The Decision-Making Journey of Malaysian Women with Early Breast Cancer : A Qualitative Study

It is estimated that of the 1.4 million new cases of breast cancer worldwide in 2012, at least 50% will occur in low and middle income countries such as Malaysia (Porter et al., 2008). In many developed countries where population-based screening programmes are the norm, many newly diagnosed breast cancer patients present at an early stage and have a high chance of survival (The Lancet, 2009). By contrast, the majority of women in low and middle income countries present with late stage disease and face poorer survival. In Malaysia, breast cancer is the most common cancer among women and it comprises 31% of all female cancers (Yip et al., 2011). The 5-year survival ranges from 43.5% to 75.7% (Taib et al., 2011; Ibrahim et al., 2012) in large partly because of late presentation (Taib et al., 2008). From clinical experience, when women do present early,


Introduction
It is estimated that of the 1.4 million new cases of breast cancer worldwide in 2012, at least 50% will occur in low and middle income countries such as Malaysia (Porter et al., 2008). In many developed countries where population-based screening programmes are the norm, many newly diagnosed breast cancer patients present at an early stage and have a high chance of survival (The Lancet, 2009). By contrast, the majority of women in low and middle income countries present with late stage disease and face poorer survival.
In Malaysia, breast cancer is the most common cancer among women and it comprises 31% of all female cancers . The 5-year survival ranges from 43.5% to 75.7% (Taib et al., 2011;Ibrahim et al., 2012) in large partly because of late presentation (Taib et al., 2008). From clinical experience, when women do present early, many do not complete treatment. The reasons for this have not been explored. However a published study, which looked at late presentation, reported one major factor is the patient's belief in complementary and alternative medicine (CAM) in favour of hospital-based treatments (Taib et al., 2008). It was found that 15.5% of women with breast cancer in Malaysia sought CAM, such as nutritional and herbal medicine, traditional Chinese medicine and spiritual healing, prior to visiting a breast cancer clinic (Taib et al., 2007).
Research in predominantly Caucasian women in developed countries has shown that patients want to be involved in treatment decision making (Nakashima et al., 2012) and that attaining their preferred role in decision making leads to better quality of life (Hack et al., 2006). For example, women diagnosed with early stage breast cancer can choose either mastectomy or wide local excision, because these two options have similar survival rates, and the choice often depends on patients' preference, such as whether to conserve the breast (Morris et al., 1988;Fallowfield et al., 1994). Studies have found that there is a wide variation in the extent to which patients are involved in decision making (Coulter et al., 2005) and often, patients want to be involved in decision making but are not given the option to do so. In order to involve patients in making treatment decisions, a number of patient decision support interventions, such as patient decision aids, have been developed and these improve decisional quality and patient involvement in decision making (Coulter et al., 2005).
To date, there has been a paucity of information on local women's desire to be involved in treatment decisionmaking and tools for patient decision support. This has resulted in wide variation on how patients are being supported during decision-making, which may have an impact on their choice of cancer treatment.
We aimed to explore the decision making process of Malaysian women diagnosed with early breast cancer. In particular, we sought to understand how they made decisions regarding different treatment options namely surgery or CAM therapy, and who influenced their decisions and their views. The findings from this study had been used to inform the development of a treatment decision support tool for Malaysian women with early breast cancer.

Design
We used a qualitative study methodology to gain an in-depth understanding of the decision making process of a group of multi-ethnic women diagnosed with early breast cancer. A qualitative approach was chosen because it allows us to probe women's beliefs, experiences and views on the complex health issue of decision making (Pope et al., 1995). Women's accounts were captured using individual in-depth interviews. The one to one interview set-up provided a safe environment for the participants to discuss personal and sensitive issues and to express their emotions more freely if necessary.

Setting
The study was carried out at two breast surgical units in Klang Valley, an urban area in Malaysia. One unit was located at a university-based tertiary hospital and the other at a busy Ministry of Health secondary hospital.

Participants, recruitment, sampling
We recruited women who were diagnosed with early breast cancer (Stage 1 or 2) by a breast surgeon; were aware of the diagnosis; and had not undergone surgery, chemotherapy or radiotherapy. The reasons for selecting this specific group of women were to ensure that the information gathered is current and not subjected to recall bias. These also reduce the possibility of rationalization of the decisions by the women once they have undergone the treatments. The background of the women ranged from middle to lower socio-economic class. We used purposive sampling method to recruit women who were at different stages of decision making (decided vs. undecided) and who preferred different treatment options (surgery vs. CAM therapy). Breast surgeons and nurses from the two hospitals helped to recruit the participants. Sample size was determined by data saturation and interviews were stopped when consensus was reached amongst three researchers that data categories were established and any new data fit into categories already devised.

