Patient Interest in Exploring Nonsurgical Treatment Approaches for Early-Stage Breast Cancer: A Qualitative Study

Abstract

Purpose:

Advances in radiation therapy have enabled the ability to deliver ablative treatments, but there has been limited application of these treatments to early-stage breast cancers with a goal of omitting surgery. The purpose of this study was to explore patient interest in pursuing nonsurgical treatment approaches for their early-stage breast cancer.

Methods and Materials:

We conducted a qualitative study involving interviews with 21 patients with early-stage breast cancer who were eligible for participation in a phase 2 clinical trial offering omission of definitive surgery. Interviews were transcribed and an inductive, thematic analysis was performed by 3 independent reviewers to generate themes and subthemes.

Results:

Data analysis revealed the following factors that affected patient willingness and desire to explore nonsurgical treatment options: (1) perceptions and feelings about their cancer; (2) current quality of life and the level of support available in their daily life; (3) external conversations focusing on family members’ and friends’ experiences with cancer and/or cancer treatments; (4) personal health care experiences, including their current breast cancer diagnosis; (5) perceptions and feelings about their physicians; (6) conversations with their physicians about their treatment options; and (7) self-identified desire to direct care decisions. Specifically, patients verbalized fearing surgery and surgical recovery; wanting to preserve their breast(s); the prior negative surgical experiences of friends, family, and themselves; a desire to receive treatment per the latest research; wanting to match the level of treatment with the severity of their cancer; and other comorbidities as reasons for wanting to explore omitting surgery.

Conclusions:

Our findings demonstrate an unmet need directed by patient interest to explore nonsurgical options for early-stage, biologically favorable breast cancer. These results may shape conversations around shared decision-making and clinical trial design, and result in more personalized treatment options for women with early-stage breast cancer.

Introduction

Outcomes in early-stage, hormone-receptor-positive breast cancer are outstanding,¹ leaving open the possibility of over-treatment and reflection on alternative options with de-escalation of therapies. Standard of care includes surgical options as well as radiation treatment and drug therapies, depending on the type of surgery and tumor biology. Efforts have been made to de-escalate treatments to avoid radiation^2–4 or chemotherapeutics.⁵ Less attention has been paid to avoiding surgery, as surgery is the cornerstone of breast cancer treatment.⁶ Breast-conserving surgery is a relatively well-tolerated procedure, but even so, patient-reported satisfaction scores appear to decline similarly up to 8 years after surgery for both lumpectomy and mastectomy, indicating that alternative approaches may warrant further investigation.⁷

Advances in radiation therapy treatment planning and delivery have enabled the ability to focally target high doses of radiation to tumors to ablate cancers and thereby avoid surgery in select cases.⁸ Stereotactic ablative radiation therapy (SABR) involves the delivery of high doses of radiation in a targeted manner and relies on the use of immobilization devices to ensure minimal patient movement during SABR delivery, high-quality imaging to enable appropriate radiation therapy targeting, and the ability to modulate radiation dose to provide a steep dose fall off to spare normal adjacent tissues. For favorable breast cancers, there are ongoing efforts to evaluate SABR-delivered local control in elderly patients who are not surgical candidates,⁹ as well as studies assessing the rates of pathologic complete response after neoadjuvant SABR.¹⁰ Currently, a phase 2 clinical trial (NCT02945579) is being conducted at University of Texas MD Anderson Center, enrolling patients with breast cancers planned for or being treated with neoadjuvant therapies, for which omission of surgery is offered in excellent responders to these therapies.¹¹

Although the oncologic efficacy of SABR is being explored, a broader question remains regarding patient interest in pursuing a nonsurgical treatment option for breast cancer. Given the relatively high rate of patient-driven use of mastectomy for early-stage breast cancer¹² and prophylactic contralateral mastectomy even in the setting of no genetic mutation,¹³ it is unclear whether there is meaningful patient interest in a non-surgical approach. Specifically, we sought to understand patient interest in avoiding surgery among those eligible for the aforementioned clinical trial. We acknowledge that parsing patient interest in a nonsurgical approach is challenging given the strong biases of oncology providers, which may shape clinical decision-making discussions.^6,14 However, as technology advances have enabled the delivery of ablative dose radiation therapy, there remains an unmet need to understand the factors that affect patient interest in this definitive therapeutic intervention.

