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 Outcomes and Measures: 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.