Lawrence S. Bloomberg Faculty of Nursing

Kelly Metcalfe receives CIHR grant to develop decision tool to aid in breast cancer management

The Canadian Institutes of Health Research (CIHR) has funded Dr. Kelly Metcalfe, Bloomberg Nursing associate professor and interim director of research, and Dr. Stefan Hofer, associate professor, division of plastic surgery at the University of Toronto, to develop and test a decision support tool for post-mastectomy breast reconstruction (PMBR)

“PMBR is proven to be oncologically safe and beneficial in a number of important areas of physical, social and psychological functioning, yet it remains an underutilized treatment option in Canada,” says Metcalfe, co-principal investigator for the study. “The lack of access to credible information is a discernible gap that needs to be addressed if the number of women electing to undergo PMBR is going to increase.”

Restoring the appearance of breast mounds through reconstructive surgery following mastectomy can enhance a woman’s sense of self and femininity. However, the choice of breast reconstruction is highly complex and must incorporate the individual’s personal values, priorities, previous surgical and medical treatment as well as her anatomy. In addition, while deciding to undergo PMBR, the patient must choose between alternative methods of reconstruction and timing (immediate vs. delayed) patterns. A decision regarding the acceptance or rejection of an elective procedure such as this can be challenging since it does not increase survival benefit.

The Commission on Cancer of the American College of Surgeons found “breast reconstruction is an underused option in breast cancer management.” In Canada, only 7.9 per cent of breast cancer patients undergo PMBR, even though doing so has been shown to result in increased psychosocial functioning in breast cancer survivors who have undergone a mastectomy. Preliminary evidence indicates women need guidance in making these difficult decisions, but there is currently no framework in place to guide mastectomy patients through the complex processes of decision-making about PMBR. A recent survey by the Cancer Support Community found 43 per cent of patients do not receive information about PMBR choices when they must make treatment decisions.

Metcalfe et al. recommend both physician and patient education to incorporate the use of breast reconstruction in early-stage breast cancer management. Therefore, they propose to develop a decision support tool to help post-mastectomy breast cancer patients make well-informed decisions about their breast reconstruction options and reduce their uncertainty about treatment options. Decision aids have been advocated to promote patient involvement in the decision-making process for treatment options by streamlining and standardizing communication between the patient and the health care professional. The tool will provide information on each reconstructive treatment option, including indications, contraindications, advantages, disadvantages, and complications.

The study will be conducted in three phases over two years: 1) the support tool will be developed with input from clinical experts and women living with mastectomy; 2) the tool will be pilot tested for usability; and 3) formal preliminary evaluation of the effectiveness of the support tool to help mastectomy patients make informed decisions about their breast reconstruction surgery options will be conducted.

Metcalfe has significant experience in developing and testing decision support tools for various conditions. She’s received funding from CIHR to develop and test a decision aid for breast cancer prevention in women with a BRCA1 or BRCA2 mutation; pilot test results indicated the decision aid affected primary outcomes. The Canadian Breast Cancer Research Alliance then funded the randomized controlled trial of the decision aid for which final results are pending. In addition, Metcalfe extended her decisional sciences expertise by serving as the co-investigator of a study funded by CIHR to develop and pilot test a decision support tool for individuals with angina.

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