How to Improve Shared Decision-Making in Breast Cancer Care

Clear communications and respect between clinicians and patients is key when navigating optimal breast cancer care routes, says Lidia Schapira, MD, FASCO, professor of medicine at Stanford Medicine, medical oncologist, and director for the Stanford Cancer Institute and the Stanford Comprehensive Cancer Center.

This transcript was lightly edited; captions were auto-generated.

Transcript

How can shared decision-making be improved in breast cancer care?

I really feel that shared means that both patient and clinician listen to one another, and that both can come to the conversation as experts. A patient may be an expert in their life, their worldview, their experience, their hopes. The clinician may have expertise in treating that particular disease and may, by virtue of their experience, have treated many people. They may have a lot to bring to the table, but it really has to be a conversation about what the problem is first, that clearly stated what the standard of care is, what the guidelines say, what new treatments or novel treatments are available, what may be offered even through experimental treatments. That's the clinician's job to present these things in a clear way, and the patient’s role is to feel safe asking the questions they need to ask, so that they can actually make an informed decision and a reasonable decision. The process, I think, if we really honor it, takes time. People may need more than one conversation to absorb all of the nuances of the treatment. If somebody's going to get a treatment, maybe associated with a high rate of success, but also high rate of having serious toxicities that could limit their function, or they need to incur great expenses, sell property, or liquidate their college savings they have for their kids. Those may be important things to bring to the table, and that's when the clinician needs to really help the patient to feel supported in making that decision.

For me, shared decision-making involves clarity, respect, explanations, and also sorting through options together as a team; partnering, saying, “If what we're looking for is a very small expectation of clinical benefit, it may not be worth risking all these other things or it may not be worth [it] at this time,” and helping people and supporting their decisions. So shared decision-making, I think, is more than just a title. It really involves effort and involves communication, sorting through options, and really being there for a person; understanding that these decisions may be incredibly difficult and that people are just not prepared for them.

How can health care systems better support clinicians in addressing disparities in breast cancer outcomes, particularly among historically underserved populations?

Health care systems need to invest more effort and resources in reducing barriers to care for people from underresourced communities and underresourced minorities. The system needs to be more nimble, less rigid. The system needs to form relationships with communities and perhaps use community health workers or patient navigators; people who really are part of those communities, to bring to systems the voice of the patient, and to act as go-betweens or to facilitate communication. I think systems really need to also figure out why it is that people from certain underrepresented communities don't go there. Maybe they can't afford to. Maybe they find it a hostile environment, and they need to be more open to change.

I think my answer is health care systems should examine their demographics and try to see if those demographics really mirror the demographics of the community that they're in. If they don't, then they need to go through a process of seeing what the barriers may be for those people to come in. I think the systems also need to have staff and health care professionals that also represent the community that they're serving. I think there are a number of things that could be done to make it easier to access and to make the environment more welcome to people. And again, I always start by thinking that we don't need to know everything about every group or every underrepresented minority group, but we need to be curious and we need to be respectful. I think that, to me, has to be baked into the way things are done, and baked into the organizational culture.