Effect of a multilevel implementation programme on shared decision-making in breast cancer care.

BACKGROUND: Women with newly diagnosed breast cancer face multiple treatment options. Involving them in a shared decision-making (SDM) process is essential. The aim of this study was to evaluate whether a multilevel implementation programme enhanced the level of SDM behaviour of clinicians observed in consultations. METHODS: This before-after study was conducted in six Dutch hospitals. Patients with breast cancer who were facing a decision on surgery or neoadjuvant systemic treatment between April 2016 and September 2017 were included, and provided informed consent. Audio recordings of consultations made before and after implementation were analysed using the five-item Observing Patient Involvement in Decision-Making (OPTION-5) instrument to assess whether clinicians adopted new behaviour needed for applying SDM. Patients scored their perceived level of SDM, using the nine-item Shared Decision-Making Questionnaire (SDM-Q-9). Hospital, duration of the consultation(s), age, and number of consultations per patient that might influence OPTION-5 scores were investigated using linear regression analysis. RESULTS: Consultations of 139 patients were audiotaped, including 80 before and 59 after implementation. Mean (s.d.) OPTION-5 scores, expressed on a 0-100 scale, increased from 38.3 (15.0) at baseline to 53.2 (14.8) 1 year after implementation (mean difference (MD) 14.9, 95 per cent c.i. 9.9 to 19.9). SDM-Q-9 scores of 105 patients (75.5 per cent) (72 before and 33 after implementation) were high and showed no significant changes (91.3 versus 87.6; MD -3.7, -9.3 to 1.9). The implementation programme had an association with OPTION-5 scores (ß = 14.2, P < 0.001), hospital (ß = 2.2, P = 0.002), and consultation time (ß = 0.2, P < 0.001). CONCLUSION: A multilevel implementation programme supporting SDM in breast cancer care increased the adoption of SDM behaviour of clinicians in consultations.

Factors associated with frequency of discussion of or referral for counselling about fertility issues in female cancer patients.

Current practices in counselling of female cancer patients with respect to fertility issues need considerable improvement, particularly given the general underuse of fertility preservation options and the negative impact that infertility can have on quality of life. We investigated the relationship between physicians' and physician-related factors and the frequency of physicians discussing fertility issues and referring to a reproductive specialist. We invited 1,832 physicians in the Netherlands who had treated at least five reproductive-age female cancer patients within the past year to complete a questionnaire. Of the 748 respondents, 406 met our inclusion criteria, and 280 participated. Analysis revealed that 79% of the participants usually or always discuss fertility issues. Specialty, confidence in knowledge regarding fertility issues and a lack of reproductive specialists in their region contributed independently to the variance in the frequency of discussing fertility issues. Moreover, 54% either regularly or always refer. Specialty and frequency of discussion contributed independently to the variance in referral. In conclusion, although high, frequency of discussion of fertility issues is not optimal, and referral seems limited. Patients would benefit from more knowledge among physicians regarding fertility issues and referral options, both in terms of informed choice, and more importantly, quality of life.

[Fertility preservation in female oncology patients]. / Fertiliteitspreservatie bij vrouwen met kanker.

Four women were referred to the department ofGynaecology for fertility preservation. A 33-year-old nulliparous woman with breast cancer stage pT1cN0M0 underwent an IVF-ICSI cycle; five embryos were frozen. Pre-implantation genetic diagnosis (PGD) because of BRCA2 gene mutation carriage was not carried out and more recently follow-up oocyte donation options are being considered. A second, 32-year-old nulliparous woman with breast cancer stage pT2N1M0 underwent an IVF cycle; seven embryos were frozen. The third patient was a 14-year-old girl with osteosarcoma of the distal femur, who underwent a laparoscopic unilateral ovariectomy, one day after referral, and cortical tissue was frozen. The fourth patient was a 33-year-old nulliparous woman without partner, with non-Hodgkin lymphoma stage IIA. She underwent laparoscopic ovariectomy and cortical tissue was frozen. Infertility due to cancer treatment and fertility preservation options should be discussed early in treatment planning. Patients' expectations and fertility preservation limitations are important to consider. Fertility preservation options can be conducted in specialised hospitals under institutional review board approval. It still has an experimental status.

[The consequences of postponing pregnancy]. / Gevolgen van uitstel van zwangerschap.

The postponement of childbearing is determined by societal factors and is related to the fact that it is often difficult for women to combine an education, a job or a career with having children and taking care of a family. Especially gynaecologists are increasingly confronted with women who undergo the medical consequences of such postponement. Postponing the first pregnancy is accompanied by an increased risk of unwanted infertility. If women do succeed in becoming pregnant later in life, there is an increased risk of complications during pregnancy and delivery. The child runs a greater risk of chromosomal aberrations and of mental and physical handicaps related to increased numbers of premature births and fertility treatments. All these problems begin to increase after age 30, but especially after age 35. Finally, the risk of breast cancer is also increased if a woman delays the birth of her first child or remains childless.