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Original Article |

Factors That Determine Satisfaction With Surgical Treatment of Low-Income Women With Breast Cancer FREE

Amardeep Thind, MD, PhD; Allison Diamant, MD; Yihang Liu, MD, MS, MA; Rose Maly, MD, MSPH
[+] Author Affiliations

Author Affiliations: Department of Epidemiology and Biostatistics, and Center for Studies in Family Medicine, Schulich School of Medicine, The University of Western Ontario, London, Ontario, Canada (Dr Thind); and Departments of General Internal Medicine (Dr Diamant) and Family Medicine (Drs Liu and Maly), David Geffen School of Medicine, University of California, Los Angeles.


Arch Surg. 2009;144(11):1068-1073. doi:10.1001/archsurg.2009.190.
Text Size: A A A
Published online

Objective  To analyze the relationship between patient satisfaction with surgical treatment and 4 consultation skills and processes of the surgeons (time spent, listens carefully, explains concepts in a way the patient can understand, and shows respect for what the patient has to say), controlling for a range of patient, surgeon, and treatment characteristics.

Design  Cross-sectional survey.

Setting  The Breast and Cervical Cancer Treatment Program for the state of California.

Patients  A statewide sample of 789 low-income women who received treatment for breast cancer from February 1, 2003, through September 31, 2005.

Main Outcome Measure  Satisfaction with surgical treatment.

Results  Three of every 4 women reported being extremely satisfied with the treatment they received from their surgeon. African American women and those with arm swelling were less likely to be satisfied, whereas those reporting that the surgeon always spent enough time and explained concepts in a way they could understand were more likely to report greater satisfaction.

Conclusion  Our findings highlight the importance of 2 relatively simple behaviors that surgeons can easily implement to increase patient satisfaction, which can be of potential benefit in the litigious world of today.

Surgeons play a key role in the treatment of patients with breast cancer. In the clinical environment of today, the traditional indicators of clinical care quality (such as 5-year survival rate) are increasingly being complemented with patient-centered outcomes, such as patient satisfaction. There is a rich body of literature that focuses on determinants of patient satisfaction with their physicians, their treatment, and the decision-making process.15 In terms of surgical treatment of breast cancer, the literature focuses on patient satisfaction with body image, decision regret, treatment decision making, and concordance with treatment wishes.1,58 A few studies1,5 have ascertained the relationship of overall patient satisfaction with the treatment provided by consultation process and skills of the surgeon. In this limited subset, most studies control for patient characteristics (eg, age, education level, income, disease stage) and those of the surgeon, but few control for confounding caused by factors such as treatment delay, patient self-efficacy, surgical concordance, and surgical outcomes. In addition, none of the studies examines this relationship in a population of low-income women.

In a statewide sample of 789 low-income women in California who received treatment for breast cancer under the Breast and Cervical Cancer Treatment Program (BCCTP) of California, we analyzed the relationship between satisfaction with surgical treatment and 4 consultation skills and processes of the surgeon (time spent, listens carefully, explains concepts in a way the patient can understand, and shows respect for what the patient has to say), controlling for a range of patient, surgeon, and treatment characteristics.

STUDY DESIGN AND DATA SOURCE

The details of the study design and sample have been described in a previously published article9 and are reviewed briefly herein. We conducted a cross-sectional survey of low-income women 18 years and older living in California who were newly diagnosed as having breast cancer. The study was approved by the UCLA Human Subjects Protection Committee and the California State Department of Health Services Human Subjects Protection Committee. A consecutive sample of all women treated through the California BCCTP from February 1, 2003, through September 31, 2005, was recruited for the study. The BCCTP was legislated by the federal government as part of the Breast and Cervical Cancer Prevention and Treatment Act of 2000 to fund the treatment of breast and cervical cancer for uninsured and underinsured, low-income women (at or below 200% of the federal poverty level). The BCCTP in California is supported via federal funding through Medicaid and separate state funding.

A total of 921 women were recruited into the study. Women who did not speak English or Spanish, had a previous history of breast cancer, or were receiving treatment for another type of cancer were excluded from the study. Our overall response rate was 61.0%. Compared with survey responders, nonresponders tended to be older (52 vs 50 years, P < .001), were more likely to be Asian/Pacific Islanders (11.6% vs 7.4%), and less likely to be Latina (37.6% vs 53.4%, P < .001). Further details about the design and flow of the study can be found in a previous article.9 Our analysis for this article is based on 789 women who completed telephone interviews approximately 18 months after diagnosis and for whom medical records from a systematic medical record abstraction were available.

