for postmenopausal women with osteoporosis. Patient Educ Couns. 2002;47:245255.
Henry JD, Crawford JR. The short-form version of the Depression Anxiety Stress Scales (DASS-21): Construct validity and normative data in a large non-clinical sample. Br J Clin Psychol. 2005;44:227239.
Sarason IG. A brief measure of social support: Practical and theoretical implications. J Soc Pers Relat. 1987;4:497510.
Ananian P, Houvenaeghel G, Protière C, et al. Determinants of patients’ choice of reconstruction with mastectomy for primary breast cancer. Ann Surg Oncol. 2004;11:762771.
Monroe M, Skowronski J, MacDonald W, Wood S. The mildly depressed experience more post-decisional regret than the non-depressed. J Soc Clin Psychol. 2005;24:665690.
Kajiyama B, Thompson LW, Eto-Iwase T, et al. Exploring the effectiveness of an internet-based program for reducing caregiver distress using the iCare Stress Management e-Training Program. Aging Ment Health 2013;17:544554.
Manicavasagar V, Horswood D, Burckhardt R, Lum A, Hadzi-Pavlovic D, Parker G. Feasibility and effectiveness of a web-based positive psychology program for youth mental health: Randomized controlled trial. J Med Internet Res. 2014;16:e140.
Ben-Ezra M, Bibi H. The association between psychological distress and decision regret during armed conflict among hospital personnel. Psychiatr Q. 2016;87:515519.
van Randenborgh A, de Jong-Meyer R, Hüffmeier J. Decision making in depression: Differences in decisional conflict between healthy and depressed individuals. Clin Psychol Psychother. 2010;17:285298.
Trikalinos TA, Wieland LS, Adam GP, Zgodic A, Ntzani EE. AHRQ Comparative Effectiveness Reviews. Decision Aids for Cancer Screening and Treatment. 2014.Rockville, Md: Agency for Healthcare Research and Quality.
Hersch J, Barratt A, Jansen J, et al. The effect of information about overdetection of breast cancer on women’s decision-making about mammography screening: Study protocol for a randomised controlled trial. BMJ Open 2014;4:e004990.
Diefenbach M, Mohamed NE, Horwitz E, Pollack A. Longitudinal associations among quality of life and its predictors in patients treated for prostate cancer: The moderating role of age. Psychol Health Med. 2008;13:146161.
Antypas K, Wangberg SC. An Internet- and mobile-based tailored intervention to enhance maintenance of physical activity after cardiac rehabilitation: Short-term results of a randomized controlled trial. J Med Internet Res. 2014;16:e77.
Spillane AJ. What is new in the surgical management and prevention of breast cancer? Med J Aust. 2016;8:311314.
American Cancer Society. Breast reconstruction after mastectomy. Available at: http://www.cancer.org/acs/groups/cid/documents/webcontent/002992-pdf.pdf. Accessed March 11, 2015.