The purpose of this study was to explore patient interest, or lack thereof, in pursuing nonsurgical, definitive treatments for early-stage, hormone-receptor-positive breast cancer. Our goal was to hear the “voice of the patient,” which is often missing from these discussions.⁶ We believe our findings will be of interest to medical providers who are exploring the use of definitive radiation therapy. Given the more than 300,000 newly diagnosed breast cancers anticipated in 2023 in the United States alone,¹⁵ definitive radiation therapy could result in offering more personalized treatments to a large number of patients, even if embraced by only a minority of patients with breast cancer. Early-stage, luminal A breast cancers appear to be particularly radioresponsive,¹⁶ suggesting that a nonsurgical, radiation therapy-focused approach may be particularly ideal for these cancers. How these approaches can best be implemented for patients with breast cancer remains uncertain. It is clear, however, that a patient-driven approach to implementing nonsurgical, definitive treatments should remain the focus of the oncology care paradigm.

Methods and Materials

We conducted qualitative, semistructured interviews with patients who had received a diagnosis of breast cancer. All participants were eligible to enroll in a phase 2 clinical trial (NCT02945579) in which surgery is omitted for patients with an excellent response as defined by no residual disease on image-directed biopsies after neoadjuvant therapy. All participants were recruited from the University of Texas MD Anderson Center. Participants were required to be at least 40 years of age, be planned for and be amenable to or to have received neoadjuvant systemic therapy, and have received a diagnosis of either: (1) cT1N0M0 unicentric invasive ER+ and/or PR+ and HER2− breast cancer, or (2) cT12N0-1M0 triple negative (ER−, PR−, HER2−), or HER2+ breast cancer. Patients enrolled on NCT02945579 with ER+ breast cancers were offered treatment with neoadjuvant hormone therapy and SABR to the intact breast tumor followed by image-directed biopsies. Patients on this trial with ER− or HER2+ breast cancer were treated with neoadjuvant chemotherapy followed by image-directed biopsies and adjuvant radiation therapy to the breast ± nodes.

We sought to recruit patients within 6 weeks of their first presentation to the breast oncology clinic at our institution, so that they would be able to accurately recollect the reasoning behind their treatment decisions. Due to COVID-19 pandemic restrictions that affected our ability to recruit patients, this timeline was not strictly enforced. Of note, most patients treated at University of Texas MD Anderson Center received their breast cancer diagnosis at an outside facility, thereby also increasing the time from diagnosis to treatment decision-making and potential recruitment to this study. We excluded patients who were not fluent in English.

In recruiting our participants, we employed purposive sampling to enhance diversity in age, race, and ethnicity in our accrued population. In addition, we recognized that provider bias likely affected which patients were offered enrollment in NCT02945579. To ensure we captured a broad range of viewpoints, we sought to also recruit patients who were eligible for NCT02945579 but were not presented with the option to enroll in this trial by their providers.

We used a semistructured interview guide (see E1 in the supplementary materials) that was developed based on existing scientific literature, discussions with content and methodological experts, and the overarching scientific aims of the project. This interview guide was tested during the first 2 interviews, which were also included in our results. Additional questions were then added to explore topics that emerged in the 2 initial interviews. The topics explored in the interview guide include (1) patient perceptions of their cancer, (2) treatment options with which they were presented, (3) motivations to participate/not participate in a trial to avoid surgery, (4) perceptions of the treatment option that they pursued, and (5) perceived advantages and disadvantages of avoiding surgery.

Patients presenting to the University of Texas MD Anderson Center Breast Center were screened through the electronic medical record and recruited over the phone between June and November 2021. Interviews were conducted by the first author over the Zoom video platform and lasted approximately 30 minutes. All interviews were audio recorded. Audio files were professionally transcribed shortly after they were recorded, and patient names were replaced with an anonymized identification number to maintain privacy. Concurrent with performing the interviews, the first author conducted a preliminary analysis of the transcripts to identify emerging themes. Recruitment was stopped once data saturation was achieved (ie, new themes stopped emerging in the preliminary analysis of the interviews).

Data analysis of the transcripts was performed using MaxQDA software. A semantic, inductive-level thematic analysis was conducted according to Braun and Clarke’s 6 flexible and recursive steps: familiarization with the data, generation of initial codes, searching for themes, reviewing themes, defining and naming themes, and producing a report.¹⁷ We employed Braun and Clarke’s methods to ensure credible results.^17,18 In particular, motives and barriers for (non)participation were clustered into subthemes and main themes and associated with quotations from individual participants.¹⁷ The thematic analysis was separately performed by the first and third authors, with the second author initially reconciling the analyses. The study team then discussed and further reconciled the analysis at team meetings.