MODEL AND VARIABLE SPECIFICATION

Variables were constructed by means of both patient self-report and medical record abstraction data. Our dependent variable was based on the response to the question, “Altogether, how satisfied are you with your treatment by the surgeon?” A similar format has been used in the literature to assess patient satisfaction.6,1013 Response categories were based on a 5-point Likert scale: extremely satisfied, somewhat satisfied, neither satisfied nor dissatisfied, somewhat dissatisfied, and extremely dissatisfied. Because of the skewed nature of the responses (74.0% reported being extremely satisfied), we dichotomized the variable (extremely satisfied vs not extremely satisfied).8,13

The key independent variables that captured the consultation skills and process were based on the 4 questions from the Consumer Assessment of Healthcare Providers and Systems survey,14 which evaluates the surgeon-patient interaction. These questions were as follows: (1) “How often did [the surgeon you saw the most] spend enough time with you?” (2) “How often did he/she listen carefully to you?” (3) “How often did he/she explain things in a way you could understand?” and (4) “How often did he/she show respect for what you had to say?” Responses to these questions were on a 4-point Likert scale: never, sometimes, usually, and often. Because of the sparse responses in the “never” category, we combined the “never” and “sometimes” responses into 1 group.

Control variables included characteristics of the patient, surgeon, and treatment. Patient characteristics included age (≤50 or >50 years), education level of less then grade 12 (no or yes), ethnicity (white, African American, Latina, or other), annual household income (<$10 000, $10 000-$19 999, $20 000-$29 999, or ≥$30 000), and stage of disease (0, 1, 2, 3, or 4). Self-reported general health status was assessed with the question, “In general, would you say your health is . . . ?” and measured on a 5-point scale from 1 (poor) to 5 (excellent). Depression was evaluated by means of the Center for Epidemiologic Studies–Depression (CES-D) scale.1517 Patient self-efficacy was measured by means of the validated Perceived Efficacy in Patient-Physician Interactions (PEPPI) questionnaire.18 The PEPPI questionnaire measures the perceived ability of patients to obtain needed medical information and attention to their chief medial concerns from physicians. The PEPPI sum scale ranges from 0 to 50, and the Cronbach α in our sample was 0.96.

Treatment characteristics included type of surgery (lumpectomy, mastectomy, or other/unsure), treatment delay (coded “yes” if the woman reported a period of ≥60 days between the time she first became aware that something was wrong and the first invasive diagnostic procedure [ie, biopsy or surgery]), surgical concordance (“yes” if the woman received the type of surgery she preferred and “no” if she did not), and presence in the previous 4 weeks of arm swelling and decreased arm movement. We also controlled for sex of the surgeon and time elapsed since surgery to adjust for confounding by time.

STATISTICAL ANALYSIS

Descriptive statistical analyses were used to understand the characteristics of the patients and surgeons. Unadjusted bivariate relationships between the dependent and independent variables were examined. Logistic regression was used to obtain the odds ratios between the dependent variable and the regressors of interest, controlling for other covariates. Regression diagnostics were conducted by means of the Hosmer-Lemeshow goodness-of-fit tests. Second-order interactions were tested for, but none were found to be significant in the final models. P < .05 was considered statistically significant. All data analysis was performed by means of Stata/SE statistical software, version 10.0 (Stata Corp, College Station, Texas).

Our sample of 789 women was predominantly Latina (53.9%), with whites accounting for approximately a third (31.9%) of patients (Table 1). Half the women (50.7%) were older than 50 years, and most (58.5%) had an education level of more than grade 12. More than half (60.1%) had an annual household income of less than $20 000. Almost one-third of the women (31.2%) had early-stage disease (0 or 1), and more than one-third had stage 2 disease (36.4%). Approximately half the women reported that they had undergone lumpectomy (51.6%), and more than half (51.3%) reported at least a 60-day delay in undergoing biopsy or surgery from the time they noted something was wrong.

