Cancer Treatment: Making the Hard Choices

Medical students help patients sort through the difficult decisions when there is no "right" choice

After a breast cancer diagnosis decisions about treatment must be made quickly. Science doesn't always offer clear-cut answers. When patients have someone to help them ask questions and define priorities, it is often easier to decide.

One of the most difficult decisions a woman faces after a breast cancer diagnosis is whether to keep her breast: should she remove just the cancerous tissue (lumpectomy) or the entire breast (mastectomy)? Sometimes breast reconstruction can occur in the same operation, which adds yet another decision to make quickly. If there is no right or wrong answer clinically, how do women decide on their care?

Breast cancer program increasing patient's knowledge and participation

About 15 years ago, Norris Cotton Cancer Center's Comprehensive Breast Cancer Program began to offer Shared Decision Making to patients and their family members. The process goes beyond describing the pros and cons of different procedures—it brings patients and health care providers together to identify, discuss, and weigh treatment options. Patients clarify their values and beliefs and identify their priorities. Then they check the certainty of their decision.

New support for women making decisions about breast cancer surgery

Geisel School of Medicine at Dartmouth has launched a new pilot program, the Patient Support Corps, which offers individual support and assistance to breast cancer patients at Norris Cotton Cancer Center. A first-year medical student is available to serve as a personal assistant during the decision-making process, helping patients collect their thoughts, sort through their options, and record their conversations with physicians.

As a first step, the Patient Support Corps member and patient have a 30-60 minute telephone interview. During this call, the medical student records all the patient's questions and concerns. A patient may wonder: How big will the scars be? Will I have to stop playing tennis? Will my clothes still fit? What is involved in reconstruction?  How will we know if we got all the cancer? Will my hair fall out? What if it doesn't work? The Patient Support Corps volunteer assembles these questions and concerns in a transcript for the physician.

Patients can talk and listen freely without the pressure to take notes

"When I was first diagnosed with breast cancer, I felt like I had been punched in the gut," says Christine Giddings, a patient who has participated in the Patient Support Corps. "The doctor would say one thing and after that I would hear blah, blah, blah because my mind couldn't go any farther."

When it came time for Giddings to consider breast reconstruction, the Patient Support Corps was up and running in the Comprehensive Breast Program. She was offered the free service—which is run through Dartmouth-Hitchcock's Center for Shared Decision Making—and matched with Asha Clarke, now a second-year medical student at Geisel.

"It was great having Asha there because it meant somebody was taking notes, somebody was recording, and I could totally focus on the doctor," says Giddings. "I was against having breast implants. Asha helped me formulate questions I had about options, and through this process I realized that deep down I was not happy with the way my chest looked. I really wanted reconstruction."

Medical students practice their listening skills

Student volunteers do not give medical advice as part of the Patient Support Corps: they listen, record, and transfer information between the patient and treating physician. First-year medical students typically don't have a lot of patient interaction, instead they hit the books and undergo information overload. "I missed interactions with patients. It was really lacking for me, so this program was wonderful because it allowed me to be present in conversations, to be a support, and was not a test of my knowledge," said Clarke.

Dale Vidal, MD, a breast surgeon who is director of the Patient Support Corps and the Center for Shared Decision Making, started the program after seeing something similar at the University of California. She says the students benefit as much as the patients: "It brings the focus back to the patient, and helps us train more empathetic physicians."

The Patient Support Corps program is funded by a generous grant from the Arthur Vining Davis Foundation.

More information about the Center for Shared Decision Making

More information about Norris Cotton Cancer Center's Comprehensive Breast Program

April 21, 2014