Results

Eighteen of our 21 participants had hormone-receptor-positive, cT1N0M0 breast tumors and were amenable to pursuing neoadjuvant hormone therapy and the remaining 3 participants required neoadjuvant chemotherapy (2 for triple-negative breast cancer and 1 for an HER2Neu amplified tumor). Participant demographic information is provided in Table 1. Slightly less than half (43%, n = 9) had been informed about protocol NCT02945579 by their medical providers, and 38% (n = 8) were enrolled in this study. The mean age of recruited participants was 64.9 years (SD 10.61), and the median time from diagnosis to interview was 129 days (range, 23-358 days). Few participants (19%, n = 4) had not received any curative intent treatment before their qualitative interview; 38% (n = 8) of study participants had received surgery prior to their interview.

Table 1.

Demographic information for participants

Characteristic	No. (%)
Mean age ± SD	64.9 ± 10.61 y
Race
Caucasian	18(86%)
African American	2(9%)
Asian	1(5%)
Ethnicity
Hispanic	3(14%)
Not Hispanic or Latino	18(86%)
Hormone receptor type
ER+, PR+, HER2−	18 (86%)
ER−, PR−, HER2+	1(5%)
ER−, PR−, HER2−	2 (9%)
Parent study status
Approached to participate in parent study and enrolled	8 (38%)
Approached to participate in parent study and declined enrollment	1 (5%)
Not approached to participate in parent study	12 (57%)
Time from diagnosis of breast cancer to qualitative interview median (range) in days	129 (23-358)
Treatments received before qualitative interview
None	4(19%)
Hormone therapy	1(5%)
Hormone therapy and radiation	5(24%)
Surgery	5(24%)
Surgery, radiation, and hormone therapy	3(14%)
Chemotherapy	2(10%)
Chemotherapy and radiation (no surgery planned – on study)	1 (5%)

We identified a total of 7 themes with numerous subthemes. The themes and subthemes that were mentioned by at least 20% of participants are enumerated in Table 2. Table 3 provides representative participant quotations for each subtheme.

Table 2.

Themes and subthemes identified by at least 20% of participants

Themes and subthemes (indented)	Participants who referenced in interview, no. (%)
Perceptions and feelings about cancer treatment options	21 (100%)
Wanting treatment over with	13(62%)
Fearing surgery	13(62%)
Matching treatment with cancer severity	11 (52%)
Wanting to avoid or minimize surgery	10(48%)
Wanting to avoid cancer medications/chemotherapy	9 (43%)
Positive views of nonsurgical treatment options	8 (38%)
Wanting to avoid or minimize radiation therapy	8 (38%)
Seeing surgery as the first step in cancer treatment	8 (38%)
Willing to undergo any treatment that helps get rid of the cancer	7 (33%)
Not minding surgery/Not feeling the need to avoid surgery	6 (29%)
Perceptions and feelings about their cancer	21(100%)
Positive perceptions and outlook toward their cancer	18 (86%)
Negative perceptions and outlook toward their cancer	18 (86%)
Understanding of their cancer	17(81%)
Being surprised with diagnosis	10(48%)
Wanting to preserve the breast	8(38%)
Not being concerned about what the breast looks like afterward	5 (24%)
Perceptions and feelings about physicians and health care system	21 (100%)
Positive perceptions/feelings and physicians/health care system	21 (100%)
Negative perceptions/feelings about physicians/health care system	7 (33%)
Conversations with their physicians about treatment options	21 (100%)
Being given options	16(76%)
Relying on physicians’ advice	10(48%)
Relying on prior research/prior patients’ experiences	9 (43%)
Physicians communicating effectively	8(38%)
Not being given options/Being told what to do	7 (33%)
Participating in/Directing own care decisions	18 (86%)
Advocating for oneself/Participating in own care	17 (81%)
Own personality impacting decision-making	13 (62%)
Researching cancer treatments oneself	11(52%)
Wanting /Needing to make own decision	9 (43%)
Working in the health field/Having some medical knowledge	5 (24%)
External conversations with family and friends	15 (71%)
Friend/family impacting decision	13 (62%)
Friend/family having experience with cancer	13(62%)
Friend/family having negative experiences with surgery	7 (33%)
Friend/family avoiding or minimizing surgery	6 (29%)
Friend/family having positive experiences with surgery	5 (24%)
Current quality of life and level of support in their daily life	21 (100%)
Current quality of life	19(90%)
Current level of support	18(86%)
Having underlying health issues that alter choices/experiences	11 (52%)
Age impacting approach to cancer diagnosis/treatment	9 (43%)

Table 3.