Table Graphic Jump LocationTable 1. Characteristics of the Study Patients, Surgeons, and Treatment

Most women reported being treated by a male surgeon (76.4%). Most believed that the surgeon always spent enough time with them (51.9%), always listened carefully to what they had to say (63.9%), always explained concepts in a way they could understand (62.5%), and always showed respect for what they had to say (62.6%). Less than three-fifths of women (58.2%) received the type of surgical procedure they preferred. Almost three-quarters of women (73.5%) did not report having any arm swelling during the preceding 4 weeks, and three-fifths (60.1%) did not report any decreased arm movement during that time. The mean (SD) score on the self-reported general health scale was 3 (1), and the mean (SD) score on the CES-D scale was 9.2 (7.5).

In the unadjusted bivariate analyses, among patient characteristics, statistically significant associations were noted between satisfaction and ethnicity, patient self-efficacy (as measured by the PEPPI scale), self-reported general health, and CES-D score (Table 2). African American women and those categorized as “other” were less likely to report being extremely satisfied. Women who scored higher on the self-efficacy scale were more likely to report being extremely satisfied, whereas an increase in the general health and CES-D scores were associated with lower likelihood of being extremely satisfied. Among surgeon characteristics, all 4 surgeon-patient communication measures (spending enough time, listening carefully, explaining concepts, and showing respect) were strongly associated with satisfaction. None of the treatment characteristic variables was associated with satisfaction.

Table Graphic Jump LocationTable 2. Unadjusted and Adjusted Odds Ratios of Determinants of 740 Women Being Extremely Satisfied With Treatment by Their Surgeon at 18 Months

After controlling for other variables in the logistic regression model, these findings were attenuated, as depicted in the last column of Table 2. African American women had significantly lesser odds of being extremely satisfied with treatment from the surgeon compared with white women. The PEPPI score remained significant, with effect size nearly identical to that in the unadjusted analyses. Among the 4 measures of surgeon-patient communication, only spending enough time and explaining concepts remained significant, with an attenuation of the effect size compared with the unadjusted analyses. Women who had arm swelling were less likely to report being satisfied with treatment from the surgeon compared with those who had not had arm swelling in the previous 4 weeks.

In our statewide sample of low-income women in California, 3 of every 4 women reported being extremely satisfied with the treatment they received from their surgeon. This high percentage of satisfaction is similar to that reported in other studies.1,2,5,8,19 The BCCTP is a safety net for women who “fall through the cracks” and are not eligible for other insurance coverage options. Thus, low-income women in this sample are relatively enabled in terms of their access to care by virtue of their enrollment in the BCCTP. Thus, it is highly probable that this high rate of satisfaction may reflect a sense of gratitude among women for the receipt of care for a life-threatening condition.

Among the 4 measures of patient-physician communication, 2 were statistically significantly associated with satisfaction: time spent and explanation of concepts. The breast cancer diagnosis is often experienced as being devastating, and patients are likely to seek succor from their treating physicians. Spending enough consultation time with the patient is 1 way in which surgeons can underscore the gravity of the situation; in addition, it allows them adequate time to address the concerns and questions of the patient. Evidence from a regional breast cancer center suggests that surgeon consultations average approximately 20 minutes,20 and a recent report1 suggests that breast cancer patients whose consultation was longer than 15 minutes were more likely to characterize the surgeon-patient interaction as extremely helpful. To explain things in a manner that the patient can understand may be helpful to allay and address patient concerns and questions and to decrease patient anxiety about surgery that is often invasive and sometimes mutilating.21

Compared with white women, African American women were significantly less likely to report being extremely satisfied with treatment from their surgeon; this result is similar to that of Lantz et al.8 The finding could be owing in part to the well-documented disparities in health care that African Americans have historically experienced.2224 Even in our sample, a significant difference was found in the self-reported treatment delay; African American women were significantly more likely to report at least a 60-day treatment delay (data not shown). The self-efficacy of a woman was related to higher satisfaction; women who were more self-efficacious could presumably obtain the information they needed from the surgeon during the consultation, thus increasing their satisfaction with treatment from the surgeon. Self-efficacy has previously been shown to be a predictor of satisfaction.1,20,25

