Understanding older women’s decision making and coping in the context of breast cancer treatment

Background: Primary endocrine therapy (PET) is a recognised alternative to surgery followed by endocrine therapy for a subset of older women with breast cancer. Choice of treatment is therefore preference sensitive and may require decision support. The Coping in Deliberation (CODE) framework (Witt et al., 2012), which includes both cognitive and emotional appraisals of decision making and coping, is a framework which can be adapted to guide the understanding of preference-sensitive treatment decisions. Older patients are often conceptualised as passive decision-makers, and strategies to cope with stressors in older age may be different to those used by younger people. The current study aimed to examine decision making and coping in a group of older women who have faced breast cancer treatment decisions in order to inform the development of a decision support intervention. Methods: Semi-structured interviews with older women who had been offered a choice of PET or surgery from five UK hospital clinics explored their information/support needs and preferences for involvement in treatment decisions. Interview transcripts were analysed using the CODE framework to examine women’s appraisals of health threat and coping throughout the deliberation process. Results: Interviews were conducted with 36 women aged 75-98 years. Appraisals of breast cancer and treatment options were sometimes only partial, with most women forming a preference relatively quickly. Appraisals related to past experiences, scope for choice, risks, benefits and consequences of treatment, instincts about treatment choice as well as healthcare professionals’ recommendations. Strategies to cope with breast cancer treatment decisions were described, including collaborative decision making with support from healthcare professionals, friends and relatives. Conclusions: Many older women with breast cancer may be conceptualised as collaborative decision makers, and may benefit from decision support interventions designed to support decision making and coping within and beyond the clinic setting. Concise information about treatment options may be preferred by women who wish to make treatment decisions on a resource-conserving, rule of thumb basis.