Exploring and supporting older women's chemotherapy decision-making in early-stage breast cancer

Abstract

Background:

Few studies have focused on the therapeutic decision-making process in older adults with breast cancer. This study investigated older adult breast cancer patients' perspectives on neo/adjuvant chemotherapy, thereby identifying informational needs and preferences as patients navigate the treatment decision-making process.

Materials and methods:

Women ≥65 years diagnosed with early-stage breast cancer were recruited from an academic cancer center after deciding whether or not to receive neo/adjuvant chemotherapy. Participants completed surveys assessing sociodemographic characteristics, health literacy/numeracy, and shared decision making. They took part in individual semi-structured interviews to explore their perspectives, experiences, and values regarding treatment. Interviews were audio-recorded and transcribed. Transcripts were analyzed using the Sort and Sift, Think and Shift qualitative approach. Quantitative data was summarized using descriptive statistics.

Results:

Of the 26 participants (age range 65–92 years; 81% non-Hispanic White; 72% ≥ college degree; 50% unmarried), 58% elected to undergo chemotherapy and 42% declined. The majority of participants had adequate health literacy/numeracy and engaged in shared decision-making. Thematic analysis revealed several commonalities regardless of the decision to undergo chemotherapy. Participants sought information regarding their disease/treatment. They referenced subjective experiences of friends/family members with cancer. Self-perception of health and the side effects of chemotherapy were also key factors. Participants placed importance on the maintenance of quality of life throughout treatment.

Conclusions:

Decision-making strategies in older patients were shaped by knowledge, values, and the anecdotal experiences of others. Results can inform the development of decision support tools for older patients and physicians to better facilitate the shared decision-making process.

1. Introduction

Breast cancer is the most common malignancy affecting women in the Western world, with approximately one-third of cases occurring in women ≥70 years [1]. As the aging population grows, a 67% increase in the overall cancer incidence in women ≥65 years is expected [2]. However, there is a marked knowledge gap in the treatment of older cancer patients. The National Academies of Science Institute of Medicine (IOM) and the American Society of Clinical Oncology (ASCO) have highlighted a need for research in this area [3-7].

Although various studies have assessed the impact of aging on cancer, few have focused on therapeutic decision-making among older adults. In early-stage breast cancer, the decision-making process for chemotherapy in older women is complex [8]. Some studies have found that older women have similar gains from adjuvant chemotherapy relative to their younger counterparts [7,9]. Nevertheless, because older adults are underrepresented in clinical trials, efforts are needed to understand the safety and efficacy of chemotherapy in this population [3].

The central decision-making issue in early-stage breast cancer is weighing the benefits of chemotherapy (e.g., reduced recurrence risk) compared with potential downsides, such as treatment-related toxicities and competing causes of mortality [7]. However, the threshold of reduction in relapse and improvement in survival at which adjuvant chemotherapy should be recommended to older patients is unclear. Moreover, treatment decisions are often preference sensitive, which necessitates an understanding of patients' values to achieve a well-informed decision. Studies in older cancer patients show that they often prioritize functional independence and are reluctant to pursue treatments that negatively impact functional status or cognitive function [10,11].

Although few studies have examined decisions regarding chemotherapy in older women with early-stage breast cancer, findings suggest that treatment decision making in older breast cancer patients is often influenced by factors such as tumor characteristics, the ratio of treatment benefits to risk, logistics (e.g. transportation), and comorbidities [12]. This qualitative study assessed older adult breast cancer patients' perspectives on neo/adjuvant chemotherapy and identified informational needs and preferences regarding the treatment decision-making process. We were particularly interested in understanding older women's information-gathering processes and contextual considerations related to their decision making.

2. Materials and Methods

2.1. Procedures

Participants were recruited from the Breast Oncology clinic at The University of Texas MD Anderson Cancer Center (MDACC) in Houston, Texas. Eligible women were: ≥65 years, diagnosed with early-stage breast cancer, English-speaking, and facing a chemotherapy decision. Only patients for whom chemotherapy was given as an option for treatment by their treating oncologist were included, as confirmed by a breast medical oncologist (MSK) reviewing their electronic medical record (EMR). Eligibility was determined through chart review by MSK in advance of patients' scheduled clinic visits with their oncologist to discuss treatment options. The oncologist flagged eligible patients and arranged for the trained interviewer (AJH) to follow up with them either in person or over the telephone following their decision-making appointment to provide a detailed description of the study, verify eligibility, and schedule individual in-depth interviews. Patients were screened prior to initiating chemotherapy, if pursued, to avoid the influence that their treatment experiences may have on their recall of the decision-making process. We used this method of convenience sampling because older women often initiate treatment soon after making their decision with their provider [13]. Of the 40 patients who were screened, 26 were interested, eligible, provided consent, and participated in interviews.