Representative quotations for each subtheme

Perceptions and feelings about cancer treatment options
Wanting treatment over with	“Yeah, because all I wanted was like, let’s just get this over with. I don’t want to spend the rest of my life on cancer.” (Participant 8)
Fearing surgery	“My recovery is always rough postop—severe postop nausea, vomiting. So, I wasn’t really excited about going under and doing surgery again, going under anesthesia and having surgery so soon.” (Participant 20)
Matching treatment with cancer severity	“I Googled about what people do, and I remember reading this article that said women are throwing an atomic bomb at a problem that a firecracker can fix. And talking about having a radical mastectomy, and I’m like, you know what? There’s a lot of truth to that. And so I let the fear go and just decided that this is what I want to do. I want to keep my breast.” (Participant 1)
Wanting to avoid or minimize surgery	“Because I didn’t want the big invasive surgery. I was scared to have surgery, period. I wanted it out of there with less invasive [surgery].” (Participant 17)
Wanting to avoid cancer medications/chemotherapy	“My husband said if the doctor recommends it, then he’s in favor of it, but I’m not sure that I am because I have read a lot about … the side effects of chemotherapy, how long it takes to get over it and all that. And I’m not sure that I’m signed up for that. So, I guess if the doctor recommends, like, a midpoint, I would say no. But if he said, okay, it’s like 100 percent positive, you need it, well then I might think about it.” (Participant 3)
Positive views of nonsurgical treatment options	“And when I saw the progress [on the Taxol] almost immediately, the tumor started shrinking, and then it was like down to nothing. I couldn’t even feel it. It was just bigger than a golf ball before that, you know?” (Participant 8)
Wanting to avoid or minimize radiation therapy	“They wanted me to follow it up with thirty-five radiation treatments. And radiation just isn’t something I want to go through thirty-five times. I didn’t want to put my body through that.” (Participant 1)
Seeing surgery as a first step in cancer treatment	“I don’t even think I researched the surgery because I guess I thought I have to have it. I don’t want to read about it.” (Participant 3)
Willing to undergo any treatment that helps get rid of cancer	“It’s definitely not what I wanted. I know that radiation would have been a cakewalk compared to chemo. No, I’m not looking forward to the next few months. But I feel like it’s the right choice because, we all want to have the best chance for a better life. I don’t want to have to worry about—I mean, there’s a small chance of it recurring even with all this. But it brought my chance of recurrence down … if I add the chemo.” (Participant 13)
Not minding surgery/not feeling the need to avoid surgery	“I would not have minded having the surgery at all, I’ve had major surgery several times and never with a problem, so that was not the issue at all.” (Participant 2)
Perceptions and feelings about their cancer
Positive perceptions and outlook toward their cancer	“It didn’t worry me at all because it was such a small tumor, and it was stage one. And I just figured it would be taken care of. So, I didn’t worry about it” (Participant 10)
Negative perceptions and outlook towards their cancer	“Honestly, I felt like I just wanted it out of me, I felt like now that I knew it was there—I mean, it could have been there for five years or ten years, I have no idea. But when the biopsy results came back, and they said it was aggressive and high grade, I knew that wasn’t good.” (Participant 6)
Understanding of their cancer	“It made it seem that it was not serious. Not as serious as it could be.” (Participant 3)
Being surprised with diagnosis	“I was scared; I didn’t know what to do. I didn’t know where to start. You just don’t know what to do. You hear that word, and it’s just too big a word for you to know what to do.” (Participant 5)
Wanting to preserve the breast	“These are the breasts from which I suckled my children and that had been fondled and now, what am I going to be like?” (Participant 7)
Not being concerned about what the breast looks like afterwards	“For me, saving my life was more important than worrying about the shape of my breasts.” (Participant 18)
Perceptions and feelings about physicians and health care system
Positive perceptions/feelings and physicians/health care system	“I had total confidence that they [the doctors] were doing everything they could to help.” (Participant 2)
Negative perceptions/feelings and physicians/health care system	“When he [the doctor] did the biopsy, he told me the next day what it was and never had a plan. He went on vacation the very next day, told me that they would do something else in three weeks. So he just, basically, left me like that for almost three weeks—and I wasn’t going to have that.” (Participant 13)
Conversations with their physicians about treatment options
Being given options	“They [the doctors] told me that I have an option. … You want to start your treatment and then surgery, or you want to start surgery and then —and I was the one who said, let’s do surgery first.” (Participant 5)
Relying on physician advice	“I guess I felt like [my doctors] were more experienced. They’ve done this and so that they were able to provide me information that I felt that I could make a decision as to whether I wanted to do the trial or just go ahead and do the lumpectomy.… So, it put me at ease.” (Participant 14)
Relying on prior research/prior patients’ experience	“There are thousands and thousands of patients that they see. And so, I feel like they have so much data, and … I feel like they can tell you the right thing to do.” (Participant 6)
Physicians communicating effectively	“They explained all of that so well that it made me comfortable with what I was going to be having done. And having all three of the doctors come in and sit down with me, introducing themselves, explaining what their part of my treatment would be, put me at ease. And then each one coming back in and talking to me more in depth on what they were going to be doing, that put me at ease also.” (Participant 15)
Not being given options/being told what to do	“They [the doctors] mentioned that surgery kind of had to be done and was the only option.” (Participant 15)
Participating in/directing own care decisions
Advocating for oneself/participating in own care	“Make them [the doctors] explain to you what that is. Anything you felt that you needed to know. Don’t leave nothing unturned. Just ask questions.” (Participant 13)
Own personality impacting decision making	“I really don’t. I guess part of it is my personality that I don’t panic. I don’t have a vivid imagination. And … after talking to him [the doctor], I felt that it [the cancer] would be taken care of.” (Participant 2)
Researching cancer treatments oneself	“And then, I just immediately turned to my computer. I was like, okay. I shifted into gear, and let me do something.” (Participant 18)
Wanting/needing to make own decision	“She said this is what you will do. And I was like, ‘no—no, my body, my decision.’” (Participant 1)
Working in the health field/ having some medical knowledge	“So I know I’m very aggressive, because being in the medical field, too, I know what I want, and I’ve done all my research. I’ve read up [on] most of this stuff, and so I know what’s needed.” (Participant 4)
External conversations with family and friends
Friend/family impacting decision	“But I have my husband telling me that he wants to make sure that I’m cured, and he wants me to do everything that they want to do to cure me.” (Participant 3)
Friend/family having experience with cancer	“Two weeks after I was diagnosed with breast cancer, my daughter out in Phoenix was diagnosed with the same kind of cancer. And so we were talking back and forth, what her options were and what she was going to do too.” (Participant 5)
Friend/family having negative experiences with surgery	“And I had a discussion with my aunt who had a double mastectomy reconstruction, and she said it was definitely a loss for her. You know, she went through a period of, somewhat depression that her body changed.” (Participant 16)
Friend/family avoiding or minimizing surgery	“My friend that I was telling you about, they did a lumpectomy on her, and they didn’t clean her out good enough.” (Participant 13)
Friend/family having positive experiences with surgery	“No, no, it [the surgery] didn’t scare me at all because, like I said, I saw my mom’s recovery.” (Participant 19)
Current quality of life and level of support in their daily life
Current quality of life	“If I don’t walk, it’s a real downer for me … I just figured if I had surgery, it meant that there might be some time that I couldn’t exercise. So, I was afraid of what that was going to do to my mental state. And the fact that they [the doctors] assured me that I would not be putting myself at risk by going this route. So, I mean, this is why I opted this way.” (Participant 14)
Current level of support	“I’m really glad to have a very attentive husband and, you know, children who check in that they don’t live here. They’re checking in on it all.” (Participant 7)
Having underlying health issues that alter choices/experiences	“I take a lot of medicine because of my heart, my kidneys, and my liver.… I’m taking a lot of pills, and that would just add another one to it. So that was another thing that made my decision to have the surgery instead.” (Participant 5)
Age impacting approach to cancer diagnosis/treatment	“[The doctor] even said there have been discussions … about women in my age group not doing anything and certainly not having surgery.” (Participant 2)

