This week we hear about another of the studies nominated for the Best PhD Prize and conducted by Richard De Abreu Lourenco, of the Centre for Health Economics Research and Evaluation (CHERE) at UTS
Health and Self
When women receive a breast cancer diagnosis they face choices not only about their immediate treatment but also about how to manage the risk of recurrence. For a growing number of women (http://www.ncbi.nlm.nih.gov/pubmed/24685410) that involves surgery to remove a healthy breast.
A study by Richard De Abreu Lourenco, of the Centre for Health Economics Research and Evaluation (CHERE) at UTS, seeks to understand what factors influence this choice.
“My broader research looks at how we ‘value’ the experience of health care and how people engage with the health care system beyond just what it does to our health – things like convenience and control,” De Abreu Lourenco says.
“With breast cancer, sometimes a decision isn’t just about what it’s going to do to a woman’s health but about the implications for other aspects of her life – how she feels about herself, her appearance, whether she feels constantly under threat from this cancer coming back.”
De Abreu Lourenco is a health economist and Research Fellow with CHERE, a centre of excellence known for its policy-relevant research. The centre marks its 25th anniversary this year.
In the first stage of his project, and guided by two patient representatives, Kim Parish (photo) and Domini Stuart, De Abreu Lourenco met with breast cancer survivors. They shared what mattered to them in making treatment choices.
“Those focus groups were a very enlightening first step because there were aspects people hadn’t really thought about,” he says.
An important finding was the big difference between women who removed their healthy (contralateral) breast and those who didn’t after a diagnosis of cancer in the other (ipsilateral) breast, in terms of “cancer fear”.
“Women who chose not to remove their contralateral breast really couldn’t understand why the women who did remove the breast were so afraid of the cancer coming back,” De Abreu Lourenco says. “So there was a very large difference in motivating factors.”
That set the scene for the second stage of his research, which involved a survey of nearly 500 women (only 3.5 per cent of whom were breast cancer survivors).
The women were presented with a series of choices, that varied each time, and asked to decide whether, in those circumstances, they would remove their healthy breast or have routine monitoring only.
“The first big result that hits you is how many women have a very strong preference one way or the other,” De Abreu Lourenco says. Regardless of how he adjusted the parameters, nigh on 60 per cent of the women stuck with their original choice.
Just over 49 per cent always chose routine monitoring, while 8.4 per cent always chose surgery, no matter how the choices were framed.
The remainder of the women were willing to ‘trade’ depending on the scenario, sometimes selecting routine monitoring and sometimes choosing surgery.
What influenced those choices, most of the time, was the perceived risk of the cancer returning, the researcher says.
When he evened out that risk in the choice questionnaire – making it the same regardless of surgery or monitoring – other factors then emerged.
“The way they were monitored became important,” he says. “Women wanted a less invasive type of monitoring – they wanted ultrasound rather than a mammogram.”
Involvement in decision making also emerged as a key factor.
De Abreu Lourenco says his study has implications for how we inform women of their choices, especially when data suggest only a marginal improvement in long-term life expectancy from contralateral prophylactic mastectomy.
“One of the things that will hopefully come out of this is that it will help to frame education pieces,” he says. “Does CPM represent the value that people think it does? Or could that money be better spent in other ways?”
Richard is employed as a Senior Research Fellow with the Centre for Health Economics Research and Evaluation. He is currently working as the Senior Evaluator for the PBAC Team and as the Project Officer/Coordinator for the Cancer Research Economics Support Team (CREST). Richard is a very experienced health economist who has spent the last 12 years working in the field of market access and reimbursement for pharmaceuticals and medical devices in Australia. Most recently, this included seven years with Covance, a clinical research organisation, as a Director of Health Economics. This work has involved liaison with multiple stakeholders throughout the treatment development pathway including clinical trialists, clinicians, patients and patient support networks, statisticians and the reimbursement authorities. He has a keen interest in applied economic evaluations, the economics of specialty health areas, patient preference and quality of life, and priority setting. Richard’s primary interest and focus in specialty health has been in the fields of oncology/haematology, across a broad range of indications and clinical settings. Prior to joining Covance, he spent five years as a member of the health economics team at Novartis Pharmaceuticals, and prior to that four years CHERE. He commenced his career as an Economist with the Reserve Bank of Australia. He holds an MEc (Hons) from Sydney University, and a BEc (Hons) from Murdoch University.