Specific health data were abstracted from the EMR: age at diagnosis, and tumor characteristics. Participants also completed questionnaires to assess: sociodemographic characteristics, health literacy (Single Item Literacy Screener; SILS) [14], numeracy (Subjective Numeracy Scale; SNS) [15], and shared decision-making (SDM-Q-9) [16]. The guide used open-ended questions to assess: 1) understanding of the diagnosis, 2) perception of potential benefits and risks of chemotherapy, 3) how certain psychosocial factors factored into decision-making. Interviews were conducted in English, lasted 30–60 min, and were audio-recorded. Audio recordings were transcribed verbatim and reviewed by the interviewer for accuracy. Participants were provided a $50 incentive and a parking voucher. Study procedures were approved by the MDACC Institutional Review Board.

2.2. Data Preparation and Analyses

Descriptive statistics were used to summarize patient characteristics and questionnaires. Qualitative analysis was performed using the Sort and Sift, Think and Shift approach [17]. This multidimensional approach integrates research knowledge and clinical insights incorporating principles from phenomenology, grounded theory, case study, and narrative research. The Sort and Sift, Think and Shift approach was selected to enrich understanding of the patient experience in the context of applied clinical knowledge. The qualitative research team included experts from medical oncology, psychology, occupational therapy, public health, qualitative research methodology, and sociology. Using an iterative process, the research team reviewed transcripts to establish a comprehensive understanding of the data. Subsequently, a minimum of two trained research team members utilized “bridging” and “threading” to identify shared concepts and topics among transcripts. This enabled an in-depth exploration of the data to ascertain commonalities and differences. Finally, the team reviewed the identified concepts and topics and situated the analysis within the clinical/research context.

3. Results

3.1. Participant Characteristics

Twenty-six patients completed the interviews. None of the patients who were approached by the research team declined participation. Mean age was 74 years (SD = 6.6), with a range of 65–92 years. Most (n = 21) participants were non-Hispanic White, had a college degree or higher (n = 21), and half (n = 14) were unmarried. In terms of therapeutic decisions, fifteen patients elected to undergo chemotherapy and eleven declined. Breast cancer subtypes of participants were included in Table 1. Most patients had adequate health literacy (SILS mean = 4.31; SD = 1.1) and numeracy (SNS mean = 4.4; SD = 1.0) (Table 2). Additionally, most participants scored high on the shared decision-making questionnaires (SDM-Q-9, mean = 5.3, SD = 0.7), as did participating oncologists (n = 25; mean = 5.0; SD = 0.49), see Table 3.

Table 1.

Demographic characteristics.^a, ^b

Demographic characteristic	Total
n = 26	n (%)
Age in years, Mean (SD)	74.1 (6.6)
65–74 years	17 (63.4)
≥ 75 years	9 (34.6)
Race
Asian	3 (11.5)
Black/African American	1 (3.8)
Other (Mexican American)	1 (3.8)
White	21 (80.9)
Ethnicity
Hispanic/Latina	2 (7.7)
Non-Hispanic/Latina	24 (92.3)
Marital Status
Married/Living with Partner	12 (46.2)
Single	4 (15.4)
Widow	5 (19.2)
Divorced	4 (15.4)
Other (Companion)	1 (3.8)
Education
Lower Educationa	5 (17.2)
Higher Educationb	21 (72.4)
Receipt of Neo/Adjuvant Chemotherapy
Yes	15 (57.7)
No	11 (42.3)
Breast Cancer Subtype: Y = yes chemo (n); N = no chemo (n)
Hormone-receptor positive	11 Y(2); N (9)
HER-2/neu amplified	8 Y(6); N(2)
Triple negative	7: Y (6); N (0)

Note: All results are presented as number and percentage unless noted otherwise. Abbreviations: SD = standard deviation. Single Item Health Literacy Screener score > 3 indicates adequate numeracy.

^aLow education was defined as completing high school or less.

^bHigh education was defined as education beyond high school.

Table 2.

Health literacy measures (n = 26).

	Mean (SD)
Single Item Health Literacy Screener	4.31 (1.1)
Subjective Numeracy Scale	4.44 (1.0)
Single Item Health Literacy Screener: Scores range from 1 to 5, with higher scores suggesting higher health literacy
Subjective Numeracy Scale: Scores range from 1 to 6, with higher scores suggesting higher numeracy

Table 3.