Perceptions and feelings about cancer treatment options

Within this theme, participants discussed their thoughts regarding chemotherapy, radiation, estrogen suppressive treatments, and surgery to treat their breast cancer. Overall, a large number of participants wanted to avoid or minimize at least some aspect of their cancer treatment. Most notably, 38% of participants did not want to undergo mastectomy, 38% wanted to avoid or minimize radiation, and 48% of participants wanted to avoid or minimize surgery to treat their cancer. Participants dreaded the recovery from the surgery, specifically perceptions of pain and lack of mobility, as well as being isolated from family and friends during their recovery. In addition, participants mentioned fearing surgical complications, especially blood clots, and general anesthesia at an older age.

I envisioned that if there was surgery, it means I was going to have to be down for a bit. I live alone … I would be depressed all the time, I suppose, and I just figured if I had surgery, it meant that there might be some time that I couldn’t—I couldn’t exercise. So I was afraid of what that was going to do to my mental state. (Participant 14, age 64)

In addition, several participants feared radiation therapy, which they ascribed primarily due to the number of treatments they would need to undergo as well as the claustrophobia that they anticipated while receiving treatments.

They wanted me to follow it up with 35 radiation treatments. And radiation just isn’t something I want to go through 35 times. So I didn’t want to put my body through that. (Participant 1, age 60)

Several participants also felt that taking hormone therapy medication in combination with their other daily medications would cause a variety of adverse effects such as joint pain, hot flashes, and skin dryness.