Data collection
An interview topic guide was developed based on the Ottawa Decision Support Framework (ODSF). We used the factors considered in the decisional needs such as knowledge and expectations, patient values, support and resources to outline the topic guide. Information from other literatures, researchers' clinical knowledge and research experience also informed the topic guide. The interviews were carried out by at least one of the researchers who are trained to conduct qualitative interviews. Interviews were conducted either in the researcher's department or the women's own homes. A research assistant took detailed notes and observed nonverbal cues during the interviews which were used as field notes. We conducted the interviews in Malay, Mandarin and English to capture the experiences of women from different ethnicities. Each interview lasted 40-60 minutes and they were audio-recorded, transcribed verbatim and managed using NVivo 9 software (Richards, 2002). Each transcript was checked for accuracy by another transcriber and used as data for analysis.

Data analysis
Three researchers read the transcripts repeatedly to scrutinise the data before applying the thematic approach to identify the main themes. All three researchers coded two transcripts independently to identify the coding frame. This framework was then used to code two other transcripts individually. This was followed by discussion until a consensus on the common emerging themes was reached.

Ethics approval
This study received ethics approval from the

Results
Eight women with early breast cancer participated in this study (Table 1). The findings from our interviews identified four phases that women experienced prior to making a treatment decision. They can be divided into: discovery (pre-diagnosis) phase; confirmation ('receiving bad news') phase; deliberation phase; and decision (making a surgical treatment decision) phase.
Phases towards making a treatment decision a). Discovery phase: this study found that the process of making a treatment decision began before the diagnosis of breast cancer was made. Women started to suspect Asian Pacific Journal of Cancer Prevention, Vol 14, 2013 7145 DOI:http://dx.doi.org/10.7314/APJCP.2013.14.12.7143 The Decision-Making Journey of Malaysian Women with Early Breast Cancer: A Qualitative Study they might have breast cancer and consider the possible treatment options upon discovering a breast lump or an abnormal mammogram. Some women in our study made a decision to seek alternative medicine before the diagnosis of breast cancer was made. Their decisions were shaped by the positive experiences of their friends or family members who had undergone the treatment successfully.
"So because my sister herself took herbal medicine. Her little lump, after she took it (the herbal medication) and went back to see the doctor, he said that it was gone! No need surgery for the lump" Ms D, Own decision "Neighbors or friends, asked you to see that one (particular surgeon) then some people also said that you do not need any treatment and just go to see Chinese medicine practitioner, that is it" Ms B, Shared decision making b). Confirmation phase: in this phase, the diagnosis of breast cancer was confirmed and the bad news was 'broken' to the women. During the consultation, some women wanted to know more about the reasons why they had breast cancer while others did not know what they needed to know. The women mentioned that they received information about the treatment from their healthcare professionals, who focused mainly on the surgical options. Meanwhile, women who were in distress often received emotional support from their spouses and family members. The support from the healthcare professionals was not highlighted. c). Deliberation phase: the deliberation phase occurred in between visits to the breast clinic. After returning from the hospital, the women started to look for more information. The women we sampled looked for information themselves, by reading books, accessing information from the internet and/or mass media. In addition, they also received information from friends and family. The information was used to help them cope as well as to guide them to make decisions about their breast cancer treatment.

"How did I come across HL (a complementary faith healer)? It was a coincidence actually. At that time I was looking for answers when he appeared (on television) and talked about alternative treatment for breast cancer. After that a local newspaper also runs an article on him. So I immediately look for him." Mrs E, Own decision
"Ah…a breast cancer patient. A friend brought her to see me. Those with cancer and had done surgery wished to come and see people like us. They told us not to be afraid and that we must accept the treatment. You must accept it, she said. I felt better and cheered up after that" Ms B, Shared decision making

"Yeah, my doctor gave me his number so when I came across this (complementary and alternative medicine) I wanted to call him but I didn't know when would be the right time to call"
Mrs A, Shared decision making d). Decision phase: after deliberating different treatment options, the women would make a decision whether or not to proceed with surgical treatment offered by the doctor. Those who chose surgery would then face with another decision of whether to do mastectomy or lumpectomy. Some chose CAM and would consider surgery only after CAM had failed. In this study, women themselves seemed to play the main decisional role.