Shared decision-making questionnaire.

	n, Mean (SD)
Patient (SDM-Q-9)	26, 5.32 (0.68)
Provider (SDM-DOC-9)	25, 5.00 (0.49)
Shared Decision-Making Questionnaire describes the patient perception of the shared decision making visit. Scores range from 1 to 6, with higher scores suggesting.
Shared Decision-Making Questionnaire (DOC) describes the patient perception of the shared decision making visit. Scores range from 1 to 6.

3.2. Thematic Results

Thematic results for the following areas are described below: 1) types of information, 2) application/integration of information when considering benefits of chemotherapy, 3) communication/expression of preferences. The following are illustrative quotes to provide examples of participants' perspectives and the breadth of topics discussed (Table 4). Participants are described using their participant number and their treatment choice.

Table 4.

Quotes.

Theme	Sub-theme	Quotes
Types of information	Evaluating and applying probabilistic information	“And so 15%, and she said I was in a grey area. It was kind of confusing because I had no invasiveness in the lymph glands and none in the surrounding tissue. So I don't know why I'm grey except that the blood tests must've come back on borderline or something. I'm HER-Negative. And BRCA they didn't, I don't know what that came out as. But anyway, I think I did the right thing. And I think they explained it enough.” (NC P20) “My thinking is that only 2% benefit from chemotherapy is little. That's how I weighed it. I counted on the percentage of the benefit…That's how I see it. I'm willing to submit to it if needed. If needed, if it's necessary. But with a little bit benefit, I have just to forego it. And of my age. Maybe if I am younger I will submit to it. But because of my age and with two [%], five years.” (NC P21) “It was a 2 to 3% chance of, was it returning?… But I feel confident that I made the right decision.” (NC P20) “… it shows that I have genes that show in my cancer, that show the cells are dividing slower than those that are in another group where they're dividing more rapidly… and could be picked off by chemotherapy. I call it the risk benefit/ratio of why would I go through chemotherapy when there's such a small benefit to me.” (NC P09) “So I know chemo is one thing that lessens that risk because it treats everything in the body, even though I know it affects other cells. I did understand that. I knew about that part of it. But still, I think helped, lessens the risk of cancer returning. “Well, chemotherapy might prolong your life…Which is the main thing. I's going to give me the highest percentage of survival. Okay. That's what I'm ultimately looking for, is getting the best outcome and using whatever resources that are available for me to get that outcome, which is longevity.” (YC P24)
	Seeking trusted information from their physician to make their treatment decision	“We started understanding more of why there was uncertainty… as we kind of got into this and talked more and more with people here [the hospital].” (NC P09) “He did touch on the treatment, of course, on heavy duty treatment… Right now, he wants me to think on it…I'm not 100% sure, but we've got a lot of good information today. But like he said, we'll think on it now.” (YC P03) “To weigh the treatment options, we count on intelligent doctors advising us” (NC P09). “I asked her [doctor]… ‘If it were your mother, what would you say? Should I have a mastectomy to get rid of it or what?’ And she said, ‘I won't make that decision. That's your decision.’ Yeah, and she was totally correct. It was my decision (YC P01)”.
	Importance of others' medical experiences and perspectives	“The problem, what I wish I could do is find someone, I have yet to find someone who has had triple negative breast cancer. I would really like to talk to someone.” (YC P17) “My sister was treated here for a lumpectomy, and it never returned. And she never came back. She had the lumpectomy and never returned. We encouraged her to do so, and she never did it. It never returned, and she was fine. So those were factors that were important to me.” (NC P20) “I had surgery [spring month]. And I elected to have a mastectomy, as opposed to just a partial…I had a sister who died of breast cancer. And then, my older sister was diagnosed with breast cancer a year before and also had a mastectomy. So I felt like I didn't want to have that worry…[based on] The experience of my two siblings. “(NC P25) “She [a cousin] came here. And we're doing similar, but she was a lot younger than me. She was in her forties, and I'm in my seventies.” (YC P19)
Application and integration of information when considering benefits and harms of adjuvant chemotherapy.	Importance of age, evidence, and quality of life	“We talked about two different types of chemo…And one of the things concerning to me was the initial opinion I got was, they gave me two recommendations. But one was, on all of their research, was looking to be an extremely difficult regimen, treatment regimen, and very toxic. And, you know, I wanted to hear what the experts had to say. And they are recommending, they agreed, to that understanding pretty much. And it would probably be difficult for a seventy-year-old person to go through that…and there are basically four very toxic drugs used.” (YC03) “This is from my daughter, who's a pediatrician and some other people, “Don't let them shortchange you because you're [≥75 years of age]. We want you around.” (NC P09)
	Importance of patient autonomy and choice	“I want to be involved in making the (chemotherapy) decision.” (YC P10) “[My doctor] said ‘I won't make your decision [about receiving chemotherapy].' Yeah, and she was totally correct. It was my decision.” (YC P01) “I respected and wanted to know how they [medical professionals] felt because there were the ones that were going to treat me. I felt they've shared the evidence with us and helped us make decisions.” (NC P09)

