Effectiveness and implementation of a decision support tool to improve surgical decision making in young women with breast cancer

项目摘要/摘要 在美国，患有早期乳腺癌的年轻女性越来越多地选择让她们的 未受影响的乳房切除，这一过程称为对侧预防性乳房切除术(CPM)或双侧乳房切除术 (“双”)乳房切除术。CPM的临床益处(例如，没有生存益处)微乎其微，而且有 有案可查的危害，包括手术并发症风险增加和质量下降的可能性 生命的后遗症。此外，美国乳房外科医生协会和明智选择指南 建议不要在患有单侧乳腺癌的中等风险女性中常规使用CPM。之前 研究表明，乳腺癌手术的风险和益处并不是最理想的。 一些女性对乳腺癌风险有不准确的看法，这很可能 影响了他们的手术选择。生命阶段的特定因素(例如，母乳喂养、身体形象)可以使外科手术 对于年轻女性和年轻女性来说，决策尤其复杂，报告称决策冲突程度很高 关于手术决定。以最佳方式支持年轻女性做出关于乳腺癌的决定 手术，我们开发了CONSYDER，这是一个基于Web的决策支持工具，专为年轻人的独特关切而定制 病人。在我们的初步研究中，所有使用CONSYDER的女性都发现它有助于她们理解利弊 并围绕这一高度偏好敏感的决定阐明他们的价值观。CONSYDER在以下方面具有创新性 其决策支持方法是整合支持性护理资源以帮助管理压力和焦虑 将诊断作为决策工具的一部分。这些资源受到患者的重视，表明了 承认他们的心理社会需求的这种方法的可接受性。我们现在提出一个务实的， 阶梯式多中心试验，采用II型混合有效性-实施设计。我们会 测试CONSYDER在减少800名年轻女性术前决策冲突方面的有效性 在耶鲁·斯米洛癌症中心、威尔·康奈尔医学院、达纳-法伯癌症中心看乳腺癌外科医生 研究所和杜克癌症研究所。同时，我们将采用混合方法，包括调查 以及与患者和提供者的半结构化访谈，以评估 CONSYDER。实施结果将包括交付的可行性、跨站点的采用率和保真度， 对关键特征的理解，以及可持续性。我们的务实研究将测试以下内容的有效性和实施 旨在促进共同决策并减少年轻女性决策冲突的干预措施 乳腺癌。我们期望拟议研究的结果不仅能证明这一方法的有效性 新的干预措施不仅是为了通知CONSYDER的最佳交付和更广泛的传播，使 以患者为中心，为乳房年轻女性提供最高质量的偏好敏感决策支持 癌症面临手术。

Project Summary/Abstract In the United States, young women with early-stage breast cancer are increasingly choosing to have their unaffected breast removed, a procedure known as contralateral prophylactic mastectomy (CPM) or bilateral (“double”) mastectomy. The clinical benefits of CPM (e.g., no survival benefit) are minimal and there are documented harms, including an increased risk of surgical complications and the potential for negative quality of life sequelae. Additionally, the American Society of Breast Surgeons and Choosing Wisely guidelines recommend against the routine use of CPM among average risk women with unilateral breast cancer. Prior research has suggested that the risks and benefits of breast cancer surgery are not being optimally communicated and that some women have inaccurate perceptions about breast cancer risks that are likely impacting their choice of surgery. Life-stage specific factors (e.g., breastfeeding, body image) can make surgical decisions particularly complex for young women and young women report high levels of decisional conflict regarding the surgical decision. To optimally support young women making decisions about breast cancer surgery, we developed CONSYDER, a web-based decision support tool tailored to the unique concerns of young patients. In our pilot study, all women who used CONSYDER found it helped them understand the pros and cons of surgery and clarify their values around this highly preference sensitive decision. CONSYDER is innovative in its approach to decision support in that integrates supportive care resources to help manage stress and anxiety around diagnosis as part of the decision tool. These resources were valued by patients, demonstrating the acceptability of this approach that acknowledges their psychosocial needs. We are now proposing a pragmatic, stepped-wedge, multicenter trial that incorporates a Type II hybrid effectiveness-implementation design. We will test the effectiveness of CONSYDER in reducing decisional conflict before surgery among 800 young women seeing a breast cancer surgeon at Yale Smilow Cancer Center, Weill Cornell Medicine, Dana-Farber Cancer Institute, and Duke Cancer Institute. Concurrently, we will use a mixed-methods approach, including surveys and semi-structured interviews with patients and providers, to evaluate the value and implementation of CONSYDER. Implementation outcomes will include feasibility of delivery, adoption and fidelity across sites, uptake of key features, and sustainability. Our pragmatic study will test the effectiveness and implementation of an intervention designed to promote shared decision-making and reduce decisional conflict in young women with breast cancer. We expect findings from the proposed study not only to demonstrate the effectiveness of this novel intervention but also to inform the optimal delivery and broader dissemination of CONSYDER, enabling patient-centered support for the highest quality preference-sensitive decisions for young women with breast cancer facing surgery.