People often ask me in my practice why I use online decision aids. The HealthDecision program has been part of my practice for years. Initially, I used the tool looking at lipids and cardiovascular risk to help guide a discussion with my patients about whether or not to start a statin. More often than not, we saw that quitting smoking actually had a bigger impact on their 10-year risk of having a heart attack than did statin use.
The tool for breast cancer screening is a wonderful way to talk to women about their own risk of breast cancer and what goes into that risk. By visually representing the harms and benefits of a screening mammography, it also provides a venue to talk about what could happen. With bright colors and clear demonstrations of possible outcomes, women are able to conceptualize the possible harms of a screening mammogram. The USPSTF placed a “C” recommendation for women under age 50 to get screening mammography. The guideline further specified that the decision to get a screening mammogram for young women should be based on a woman’s values about screening and her personal risk factors. HealthDecision allows me to pursue this decision jointly with my patient while at the same time exploring her values.
For example, the decision aid clearly shows that if 1,000 women between 40 and 49 get annual mammograms, over half of them will get called back at least once for extra views. Now, for many clinicians or health professionals, getting called back may not be a big deal. “So what,” we may say, “so you have to get more views or an ultrasound. The majority of the time, it will end up being normal. No harm, no foul.” For many women, the process of getting called back, having extra views, and perhaps a biopsy, can be very anxiety provoking—even if the outcome is benign. Studies show that for a subset of women, the process of getting called back causes them anxiety up to 18 months later.
Looking at individual risk as compared to other women of the same age can also help women decide on a breast cancer screening plan going forward. Most of the risk factors for breast cancer are fixed (i.e. family history, previous biopsy, or breast density) and lifestyle changes cannot alter risk. But looking at personal risk compared to the average woman of the same age can provide a context for screening decisions. For example, if someone has category A breast density (mostly fatty), her risk of breast cancer is significantly lower than the average woman her age. So, she may decide not to get future screening while still in her 40s. She may wait until 50 to resume screening. On the flip side, a woman with breast density D (the highest density category) may see her increased risk and decide to get annual mammograms between 40-49. Without this added information, women are making decisions about breast cancer screening in a less well-educated manner.
Shared decision making is an important part of my practice. I firmly believe that all patients should be able to make decisions with my guidance using the most up-to-date, evidence-based information available. HealthDecision’s tools enable me to incorporate an individual’s values into the decision making process along with the clinical evidence in order to practice patient-centered care.