3.2.1. Types of Information

Participants often sought probabilistic information from their doctors when thinking about their prognosis and recurrence. This numerical information was often viewed as evidence to inform decision-making. For example, one participant said, “I like knowing about the numbers, the statistics. I like that they sourced those statistics. They look a lot better than the ones I had come across.” (Yes Chemotherapy [YC], P03). Another stated, “I feel like the doctors shared the evidence with us, and that helped us make decisions… I wanted the data more…” (No Chemotherapy [NC], P09).

3.2.1.1. Evaluating and Applying Probabilistic Information.

Participants who declined chemotherapy appeared to grapple with probabilistic information and describe their perception of risk when weighing the potential benefits and downsides of chemotherapy. One participant who declined chemotherapy stated:

“She [doctor] gave me a paper on the percentages and…what type of cancer I had… very helpful… If they said 30 percent chance of it returning, or 50, I would have had the chemo… but 15, I think that's pretty low”

[(NC, P20)]

Another participant shared that she did not perceive the chances of recurrence as high, so she considered health-related quality of life a priority at her age:

“If… percentages [of] recurrence were pretty high, then I would do whatever else I had to do. But if they weren't, I just didn't see any need in putting myself through that. After she [the doctor] showed me some of the statistics and stuff, I thought that it [radiation] would be important… and it's not as invasive as having chemo and having a radical mastectomy…I wanted the easiest way for me, at my age”

[(NC, P22)]

The topic of genomic testing (e.g., MammaPrint) provided additional insight into the benefit or lack of benefit for undergoing chemotherapy. One participant described her experience:

“…it didn't mean that I wouldn't have breast cancer recur…it's just that going through chemo wasn't going to make that even lower.…MammaPrint helped weigh those odds”

[(NC, P09)]

Participants applied both “verbatim” (a precise and exact form of information) and “gist” (a description of the core meaning of information) probabilistic information [18]. Specifically, one participant who declined chemotherapy highlighted the benefits of radiation and provided a specific, “verbatim” description when recounting her risk of recurrence:

“The benefits…I'm old already. So that's why I decided not to go with the chemotherapy after radiation. I said, ‘I'll take the radiation because it has a big benefit to me.’ The 14 percent, and out of the risks, it's very big.”

[(NC, P21)]

In the context of a “gist” summary, another participant described her reduced risk in “gist” terms:

“So I know chemo is one thing that lessens that risk because it treats everything, even though I know it affects other cells. I did understand that.… it lessens the risk of cancer returning”

[(YC, P23)]

3.2.1.2. Seeking Trusted Information from their Physician to Make their Treatment Decision.

Many participants described researching to learn about their diagnosis and treatment, and the multiple resources required to arrive at an informed decision. They acknowledged the importance of discussing their findings with their medical providers. One participant stated, “I have learned the most about the benefits and negatives about chemotherapy from reading… Well, that and from my doctor. I look at the internet, after somebody tells me which sites to get on” (NC, P22).

While acknowledging the importance of utilizing medical professionals as a trusted resource, participants expressed fears associated with seeking external information. One participant said:

“I like to talk to my doctor first. Now, when I get further into knowing more about what's going on, I will read more, and go on the internet and other things, but, I know there is a lot of misinformation, scary stuff, and I don't want to be scared”

[(YC, P12)]

Ultimately, several participants conveyed their understanding that their decision was a choice made with the guidance of medical providers. One participant said, “To weigh the treatment options, we count on intelligent doctors advising us“(NC, P09). Another stated:

“I asked her [doctor]… ‘If it were your mother, what would you say? Should I have a mastectomy to get rid of it or what?’ And she said, ‘I won't make that decision. That's your decision.’ Yeah, and she was totally correct. 1t was my decision”

[(YC, P01)]