Women who had had arm swelling during the preceding 4 weeks were significantly less likely to report being satisfied compared with women who had not had arm swelling. Mandelblatt et al6 found a similar relationship in a sample of older women (>67 years) with stage 1 or 2 disease. The mean number of days since surgery in our study was 473 (median, 499 days), so presence of arm swelling at the time of the interview would imply a persistent postsurgical sequela, which would certainly affect the satisfaction level of a patient. However, the presence of arm swelling was not statistically significant in the bivariate (unadjusted) analysis. This is because arm swelling was confounded by ethnicity; in the presence of arm swelling, African American women were more likely to report lower satisfaction compared with all other groups (data not shown). When the effect of ethnicity was controlled for in the regression model, the true effect of the arm swelling became apparent.

From a policy perspective, our findings highlight the importance of 2 relatively simple behaviors that surgeons can easily implement to increase patient satisfaction. Although our study does not provide any indication of how long an ideal consultation should be, it indicates that more is always better; to the extent the busy schedule of a surgeon allows, the benefits of spending more time with a patient are significant in terms of patient satisfaction. In addition, the surgeon should explain concepts, be they surgical options, postoperative care, or relative risks of treatment options, in a way that the patient understands. This usually entails eschewing medical jargon and not overestimating the capacity of the patient to absorb, interpret, and retain information; the corollary here is that simpler is better.2628 Such behaviors from surgeons have the potential to not only improve patient satisfaction but also to improve compliance and thereby outcomes, which will decrease potential future litigation.29 For example, the American College of Surgeons' Closed Claims Study29 found that better communication could have prevented complications in 22% of patients; in addition, for those patients among whom the expected quality of surgical care was satisfactory, communication and practice-pattern violations were the most common deficiencies in provision of care.

Some caveats should be borne in mind as one interprets the results of our study. First, our data are cross-sectional, which precludes any interpretation of causality. Second, our sample is a low-income population in California that was relatively enabled because of enrollment in a specific program; thus, our results may not be applicable to other states or populations. Third, a relatively small number of women in our study underwent breast reconstruction, so we were not able to assess the effect of breast reconstruction with regard to satisfaction. Reconstruction has been linked to satisfaction in the literature.3 Fourth, our data were obtained 18 months after the enrollment of the women in the BCCTP. Recall bias could, therefore, be an issue, although some reports30,31 suggest that patients can accurately report treatment received in the past. Controlling for time since surgery did not change our regression results.

Despite these caveats, our study has many strengths. It is among the few, to our knowledge, that has analyzed a statewide sample of low-income women. Our sample size is relatively large, and our data set allows us to control for important confounders that have not been controlled for in the past, such as treatment delay, patient self-efficacy, surgical concordance, and surgical outcomes, thus lending credence to our findings.

In conclusion, analysis of our sample of 789 low-income women who received care funded through the California BCCTP suggests that most are extremely satisfied with the treatment provided by their surgeon. Spending enough time and explaining things in a way that the patient can understand are 2 clinical skills or processes that significantly affect this level of satisfaction. In addition, being African American, reporting the presence of arm swelling in the past 4 weeks, and having a low self-efficacy score are associated with lower satisfaction. Future research would be helpful in identification of the duration of an ideal consultation.

Correspondence: Amardeep Thind, MD, PhD, Center for Studies in Family Medicine, Schulich School of Medicine, The University of Western Ontario, 245-100 Collip Cir, London, Ontario N6G 4X8 Canada (athind2@uwo.ca).

Accepted for Publication: November 14, 2008.

Author Contributions:Study concept and design: Thind, Diamant, and Maly. Acquisition of data: Diamant, Liu, and Maly. Analysis and interpretation of data: Thind, Diamant, and Maly. Drafting of the manuscript: Thind. Critical revision of the manuscript for important intellectual content: Thind, Diamant, Liu, and Maly. Statistical analysis: Thind and Liu. Administrative, technical, and material support: Diamant and Maly.

Financial Disclosure: None reported.

Funding/Support: The study was funded by grant TURSG-02-081 from the American Cancer Society and grant 7PB-0080 from the California Breast Cancer Research Program. Dr Thind is funded by a Canada Research Chair in Health Services Research.