Discussion
This study offered insight into how women with early breast cancer in Malaysia make treatment decision. We identified four phases in their treatment decision making: discovery; confirmation; deliberation; and decision phase.
Results from this study found that treatment decision making process commenced when women discovered an abnormality in their breasts. Some of the women we interviewed were exposed to CAM early on in their help-seeking effort. This may influence their subsequent treatment decisions. We found the women in our study, similar to previous studies went on an information-seeking journey once they confirmed their diagnoses; regardless of their preferred treatment options. Studies show information helps women to understand their diagnoses and to help them make treatment decisions (Butow et al., 1997;Thibodeau et al., 1997;McWilliam et al., 2000). In addition, information also helps women to gain a sense of control over their situation, reduce anxiety, change their behaviour and formulate a plan for the future (Henman et al., 2002).
Another important observation is that women's main source of information and support changes at different phases of the decision making process. Women's spouses, friends, family and healthcare professionals all played different roles at different time their treatment decision. After the women had been told of the diagnosis, the main source of information on the benefit and disadvantages of treatment was from healthcare professionals. This is similar to previous studies in which healthcare professionals are found to be the most common and preferred source of information for cancer patients facing treatment choices (Mills et al., 1999;Rutten et al., 2005). In a 2004 paper, Rutten et al reviewed 112 articles published from 1980 to 2003 summarizing cancer patients' information needs and their sources and they found the most frequent information need was treatment-related (38.1%) and most frequent information source was health care professionals (27.3%) (Rutten et al., 2005). When the bad news is broken, the women looked to their spouse or family members for support. Some women in our study found the information given at diagnosis overwhelming; others were unsure of what they needed to know and, hence were unable to assess the adequacy of the information given by their healthcare professionals.
In between visits to the breast surgeon, women with early breast cancer deliberated on the decision that they had made. In our study setting, surgical treatment dates were given to the women at the time the diagnosis was revealed and the duration between that consultation and the surgery ranged from 2-4 weeks. Women looked to their family, friends, media and internet sources for more information. The women also reported that they received advice from family members and friends without it being solicited. These advices usually pertained to the use of CAM. This finding concurred with other local studies which found that friends and family play a pivotal role in influencing patients to seek CAM (Hasan et al., 2009;Mazanah et al., 2012). Healthcare professionals did not openly discuss the option of CAM; this might have hindered the women from discussing this treatment option, which is popular in the Asian context (Taib et al., 2007). Another barrier women faced while making treatment decisions, was the lack of timely support from healthcare professionals when the needs arose. Studies have found that patients need time to deliberate, gather information about the pros and cons of the treatment options and be given the opportunity to clarify their doubts to make a more informed decision (Mills et al., 1999). However, health care professionals are not equipped with the skills to provide decisional support to patients due to the lack of awareness, knowledge and skills, concerns about time and resource pressures (Ford et al., 2002).
Findings from this study will help in the development of an intervention that could potentially support women with early breast cancer to make a treatment decision in Malaysia. Recruiting women from two sites also increase the range of views sampled as both sites have different work processes and supporting staff. For example, at one of the breast clinic trained breast surgeons with a team of breast care nurses who were proficient in their interactions with women with breast cancer ran the clinic. Whereas, in the other clinic there was only a non-specialist doctor who performed breast surgery, and there was almost no dedicated breast care nurse to support women with breast cancer. Due to this, we managed to explore the healthcare system factors that could have potentially influenced treatment decision making.
There are a few limitations in this study. Only women form the states of Kuala Lumpur and Selangor were included in this study. The belief and decision making process for women in other states particularly from the East Coast of the peninsula and East Malaysia may be different as women in these states were thought to be more passive in their role of decision making. We attempted to recruit women from these states but the response was poor. This limits the transferability of the study findings. The views from the healthcare professionals would help to further explore the decision making process of women with early breast cancer from doctors' and nurses' perspectives. Information captured from both of these sources could work synergistically to strengthen the intervention such as a Patient Decision Aid that we were planning to develop. A qualitative study has been conducted with the healthcare professionals and the findings will be reported separately.
In conclusion, the process of making a treatment decision is complex. This study offers a preliminary understanding of the factors that influence treatment decision-making in women with early breast cancer. We discovered four phases in which women with early breast cancer go through to arrive at the treatment decision. In each phase, these women are faced with issues of gathering information, garnering support and weighing the pros and cons of the different treatment options. We found that women seek information from different sources to support their final decision. Women's past experience, knowledge Asian Pacific Journal of Cancer Prevention, Vol 14, 2013 7147 DOI:http://dx.doi.org/10.7314/APJCP.2013.14.12.7143 The Decision-Making Journey of Malaysian Women with Early Breast Cancer: A Qualitative Study and social influences are important in influencing the treatment decision. These findings would allow us to develop strategies to support women in making a more informed decision in the local context.