Improving the effect of primary care physicians on uptake of chemoprevention in women at high risk of breast cancer
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Chemoprevention with tamoxifen has been shown to reduce the incidence of invasive breast cancers by up to 49%. Raloxifene is as effective at preventing invasive breast carcinoma. Despite being approved for use in breast cancer prevention by the Federal Drug Administration in 1998, tamoxifen is infrequently used by eligible women. Approximately 10 million women have breast cancer risk and are appropriate candidates for tamoxifen prophylaxis, but best estimates state that only approximately 120,000 choose to use tamoxifen or raloxifene. Factors such as education, previous history of abnormal biopsy, and worry about breast cancer have been shown to influence a patient's decision to use chemoprevention. A number of psychological and health related factors have been associated with low uptake of tamoxifen and raloxifene. Concern about serious side effects- including endometrial cancer, pulmonary embolism, stroke, deep vein thrombosis, cataracts, hormonal symptoms and sexual problems are cited often as a deterrent. While these side effects are rare, women's perceptions have a strong influence on their decisions about chemoprevention. Similarly, a woman's perceived risk of breast cancer, the efficacy of chemoprevention and communication with clinicians as well as family and friends play a large role in her decision to use tamoxifen or raloxifene prophylaxis. The recommendation of physicians has also been shown to play a major role in women's decision making processes about their health, including the decision to use chemoprevention. It is recommended that women make decisions about the use of chemoprevention based on personal values. In order to do this, a woman should understand the risk of health occurrences with and without chemoprevention. However, communication of risk to the lay population is challenging and most women do not accurately understand their risk of breast cancer or the risk of side effects. Another challenge of effective shared decision making is increasing physician awareness of a patient's knowledge, values and decision making framework. The purpose of this study is to identify areas of shared decision making about the use of chemoprevention to prevent breast cancer that should be targeted in order to improve patient satisfaction and appropriate acceptance of chemoprevention.
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