Thind  AMaly  R The surgeon-patient interaction in older women with breast cancer: what are the determinants of a helpful discussion? Ann Surg Oncol 2006;13 (6) 788- 793
PubMed Link to Article
Waljee  JFHawley  SAlderman  AKMorrow  MKatz  SJ Patient satisfaction with treatment of breast cancer: does surgeon specialization matter? J Clin Oncol 2007;25 (24) 3694- 3698
PubMed Link to Article
Parker  PAYoussef  AWalker  S  et al.  Short-term and long-term psychosocial adjustment and quality of life in women undergoing different surgical procedures for breast cancer. Ann Surg Oncol 2007;14 (11) 3078- 3089
PubMed Link to Article
Caldon  LJMWalters  SJReed  MWR Changing trends in the decision-making preferences of women with early breast cancer. Br J Surg 2008;95 (3) 312- 318
PubMed Link to Article
Noh  DYNam  SJAhn  SH  et al.  Association of clinical experiences with patient-reported outcomes among breast cancer surgery patients: Breast Cancer Quality Care Study. Qual Life Res 2008;17 (2) 215- 225
PubMed Link to Article
Mandelblatt  JSEdge  SBMeropol  NJ  et al.  Predictors of long-term outcomes in older breast cancer survivors: perceptions versus patterns of care. J Clin Oncol 2003;21 (5) 855- 863
PubMed Link to Article
Keating  NLGuadagnoli  ELandrum  MBBorbas  CWeeks  JC Treatment decision making in early-stage breast cancer: should surgeons match patients' desired level of involvement? J Clin Oncol 2002;20 (6) 1473- 1479
PubMed Link to Article
Lantz  PMJanz  NKFagerlin  A  et al.  Satisfaction with surgery outcomes and the decision process in a population-based sample of women with breast cancer. Health Serv Res 2005;40 (3) 745- 767
PubMed Link to Article
Chen  JYDiamant  ALThind  AMaly  RC Determinants of breast cancer knowledge among newly diagnosed, low-income, medically underserved women with breast cancer. Cancer 2008;112 (5) 1153- 1161
PubMed Link to Article
Bui  QUOstir  GVKuo  YFFreeman  JGoodwin  JS Relationship of depression to patient satisfaction: findings from the barriers to breast cancer study. Breast Cancer Res Treat 2005;89 (1) 23- 28
PubMed Link to Article
Geiger  AMMullen  ESSloman  PAEdgerton  BWPetitti  DB Evaluation of a breast cancer patient information and support program. Eff Clin Pract 2000;3 (4) 157- 165
PubMed
Jansen  SJTOtten  Wvan de Velde  CJHNortier  JWRStiggelbout  AM The impact of the perception of treatment choice on satisfaction with treatment, experienced chemotherapy burden and current quality of life. Br J Cancer 2004;91 (1) 56- 61
PubMed Link to Article
Mandelblatt  JKreling  BFigeuriedo  MFeng  S What is the impact of shared decision making on treatment and outcomes for older women with breast cancer? J Clin Oncol 2006;24 (30) 4908- 4913
PubMed Link to Article
Hargraves  JLHays  RDCleary  PD Psychometric properties of the Consumer Assessment of Health Plans Study (CAHPS) 2.0 Adult Core Survey. Health Serv Res 2003;38 (6 pt 1) 1509- 1527
PubMed Link to Article
Hann  DWinter  KJacobsen  P Measurement of depressive symptoms in cancer patients: evaluation of the Center for Epidemiological Studies Depression Scale (CES-D). J Psychosom Res 1999;46 (5) 437- 443
PubMed Link to Article
Orme  JGReis  JHerz  EJ Factorial and discriminant validity of the Center for Epidemiological Studies Depression (CES-D) scale. J Clin Psychol 1986;42 (1) 28- 33
PubMed Link to Article