3.2.1.3. Importance of Others' Medical Experiences and Perspectives.

Participants acknowledged that the experiences of others in their lives factored in their processing of their own diagnosis and their decisions regarding treatment. Some extrapolated elements from these stories to rationalize their choices. For example, one participant stated:

“I had surgery… and I elected to have a mastectomy, as opposed to just a partial… I had a sister who died of breast cancer, and then, my older sister was diagnosed with breast cancer a year before and also had a mastectomy. So, I felt like I didn't want to have that worry… [based on] the experience of my two siblings”

[(NC, P25)]

Participants said that interacting with others who had breast cancer played an important role in their decision-making process, especially as they accumulated experiential information and knowledge about their disease. One participant stated, “I have yet to find someone who has had my diagnosis. I would really like to talk to someone like me” (YC, P03). Another said, “I've had a couple of friends that have had breast cancer, and so they've been a big help to me” (NC, P25).

3.2.2. Application and integration of information when Considering Benefits and Harms of Adjuvant Chemotherapy

3.2.2.1. Importance of Age, Evidence, and Quality of Life.

Perceived health factored into participants' decision-making process. As they weighed their decision, some participants referenced their age with respect to how they believed it would impact their quality of life. For example, one participant said, “I am 75 and I wasn't looking forward to chemotherapy… which might cause me problems that I would have to deal with for the rest of my life” (NC, P09). Another participant acknowledged that age and life expectancy directly played into her decision not to receive chemotherapy, and that she would have made a different decision had she been younger:

“I do see the benefits of chemotherapy. If I was 30 years old…40… 50… I would say, ‘I don't care what I go through. I want to live to see my grandkids graduate.’ But, my grandkids are graduated. They're out in the world, and we're going down that road towards the end… “

[(NC, P26)]

Additionally, participants acknowledged the uncertainty in the evidence as they questioned the impact of age on tolerance to standard treatments. One participant stated:

“There's very little research that's been done on older people… It's a real curiosity to me why, and my doctor was trying to explain why he thinks this is. I understood him to be saying that in the universe of people, they didn't have enough who were older… 70 and up… they didn't really have a critical mass of people they studied”

[(YC, P03)]

Perceived impact of chemotherapy on quality of life was a significant factor for several participants. Many participants who declined chemotherapy thought it would reduce their quality of life. They were particularly concerned about side effects and how they might interfere with their ability to accomplish their personal goals and priorities. For example, one participant described:

“When you decide on treatment, you weigh the quality of what you have left of your life. I want the quality of my life to be more fun. I want to go swimming and golfing and visiting and doing the fun things I want to do. I don't want to sit with a needle in my arm, being sick and having chemotherapy…”

[(NC, P26)]

Participants also talked about specific side effects of chemotherapy that they discussed with their providers, reflecting on how these might impact them personally. A frequently raised concern was functional independence. For example, one participant described how possible side effects would impact her ability to function independently:

“… Just from my reading before, certain side effects don't apply to every patient. But I did see side effects with the chemo, like patients couldn't sleep. They had a hard time… they lost their appetite and then had diarrhea. … really, they are very sick…and they're not independent. They couldn't do anything… so I thought with me being very active, [it's] not my choice to get chemo”

[(NC, P04)]

Conversely, some participants recognized the tradeoff between side effects from chemotherapy and the benefit of risk reduction. These participants noted that for them, the scale tipped in favor of chemotherapy based on perceived benefits, particularly when considering their family roles. One participant stated:

“I chose to have chemotherapy. I have three grandchildren, [and] I want to see them grow up. I have too much to live for right now. Honey, I love life, and so I lose my hair. I got my beautician…already working on wigs. … There are other things more important… like my family”

[(YC, P14)]

3.2.2.2. Importance of Patient Autonomy and Choice.

Participants expressed the importance of autonomy regarding the choice about whether or not to undergo chemotherapy. They highlighted the need to weigh various factors before arriving at an informed decision. However, once arriving at a decision, they appeared to be certain of their choice. One participant who chose chemotherapy stated, “I think that each individual has their own choice… and if they've been informed, as I was informed by my doctor… everybody has a decision…I am totally confident (in my choice)” (YC, P24). Conversely, a participant who declined chemotherapy said, “Am I confident that I made the best choice? Absolutely… And I don't think I'm wrong…I'm absolutely positive” (NC, P20).

