Neoadjuvant systemic therapy (NAST), including chemotherapy and endocrine therapy, continues to gain acceptance as a treatment option for selected women with large and/or highly proliferative, operable breast cancer. Whilst recurrence and survival outcomes are equivalent in patients treated with adjuvant compared with NAST, some women may prefer one treatment sequence over the other. This adds complexity at a time when women may be distressed by a recent diagnosis of breast cancer and are already facing decisions about multidisciplinary treatment options.
Women (n=22) with a recent diagnosis of operable invasive breast cancer were interviewed, focussing on decisions about NAST. Women who were offered NAST (n=19) felt unable to participate in decision-making as fully as they would have liked, due to a lack of patient information, the complexity of the decision, and a sense of clinical urgency. Despite this, all participants endorsed NAST as a treatment option for tumour downstaging, to give time for consideration of other treatment options, for prognostic purposes and so that chemotherapy could be administered promptly.
Breast oncology clinicians from Australia and New Zealand (n=207) responded to an online survey on their views and practice with NAST. Seventy-eight percent reported routinely offering NAST to selected patients with operable breast cancer, however 45% and 58% wanted to increase the number in routine care and clinical trials respectively. Clinician-, patient- and system-related barriers prevented optimal use of NAST. Awareness and lack of information were key concerns.
To address the decisional complexity, lack of awareness and lack of information, a decision aid was developed for women with operable breast cancer who are considering NAST. The decision aid was based on patient and clinician perspectives, literature review, international patient decision aid standards and expert consultation. This decision aid is being tested in an ongoing prospective single arm longitudinal study.