Perceptions and feelings about their cancer

In every interview, we delineated how each participant felt about their cancer and how their feelings translated into their approach to decision-making. When first diagnosed, 48% of women were in disbelief; many of them said that they feared the cancer and questioned their ability to survive when first diagnosed. The vast majority (86%) of patients verbalized explicitly negative perceptions and feelings about their cancer diagnosis, with the same proportion also verbalizing positive emotions.

Oddly, there is a more emotional component to it than I realized I would have, actually. Yeah, I find myself, you know, looking in the mirror and thinking, so these are the breasts from which I suckled my children and that had been fondled [by my husband]. And now, what am I going to be like? (Participant 7, age 71)

Participants who were resistant to undergoing surgery mentioned that they did not feel rushed to immediately excise their tumor, were willing to explore alternative treatment options, did not want to overtreat their cancer, and felt that their breasts were central to their identity as a woman. In addition, 52% of participants expressed importance for their treatment to be in line with the severity and aggressiveness of their cancer.

Why are you mutilating your body for some–a 1-cm tumor? Women are throwing an atomic bomb at a problem that a firecracker can fix. And talking about having a radical mastectomy … I’m like, you know what? There’s a lot of truth to that. (Participant 1, age 60)

Some women felt strongly about surgery because they wanted to minimize the risk of the cancer spreading and did not care about the cosmetic appearance of their breast afterward.

But when the biopsy results came back, and they said it was aggressive and high grade, I knew that wasn’t good. So just mentally, I just felt like I wanted it out. (Participant 6, age 45)

In addition, a large proportion of participants (62%) reported fear around surgery and concerns over surgical recovery (38%), pointing to opportunities for the health care team to fully address these concerns.

Perceptions and feelings about physicians and the health care system

Verbalizing the prestige associated with their health care institution, 95% of participants reported that they whole-heartedly trusted their physician’s treatment recommendation. Several women noted that the recommendation of their physician was instrumental in their decision, and if options to avoid surgery were presented, they were more likely to consider them. The way the physician framed their options was invaluable in their decision to proceed with their specific treatment plans.

[My physician] really told me that it was a really small problem, and it would be easy to fix with surgery. He never really said—nobody ever said not to do surgery. It was just kind of—surgery is recommended. (Participant 6, age 45)

I guess I am depending on the fact that the doctors are being honest and telling me what they think is best. So if I go with that belief, then if they recommend radiation, then I’m going to go for radiation because they tell me that I’m going to feel fine. That I’m just going to have 16 sessions of radiation, and it’ll be like sunburn, and it’ll be a piece of cake. I hope they’re telling me the truth. (Participant 3, age 71)

In addition, 29% of participants wanted the opportunity to be able to contribute to research and to help future patients on their decision-making journey. Most of this group chose to participate in the clinical trial looking at nonsurgical treatment options in early-stage, biologically favorable cancers.

Just the fact that it’s going to help … the women behind me. It’s going to help them know that they don’t have to have the lumpectomy like everybody thought that they had to have in the past. (Participant 1, age 60)

Two-thirds (67%) of participants mentioned that the facility in which they received their cancer treatment made a difference because they trusted the clinicians’ advice and guidance based on the prestige of the institution with which they were affiliated.

I would definitely listen because you guys are the experts. I’m sure if it was coming from somewhere else other than (Redacted facility), I probably would just kind of not considered it at all. But I would listen to you guys and definitely consider it … this is all that you guys do, and just you all—you all take much more time with your patients than the other doctors, and you all explain things in a much more layperson’s point of view that’s better to understand. (Participant 6, age 45)

Conversations with their physicians about treatment options

The way physicians framed the conversation surrounding participant treatment options and the directiveness in which they offered options to participants influenced participants’ decision-making. Participants verbalized that they wanted a supportive approach that would emotionally comfort them, mitigate their stress, and not scare them into making a decision.

If it’s at all possible to preserve my breast … I preferred that method. I feel like my initial [diagnosis discussion] was that they scared me, whereas [my second opinion] was informative. (Participant 14, age 64)

However, 33% of participants felt that they were not given options and were being told what to do, further revealing the importance of the physician in determining options and the course of treatment.

Key factors in physicians who participants identified as empowering them in their decision-making journey included physicians who appeared honest, supportive, and informative.

