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Quantifying patient preferences for symptomatic breast clinic referral: a decision analysis study
  1. Aisling Quinlan1,
  2. Kirsty K O’Brien1,
  3. Rose Galvin1,2,
  4. Colin Hardy1,
  5. Ronan McDonnell1,
  6. Doireann Joyce3,
  7. Ronald D McDowell1,
  8. Emma Aherne1,
  9. Claire Keogh1,4,
  10. Katriona O’Sullivan1,
  11. Tom Fahey1
  1. 1 HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
  2. 2 Department of Clinical Therapies, University of Limerick, Limerick, Ireland
  3. 3 Department of Surgery, National University of Ireland Galway, Galway, Ireland
  4. 4 School of Computer Science and Statistics, Trinity College Dublin, Dublin, Ireland
  1. Correspondence to Professor Tom Fahey; tomfahey{at}


Objectives Decision analysis study that incorporates patient preferences and probability estimates to investigate the impact of women’s preferences for referral or an alternative strategy of watchful waiting if faced with symptoms that could be due to breast cancer.

Setting Community-based study.

Participants Asymptomatic women aged 30–60 years.

Interventions Participants were presented with 11 health scenarios that represent the possible consequences of symptomatic breast problems. Participants were asked the risk of death that they were willing to take in order to avoid the health scenario using the standard gamble utility method. This process was repeated for all 11 health scenarios. Formal decision analysis for the preferred individual decision was then estimated for each participant.

Primary outcome measure The preferred diagnostic strategy was either watchful waiting or referral to a breast clinic. Sensitivity analysis was used to examine how each varied according to changes in the probabilities of the health scenarios.

Results A total of 35 participants completed the interviews, with a median age 41 years (IQR 35–47 years). The majority of the study sample was employed (n=32, 91.4%), with a third-level (university) education (n=32, 91.4%) and with knowledge of someone with breast cancer (n=30, 85.7%). When individual preferences were accounted for, 25 (71.4%) patients preferred watchful waiting to referral for triple assessment as their preferred initial diagnostic strategy. Sensitivity analysis shows that referral for triple assessment becomes the dominant strategy at the upper probability estimate (18%) of breast cancer in the community.

Conclusions Watchful waiting is an acceptable strategy for most women who present to their general practitioner (GP) with breast symptoms. These findings suggest that current referral guidelines should take more explicit account of women’s preferences in relation to their GPs initial management strategy.

  • epidemiology
  • oncology
  • quality in health care

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  • Contributors All authors (AQ, KKOB, RG, CH, RMcD, DJ, RDMcD, EA, CK, KO’S and TF) were involved in the study conception and design. AQ, RG and KKOB acquired data for analysis. RMcD designed the computer-based utility analysis programme. CH and RDMcD performed statistical analysis. AQ interpreted the data and drafted the paper. KKOB, RG, RDMcD and TF critically revised the draft manuscript. All authors read and approved the final manuscript.

  • Funding Health Research Board of Ireland grant number HRC-2007-1.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval Royal College of Surgeons in Ireland Institutional Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Extra data can be accessed via the Dryad data repository at DOI: doi:10.5061/dryad.k15f3t5.

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