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Deciding About Breast Cancer Chemotherapy

As if being diagnosed with breast cancer wasn’t bad enough, many women with this diagnosis face complicated decisions about what kind of medicine or chemotherapy to take, if any, to reduce their chance of cancer recurrence.  As I discussed in a recent post, the mathematics of such decisions can be hard to comprehend for many patients.  But given that the right choice often depends on patient preferences, it would be great to help patients understand enough of their math to involve them in making the choice.

A group of researchers has developed a tool to help women with these decisions.  Called Adjuvant Online, it is a computer algorithm that takes in information about a specific woman’s cancer, and then produces survival estimates for her, illustrating her chance of survival and breast cancer recurrence based upon whether she chooses one set of treatments versus another.  Here is an example of how Adjuvant Online presents its information:

There is lots of important information in here.  But unfortunately, it is not in a format that most people can easily understand.  Horizontal bar graphs with four colors?  In research I conducted with Brian Zikmund-Fisher, we discovered that most people have a hard time figuring out what these graphs mean.

Fortunately, there is a much simpler way to present this information.  It involves a few simple changes.  First, it presents outcomes through pictographs rather than horizontal bar graphs.  My collaborators and I have learned that pictographs are much easier for people to understand. 



Second, it reduces the complexity of the four-color scheme used in Adjuvant Online, by eliminating the colors for death from breast cancer and death from other causes.

Our research discovered that is was much easier for people to determine the benefits of Adjuvant chemotherapy with this second picture compared to the first.  They were able to quickly discern that, for this hypothetical situation, Adjuvant chemotherapy increases five-year survival by 2%.

Not necessarily an easy choice to make—the misery of chemotherapy versus a slightly reduced chance of cancer recurrence.  But at least when presented this way, it is an easier choice for people to understand.

To truly empower patients, we need to help them understand their healthcare choices.  That means making use of research on how to present information to patients in ways that make complicated decisions easier to comprehend.


I am a physician and behavioral scientist at Duke University. My research and writing explores the quirks in human nature that influence our lives — the mixture of rational and irrational forces that affect our health, our happiness and the way our society functions. (What fun would it be to tackle just the easy problems?) I am currently exploring controversial issues about the role of values and preferences in health care decision making, from decisions at the bedside to policy decisions. I use the tools of decision psychology and behavioral economics to explore topics like informed consent, shared decision making and health care spending. My books include Pricing Life (MIT Press 2000) and Free Market Madness (Harvard Business Press, 2009). My newest book, Critical Decisions (HarperCollins), is coming out in September of 2012, and explores the challenges of shared decision making between doctors and patients.
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