van Wilgen  CPDijkstra  PUStewart  RERanchor  AVRoodenburg  JLN Measuring somatic symptoms with the CES-D to assess depression in cancer patients after treatment: comparison among patients with oral/oropharyngeal, gynecological, colorectal, and breast cancer. Psychosomatics 2006;47 (6) 465- 470
PubMed Link to Article
Maly  RCFrank  JCMarshall  GNDiMatteo  MRReuben  DB Perceived efficacy in patient-physician interactions (PEPPI): validation of an instrument in older persons. J Am Geriatr Soc 1998;46 (7) 889- 894
PubMed
Nold  RJBeamer  RLHelmer  SD McBoyle  MF Factors influencing a woman's choice to undergo breast-conserving surgery versus modified radical mastectomy. Am J Surg 2000;180 (6) 413- 418
PubMed Link to Article
Janz  NKWren  PACopeland  LALowery  JCGoldfarb  SLWilkins  EG Patient-physician concordance: preferences, perceptions, and factors influencing the breast cancer surgical decision. J Clin Oncol 2004;22 (15) 3091- 3098
PubMed Link to Article
Defossez  GMathoulin-Pelissier  SIngrand  I  et al. REPERES Research Network, Satisfaction with care among patients with non-metastatic breast cancer: development and first steps of validation of the REPERES-60 questionnaire. BMC Cancer 2007;7129
PubMed Link to Article
Janz  NKMujahid  MSHawley  STGriggs  JJHamilton  ASKatz  SJ Racial/ethnic differences in adequacy of information and support for women with breast cancer. Cancer 2008;113 (5) 1058- 1067
PubMed Link to Article
Montella  MCrispo  AD'Aiuto  G Difference in breast cancer stage, treatment, and survival. Arch Intern Med 2003;163 (10) 1241- 1242
PubMed Link to Article
Pfeiffer  RMMitani  AMatsuno  RKAnderson  WF Racial differences in breast cancer trends in the United States (2000-2004). J Natl Cancer Inst 2008;100 (10) 751- 752
PubMed Link to Article
Silliman  RADukes  KASullivan  LMKaplan  SH Breast cancer care in older women: sources of information, social support, and emotional health outcomes. Cancer 1998;83 (4) 706- 711
PubMed Link to Article
Gattellari  MButow  PNTattersall  MHNDunn  SMMacLeod  CA Misunderstanding in cancer patients: why shoot the messenger? Ann Oncol 1999;10 (1) 39- 46
PubMed Link to Article
Lerman  CDaly  MWalsh  WP  et al.  Communication between patients with breast cancer and health care providers: determinants and implications. Cancer 1993;72 (9) 2612- 2620
PubMed Link to Article
Lobb  EAButow  PNKenny  DTTattersall  MHN Communicating prognosis in early breast cancer: do women understand the language used? Med J Aust 1999;171 (6) 290- 294
PubMed
Levinson  WRoter  DLMullooly  JPDull  VTFrankel  RM Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997;277 (7) 553- 559
PubMed Link to Article
Griffen  FDStephens  LSAlexander  JB  et al.  The American College of Surgeons' closed claims study: new insights for improving care. J Am Coll Surg 2007;204 (4) 561- 569
PubMed Link to Article
Phillips  K-AMilne  RLBuys  S  et al.  Agreement between self-reported breast cancer treatment and medical records in a population-based Breast Cancer Family Registry. J Clin Oncol 2005;23 (21) 4679- 4686
PubMed Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. Characteristics of the Study Patients, Surgeons, and Treatment
Table Graphic Jump LocationTable 2. Unadjusted and Adjusted Odds Ratios of Determinants of 740 Women Being Extremely Satisfied With Treatment by Their Surgeon at 18 Months

