Beliefs held by breast surgeons that impact the treatment decision process for advanced breast cancer patients: a qualitative study

Reina Ozeki-Hayashi,1 Misao Fujita,2 Atsushi Tsuchiya,3 Taichi Hatta,2 Eisuke Nakazawa,1 Yoshiyuki Takimoto,1 Akira Akabayashi1,41Department of Biomedical Ethics, The University of Tokyo Faculty of Medicine, Tokyo, Japan; 2Uehiro Research Division for iPS Cell Ethics, Center for iPS Cell Research and Application Kyoto University, Kyoto, Japan; 3Industrial and Social Science, Tokushima University Graduate School of Technology, Tokushima, Japan; 4Division of Medical Ethics, Department of Population Health, New York University School of Medicine, New York, NY, USAIntroduction: Although guidelines do not recommend chemotherapy for patients with advanced cancer when death is imminent, many reports suggest the tendency to continue this treatment has been increasing every year. This study aimed to construct a model to clarify the beliefs and communication of doctors who administer chemotherapy to patients with recurrent or metastatic (hereafter, “recurrent/metastatic”) breast cancer, and determine how these beliefs are related to the process of treating patients.Materials and methods: Semi-structured interviews were conducted with 21 breast surgeons, and interview contents were analyzed using the grounded theory approach in order to conceptualize the treatment process.Results: The process of chemotherapy for patients with recurrent/metastatic breast cancer differed based on two beliefs held by doctors. One was a “belief that the patient is an entity who cannot accept death,” and throughout the treatment process, these doctors consistently avoided sharing bad news that might hurt patients, and always discussed aggressive chemotherapy. They proposed treatments as long as options remained, and when they ultimately judged that the physical condition of patients could not withstand further treatment, treatment was terminated despite the patient hoping for continuation. The other was a “belief that the patient is an entity who can accept death.” From early on after recurrence/metastasis, these doctors repeatedly gave patients information including bad news about prognosis, and when they judged that further treatment would hinder a patient’s ability to have a good death, they proposed terminating treatment.Conclusion: We demonstrated that breast surgeons treating recurrent/metastatic breast cancer patients have two beliefs and constructed a model of the treatment process based on those beliefs. This offered breast surgeons, who make decisions regarding treatment without clearly-defined guidelines, a chance to reflect on their own care style, which we believe will contribute to optimal patient care.Keywords: palliative chemotherapy, end-of-life, decision-making process, qualitative research