4. Discussion

Our study sought to expand on what is known about the experience of older women making the preference sensitive decision about chemotherapy in the setting of early-stage breast cancer. Gaining a better understanding of the myriad of factors that go into the decision will ultimately allow for more effective communication between clinicians, older women, and their family members. Several important findings emerged in our study. Participants considered a variety of information and sources when deciding about chemotherapy. While some participants indicated the importance of probabilistic information and statistics from their physician when making their adjuvant chemotherapy decision, others reported that they benefited from summaries of numerical information. They also reported adequate shared decision-making with their oncologists. Finally, information from peers regarding quality of life tradeoffs, participants' family roles and responsibilities, and health treatment stories from others appeared to influence participants' consideration of chemotherapy.

There is limited information about the perceptions of older women regarding chemotherapy for the treatment of early-stage breast cancer. Extant literature suggests that older adults often differ from their younger counterparts in their willingness to trade side effects for survival benefit [19,20]. Various factors have been determined as influencing the general acceptance of cancer treatment in older adults including their risk of adverse events, logistical barriers, and other fears regarding the discomfort of treatment [8].

We found that women have specific chemotherapy preferences when there is equipoise regarding the benefits and harms. They expressed wanting to understand the risk-benefit ratio, specifically when weighing tradeoffs between cancer recurrence and quality of life. Perception of risk and the relative tradeoffs was a central component of decision-making for those in our study. These findings align with previous studies supporting that older women require the knowledge that chemotherapy will cross certain thresholds of benefit in terms of clinical outcomes such as disease-free survival in order to accept treatment [21]. Furthermore, studies have demonstrated that low preference for chemotherapy at baseline is associated with lower quality of life during treatment, worse self-reported physical symptoms, and a higher incidence of physician-assessed adverse events during chemotherapy [20]. Thus, clinicians have an opportunity to improve the treatment process for older adult patients by discussing treatment and quality of life tradeoffs.

We also unearthed ways the experiences of others influence older women's breast cancer treatment decisions. Participants acknowledged relying on their family members for both physical and emotional support in arriving at their respective treatment decisions. Moreover, they described the important roles they played in their families, including taking care of grandchildren. They extrapolated the experience of others with cancer to their own in prognosticating how they would cope with treatment and how that may impact their family role. Given the importance of family in older women's treatment decision-making, accommodation may be needed to allow for greater inclusion of family in treatment discussions while recognizing the autonomy and preferences of older adults [12]. This finding varies from extant literature as previous studies have shown that support of family/friends is not a factor directly impacting the decision of older adults to accept or decline cancer treatment [8]. Additionally, providers would benefit from exploring the pre-existing perceptions patients have regarding cancer treatment to enhance their ability to identify treatment related myths [10,12].

We also found the importance of age in the context of quality of life. Self-rated health is a valid subjective indicator of overall health status [22]. It integrates biological, mental, social, and functional aspects of a person, including their individual cultures, beliefs and health behaviors. However, the literature has been mixed regarding the influence of personal and self-rated health on treatment decisions. Specifically, Schonberg and colleagues found that concurrent diagnoses affected older women's treatment decision [12]. Yet, others have found that the self-reported rating of health at baseline does not impact chemotherapy preference [20].

There are limitations to our study. It was performed at a single center and represents the experiences of women receiving care at this institution. Furthermore, many patients at our institution are seeking a second opinion which may represent a referral bias. Although we attempted to enroll a diverse group of women, the majority were non-Hispanic white, with higher socioeconomic status (SES), and higher levels of health literacy. Participants with higher SES and health literacy may have greater engagement with numerical information. Focus on the informational needs of those with limited health literacy should be pursued. Another limitation is that the interviews and all measures relied on self-report, which can be susceptible to recall bias. Although chemotherapy was discussed as an option with all patients, we were unable to determine the strength of their chemotherapy recommendation, given that the physician-patient encounters were not recorded and EMR documentation was not consistent. Finally, looking at patients' characteristics, it was clear that many patients with hormone-receptor positive breast cancer declined chemotherapy. The interview questions did not explore whether the fact that these patients were eligible for endocrine therapy had an impact on the rate of chemotherapy refusal. The influence of both the physician strength of recommendation and other indicated systemic therapy options (i.e., endocrine therapy) on chemotherapy would be important to explore in future studies.

5. Conclusions

Older women consider various information when deciding whether or not to undergo adjuvant chemotherapy. Quality of life tradeoffs, family roles, spirituality, and anecdotal stories from others influenced their consideration for adjuvant chemotherapy. Facilitating engagement and communication between clinicians, older women, and their support systems may contribute to higher quality decision making in the context of adjuvant chemotherapy among older women with early-stage breast cancer.