Patient and surgeon decision-making in risk-reducing mastectomy: an ethical and empirical analysis

患者和外科医生在降低风险的乳房切除术中的决策：伦理和实证分析

• 批准号: ES/J008184/1
• 负责人: Stephen Brown
• 金额: $ 21.71万
• 依托单位: University of Liverpool
• 依托单位国家: 英国
• 项目类别: Research Grant
• 财政年份: 2013
• 资助国家: 英国
• 起止时间: 2013 至 无数据
• 项目状态: 已结题
• 来源: https://gtr.ukri.org/projects?ref=ES%2FJ008184%2F1
• 关键词: Patient; surgeon; decision; making; risk

Breast cancer is one of the most common cancers in the UK, with 38,279 new cases (38,004 female) reported during 2006. Familial and genetic profiling techniques permit the estimation of both risk faced by individuals and the risk-reduction prospects of specific interventions. Risk Reducing Mastectomy (RRM) is the removal of healthy breast tissue to reduce the future risk of breast cancer. Contralateral RRM (CRRM) is the removal of tissue in the opposite breast in patients who have experienced cancer and BRRM involves to both breasts of women at high risk of cancer who have usually not personally experienced cancer. Our ability to predict and surgically reduce risk also creates a dilemma. Breast surgery can have adverse medical and psychological effects which need to be balanced against risk reduction benefits. Our pilot research indicates that potential CRRM patients do not consider the risks of surgery or future cancer in their decision-making. Instead, their preferences were determined by the degree to which they were distressed by the possibility of cancer. Surgeons appeared to show empathy to this distress and generally assented to CRRM requests. On the surface, we are concerned that the primary role of patient distress, and minor role of objective risk, in these decisions may not be in patients best interests or even ethical. However, the meaning of these findings is open to interpretation. Evidence from the risk perception literature suggests that distress does not necessarily inhibit sound decision-making. Indeed, women and surgeons use the intensity and duration of current distress to judge how distressed women will be if they do not have surgery. Thus, conducting surgery to reduce patient distress might be considered to be reasoned and ethical. From surgeons' perspectives, it is unclear whether they assist patients to form opinions about surgery or whether they question decisions that they feel are poorly made. Indeed, surgeons should encourage patients to determine the course of their treatment, and the ethical grounds on which surgeons can attempt to influence or over-rule patient choices are far from clear. These issues are not unique to breast cancer. The recent development of methods to reduce risk using invasive procedures means that these dilemmas are becoming common in a range of medical areas and are likely to grow in complexity and number. To clarify and help to resolve these issues, we intend to further examine processes of individual and joint decision-making by women and their surgeons to better understand how the key issues as viewed by each and how these views influence the decision outcome. Using a series of qualitative interviews with patients and their surgeons, we will examine how patients form preferences both for and against RRM surgery, and how surgeons deal with these preferences. To develop a better understanding of what might be appropriate actions in these situations, we will interpret our findings in the light of contemporary thought in bioethics and decision-making. In return, we expect that the conclusions that we reach from this area of research will assist in the development of these broader literatures in bioethics and decision-making.

乳腺癌是英国最常见的癌症之一，2006 年报告了 38,279 例新病例（38,004 名女性）。家族和基因分析技术可以估计个人面临的风险以及特定干预措施的风险降低前景。降低风险乳房切除术 (RRM) 是切除健康的乳腺组织，以降低未来患乳腺癌的风险。对侧 RRM (CRRM) 是指切除患有癌症的患者的对侧乳房组织，BRRM 涉及癌症高危女性的双侧乳房，这些女性通常没有亲身经历过癌症。 我们预测和通过手术降低风险的能力也造成了困境。乳房手术可能会产生不利的医疗和心理影响，需要与降低风险的益处进行权衡。我们的试点研究表明，潜在的 CRRM 患者在决策时不会考虑手术或未来癌症的风险。相反，他们的偏好取决于他们对癌症可能性的担忧程度。外科医生似乎对这种痛苦表示同情，并普遍同意 CRRM 的请求。从表面上看，我们担心在这些决策中，患者痛苦的主要作用和客观风险的次要作用可能不符合患者的最佳利益，甚至不符合道德。 然而，这些发现的意义有待解释。风险认知文献中的证据表明，痛苦并不一定会阻碍正确的决策。事实上，女性和外科医生会根据当前痛苦的强度和持续时间来判断女性如果不接受手术将会有多痛苦。因此，进行手术来减少患者痛苦可能被认为是合理且合乎道德的。从外科医生的角度来看，尚不清楚他们是否帮助患者形成有关手术的意见，或者是否质疑他们认为做出的糟糕决定。事实上，外科医生应该鼓励患者自行决定治疗方案，而外科医生试图影响或否决患者选择的道德依据尚不明确。 这些问题并非乳腺癌所独有。最近使用侵入性手术降低风险的方法的发展意味着这些困境在一系列医疗领域变得普遍，并且可能变得更加复杂和数量增加。为了澄清和帮助解决这些问题，我们打算进一步研究女性及其外科医生的个人和联合决策过程，以更好地了解每个人如何看待关键问题以及这些观点如何影响决策结果。 通过对患者及其外科医生进行一系列定性访谈，我们将研究患者如何形成支持和反对 RRM 手术的偏好，以及外科医生如何处理这些偏好。为了更好地理解在这些情况下什么是适当的行动，我们将根据当代生物伦理学和决策思想来解释我们的发现。作为回报，我们期望从这一研究领域得出的结论将有助于生物伦理学和决策领域更广泛文献的发展。

项目成果

How do women at increased breast cancer risk perceive and decide between risks of cancer and risk-reducing treatments? A synthesis of qualitative research.

• DOI: 10.1002/pon.4349
• 发表时间: 2017-09
• 期刊: Psycho-oncology
• 影响因子: 3.6
• 作者: Fielden HG;Brown SL;Saini P;Beesley H;Salmon P
• 通讯作者: Salmon P

Pervasive, hard-wired and male: Qualitative study of how UK adolescents view alcohol-related aggression.

• DOI: 10.1371/journal.pone.0191269
• 发表时间: 2018
• 期刊: PloS one
• 影响因子: 3.7
• 作者: Whitaker L;Brown SL;Young B;Fereday R;Coyne SM;Qualter P
• 通讯作者: Qualter P

Qualitative analysis of how patients decide that they want risk-reducing mastectomy, and the implications for surgeons in responding to emotionally-motivated patient requests.

• DOI: 10.1371/journal.pone.0178392
• 发表时间: 2017
• 期刊: PloS one
• 影响因子: 3.7
• 作者: Brown SL;Whiting D;Fielden HG;Saini P;Beesley H;Holcombe C;Holcombe S;Greenhalgh L;Fairburn L;Salmon P
• 通讯作者: Salmon P

Warranting the decision-maker, not the decision: How healthcare practitioners evaluate the legitimacy of patients' unprompted requests for risk-reducing mastectomy.

保证决策者，而不是决定：医疗保健从业者如何评估患者自发要求的降低风险乳房切除术的合法性。

• DOI: 10.1016/j.pec.2019.03.007
• 发表时间: 2019
• 期刊: Patient education and counseling
• 影响因子: 3.5
• 作者: Brown SL