References

Thind  AMaly  R The surgeon-patient interaction in older women with breast cancer: what are the determinants of a helpful discussion? Ann Surg Oncol 2006;13 (6) 788- 793
PubMed Link to Article
Waljee  JFHawley  SAlderman  AKMorrow  MKatz  SJ Patient satisfaction with treatment of breast cancer: does surgeon specialization matter? J Clin Oncol 2007;25 (24) 3694- 3698
PubMed Link to Article
Parker  PAYoussef  AWalker  S  et al.  Short-term and long-term psychosocial adjustment and quality of life in women undergoing different surgical procedures for breast cancer. Ann Surg Oncol 2007;14 (11) 3078- 3089
PubMed Link to Article
Caldon  LJMWalters  SJReed  MWR Changing trends in the decision-making preferences of women with early breast cancer. Br J Surg 2008;95 (3) 312- 318
PubMed Link to Article
Noh  DYNam  SJAhn  SH  et al.  Association of clinical experiences with patient-reported outcomes among breast cancer surgery patients: Breast Cancer Quality Care Study. Qual Life Res 2008;17 (2) 215- 225
PubMed Link to Article
Mandelblatt  JSEdge  SBMeropol  NJ  et al.  Predictors of long-term outcomes in older breast cancer survivors: perceptions versus patterns of care. J Clin Oncol 2003;21 (5) 855- 863
PubMed Link to Article
Keating  NLGuadagnoli  ELandrum  MBBorbas  CWeeks  JC Treatment decision making in early-stage breast cancer: should surgeons match patients' desired level of involvement? J Clin Oncol 2002;20 (6) 1473- 1479
PubMed Link to Article
Lantz  PMJanz  NKFagerlin  A  et al.  Satisfaction with surgery outcomes and the decision process in a population-based sample of women with breast cancer. Health Serv Res 2005;40 (3) 745- 767
PubMed Link to Article
Chen  JYDiamant  ALThind  AMaly  RC Determinants of breast cancer knowledge among newly diagnosed, low-income, medically underserved women with breast cancer. Cancer 2008;112 (5) 1153- 1161
PubMed Link to Article
Bui  QUOstir  GVKuo  YFFreeman  JGoodwin  JS Relationship of depression to patient satisfaction: findings from the barriers to breast cancer study. Breast Cancer Res Treat 2005;89 (1) 23- 28
PubMed Link to Article
Geiger  AMMullen  ESSloman  PAEdgerton  BWPetitti  DB Evaluation of a breast cancer patient information and support program. Eff Clin Pract 2000;3 (4) 157- 165
PubMed
Jansen  SJTOtten  Wvan de Velde  CJHNortier  JWRStiggelbout  AM The impact of the perception of treatment choice on satisfaction with treatment, experienced chemotherapy burden and current quality of life. Br J Cancer 2004;91 (1) 56- 61
PubMed Link to Article
Mandelblatt  JKreling  BFigeuriedo  MFeng  S What is the impact of shared decision making on treatment and outcomes for older women with breast cancer? J Clin Oncol 2006;24 (30) 4908- 4913
PubMed Link to Article
Hargraves  JLHays  RDCleary  PD Psychometric properties of the Consumer Assessment of Health Plans Study (CAHPS) 2.0 Adult Core Survey. Health Serv Res 2003;38 (6 pt 1) 1509- 1527
PubMed Link to Article
Hann  DWinter  KJacobsen  P Measurement of depressive symptoms in cancer patients: evaluation of the Center for Epidemiological Studies Depression Scale (CES-D). J Psychosom Res 1999;46 (5) 437- 443
PubMed Link to Article
Orme  JGReis  JHerz  EJ Factorial and discriminant validity of the Center for Epidemiological Studies Depression (CES-D) scale. J Clin Psychol 1986;42 (1) 28- 33
PubMed Link to Article
van Wilgen  CPDijkstra  PUStewart  RERanchor  AVRoodenburg  JLN Measuring somatic symptoms with the CES-D to assess depression in cancer patients after treatment: comparison among patients with oral/oropharyngeal, gynecological, colorectal, and breast cancer. Psychosomatics 2006;47 (6) 465- 470
PubMed Link to Article
Maly  RCFrank  JCMarshall  GNDiMatteo  MRReuben  DB Perceived efficacy in patient-physician interactions (PEPPI): validation of an instrument in older persons. J Am Geriatr Soc 1998;46 (7) 889- 894
PubMed
Nold  RJBeamer  RLHelmer  SD McBoyle  MF Factors influencing a woman's choice to undergo breast-conserving surgery versus modified radical mastectomy. Am J Surg 2000;180 (6) 413- 418
PubMed Link to Article
Janz  NKWren  PACopeland  LALowery  JCGoldfarb  SLWilkins  EG Patient-physician concordance: preferences, perceptions, and factors influencing the breast cancer surgical decision. J Clin Oncol 2004;22 (15) 3091- 3098
PubMed Link to Article
Defossez  GMathoulin-Pelissier  SIngrand  I  et al. REPERES Research Network, Satisfaction with care among patients with non-metastatic breast cancer: development and first steps of validation of the REPERES-60 questionnaire. BMC Cancer 2007;7129
PubMed Link to Article
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