There’s no way that you can instill in women the idea to not panic over cancer … But I think [my physician was] very honest and told me … it was not a very advanced case. And so perhaps that’s another reason I was so brave. (Participant 2, age 90)

Forty-three percent of participants also mentioned that discussing the experiences of prior patients and the evidence behind various treatments was key in their willingness to undergo a specific treatment. Sixty-two percent of participants also felt particularly supported by the coordination of multidisciplinary oncologic care visits that streamlined their discussions about therapeutic interventions.

Having all 3 of the doctors come in and sit down with me, introducing themselves, explaining what their part of my treatment would be, put me at ease. So the fear factor was taken away. (Participant 15, age 65)

Participating in/directing own care decisions

A large factor influencing participant willingness and interest in nonsurgical treatment options was related to what they defined as their intrinsic personality and desires affecting their decision-making. Specifically, some participants simply felt they had to remove the cancer from their body and were unwilling to hear other options or external resources. On the other hand, others were more hesitant to undergo an invasive procedure if there were alternatives. Sixty-two percent of participants recognized the effect of their personality in directing their decision-making.

The doctors … they advise you to do what they think is best, but ultimately, the decision is yours. It’s your body, and you know your body better than anyone else. (Participant 6, age 45)

I’m the type of person that questions everything. To me, it doesn’t mean that standard of care is all I would get or that’s all that would be my options. (Participant 20, age 59)

Eighty-one percent of participants identified a need to advocate for themselves by being well informed about their cancer and treatment options so that they could actively participate in the decision-making process. Fifty-two percent of participants recommended that future patients also take an active role and seek answers to their questions from their health care team.

I want to be an advocate for my own health, and I do not want to have the more radical surgery. There’s more complications, more risks. (Participant 7, age 71)

That if they have a mammogram to make sure to ask questions … I feel that if you’re not satisfied with the answers that you get, seek more answers … Don’t leave nothing unturned. Just ask questions. (Participant 13, age 59)

External conversations with family and friends

Participants discussed the extent to which the preferences and desires of their family and friends affected their decisions. Specifically, 62% of participants noted that their friends and family directly affected their treatment decisions, with one participant characterizing the desires of her husband:

But I have my husband telling me that he wants to make sure that I’m cured, and he wants me to do everything that they want to do to cure me. (Participant 3, age 71)

Sixty-two percent of participants modeled their decision to choose surgery or nonsurgical treatment based on the past experiences of their friends and family who had gone through breast cancer treatment.

And I had a discussion with my aunt who had a double mastectomy reconstruction, and she said it was definitely a loss for her. You know, she went through a period of, you know, somewhat depression that her body changed. (Participant 16, age 52)

In addition, a family history of cancer affected how aggressive participants wanted to be with their cancer treatments. Thirty-three percent of participants noted that friends and family had negative experiences with surgery, from surgical complications such as blood clots or nonsatisfactory breast reconstruction. These participants noted more interest and motivation in exploring nonsurgical treatment options.

Current quality of life and level of support in their daily life

Eighty-six percent of participants noted that they were well supported by their friends and family, such as adult children and spouses deciphering medical jargon, coming to medical appointments, and helping to provide food and other essentials.

Having somebody with me that had a second set of ears that could hear what they were saying and if—because it was a lot of information at one time … She’s been with me at every appointment, so that’s been—the support system has been great. (Participant 15, age 65)

Fifty-two percent of participants had underlying health conditions that affected their treatment choices and deterred them from wanting to pursue surgery.

Well, I think surgery obviously always carries a risk of some problems during the procedure, whether it’s anesthesia or whatever, and I think, obviously, as you age, those risks increase. (Participant 7, age 71)

Discussion

This study aimed to explore patient interest or lack thereof in pursuing nonsurgical treatment options for their breast cancers. Our cohort had a range of opinions about the role of surgery as a part of their breast cancer care. The majority of participants (62%) wanted their treatment completed in an expedited manner and approximately one-third (38%) viewed surgery as a first step and 29% reported not having a desire to avoid surgery. However, 48% of participants verbalized subthemes of wanting to avoid or minimize surgery, and one-third (38%) verbalized that they had seen nonsurgical options work in other settings and were interested in exploring these options. These findings, which have not been reported in the literature before, demonstrate that there is a need to explore the omission of surgery in patients with biologically favorable breast cancers. In this discussion section, we hope to highlight and contextualize factors that influenced our participants’ interest in avoiding surgery. We also outline a framework (Fig. 1) of the factors that appeared most critical to our patient population and how health care providers can engage patients in a way that best meets their needs to best enable shared decision-making in this setting.

Fig. 1.

Conceptual framework of key factors for medical providers to address with breast cancer patients considering omission of surgery.

Overall, participants felt that the emotional aspect of their cancer diagnosis and treatment could not be ignored. Anxiety, fear, and depression have been consistently found to be elevated around the time of a breast cancer diagnosis¹⁹ and to shape patient decision-making regarding their oncologic treatments,¹⁹ and can persist for up to 12 months.^20–22 In our sample, emotions focused both on the cancer diagnosis as well as concerns regarding oncologic treatments, which were heavily influenced by the shared experiences of friends and family. These emotions also influenced how participants described the time sensitivity and aggressiveness of treatment approaches desired. Physician engagement in addressing these concerns and providing appropriate treatment options in response to these emotions is critical.

Our sample was particularly interested in directing treatment decisions around their cancer and having autonomy in these choices. Others have previously identified that patients who are better informed regarding their cancer treatment options and outcomes report improved outcomes and fewer adverse effects compared with patients who followed physician-directed treatments alone.^23–27 Online tools such as iCanDecide have been built to assist patients who have breast cancer in their treatment decision-making.²⁸ In our cohort, 81% of participants verbalized a personal need to advocate for themselves and be well-informed about their cancer and treatment options, to make treatment decisions commensurate with the severity of their cancer. A study of patients aged 55 years or older with breast cancer found that surgeon solicitation of patient input about treatment preferences was a predictor of patient self-efficacy and perception of themselves as the final decision-maker for their breast cancer treatment.²⁹ Our findings align with a prior qualitative study of 20 older (defined as age ≥65 years) patients with cancer who identified similar themes around treatment decision-making, including trust in the oncologist, expected outcomes, the experience of others, and assertion of independence, as well as themes we did not identify, including concern about prolonging life and skepticism about information on the internet.³⁰ Our study was unique in that it identified that how a patient defined her innate personality and desires were key in influencing her decision to avoid surgery and made patients, at times, uninterested in considering other options. In addition, our study highlighted the importance of educating patients appropriately about their cancer risk so that they understand the necessity of each aspect of oncologic treatment. Our findings highlighted that the way that physicians framed decision-making conversations and offered treatment options were important in a patient’s interest in avoiding surgery. Indeed, based on our findings, efforts to successfully evaluate nonsurgical definitive treatment options for biologically favorable, early-stage breast cancers requires multidisciplinary health care providers interested in presenting these options to patients in their treatment discussion.

Introducing alternative treatment options to patients with cancer requires both buy-in from multidisciplinary physicians as well as an interest of the patient to explore alternative options. In considering whether SABR for early-stage breast cancer should be evaluated, much can be learned from the literature on early-stage prostate cancers, for which options of a primary surgical versus a primary radiation therapy approach are both feasible. A qualitative study of patients with prostate cancer for whom robotic prostatectomy and radiation therapy were both oncologically equivalent found that treatment choice was largely dependent on clinician recommendations.³¹ Major themes involved with the decision-making of these patients with prostate cancer resonated with those we identified in our breast cancer cohort, particularly trust in the clinical team, perceived fit between treatment options and personal circumstance, adverse effects, socioeconomic and financial considerations, and the need for tailored information delivery.^30–32

Our study has multiple limitations. Participants came from a single large-volume, independent, tertiary care cancer center. Although there was some diversity in our patient cohort, 86% self-identified as Caucasian or White, 86% as non-Hispanic, and two-thirds were age 60 years or older. Additional investigation is warranted to evaluate whether our findings pertain to broader segments of the breast cancer population. Patients seen at our tertiary care cancer center largely self-refer, as the center is not affiliated with a general hospital. It remains to be investigated whether this influenced the desire to have more autonomy in decision-making for cancer than would be found in other cohorts. Due to institutional restrictions associated with the COVID-19 pandemic, qualitative interviews were all conducted via a virtual platform and not in person, and participants were not able to attend medical visits accompanied by others, which may have affected patient recruitment and interviews, as well as interpretations of the medical visits and social supports. Lastly, others have found that a patient-identified sense of having a reasonable amount of responsibility in their medical decision-making varies by race, ethnicity, socioeconomic status, educational status, and age.^33–35 These factors warrant further investigation in a larger volume study, such as a broader survey of a more diverse population of patients with early-stage breast cancer.

Conclusion

This qualitative study revealed that some patients are very interested in pursuing nonsurgical treatments for their early-stage breast cancer. Patients placed strong importance on the physician-patient relationship, specifically the quality of communications, as well as having a space in which patients could define their autonomy in decision-making. Although outcomes with current standard approaches to early-stage breast cancer have resulted in high rates of tumor control and good satisfaction, there remains an unmet need to explore de-escalation of therapies that includes omission of surgery.

Data Sharing Statement:

Research data are stored in an institutional repository and will be shared upon request to the corresponding author.