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Making Choice an Option

to the ambiguities of medicine. When it comes to "elective" surgery there often is no "right" answer. Is radiation, surgery, or watchful waiting better for a given stage of prostate cancer? Can back pain be managed with medication or improved with exercise, or is spine surgery indicated? Is hip or knee pain so intractable that a joint replacement is called for? What about bypass surgery versus drug therapy to treat ischemic heart disease? The benefits of each option must be weighed against its risks—and then the options weighed against each other. What is right for one patient won't be right for another.

It is crucial for patients to realize that virtually any medical intervention carries the possibility of complications and side effects. "When it comes to risk, I know that many of my patients are thinking, 'I trust my doctor. He is so good that nothing bad will happen to me,' says Dartmouth's Dr. James Weinstein, an orthopaedic surgeon and the director of the Center for Shared Decision Making.

"I want to say, 'Wait. Stop. This is important. You could die. You could get an infection.' We're not trying to scare people, but . . ."

Dartmouth's Dr. John Wennberg, cofounder of the Foundation for Informed Medical Decision Making, agrees. "What the patient needs to realize is that deciding to have elective surgery is a wager," Wennberg explains, "and different patients will be comfortable with different risks."

Of course some decisions are slam dunks. If a woman is diagnosed with early-stage breast cancer, virtually everyone agrees: she needs surgery. But doctors honestly don't know what's the best treatment for early-stage prostate cancer because longterm studies comparing how similar men fare when they choose different options just haven't been done—in large part because the disease progresses so slowly. But the medical evidence on stage 1 or stage 2

Some patients also meet with program coordinator Susan Berg.

Dartmouth's John Wennberg
agrees. "What the patient needs
to realize is that deciding to have
elective surgery is a wager,"
he explains, "and different
patients will be comfortable
with different risks."

breast cancer is in. Normally, surgery is the only option.

But the breast-cancer patient does have to decide if she wants to have a mastectomy—removal of the entire breast—or a lumpectomy—removal of just the tumor and a margin of surrounding tissue. The patient has a choice because research has shown that her chance of surviving breast cancer is about the same, whether she chooses the aggressive mastectomy or the breast-sparing lumpectomy.

But when it comes to risks and benefits, there are tradeoffs. Following a lumpectomy, she will almost certainly

need radiation therapy; after a mastectomy, she is much less likely to need radiation. But if she chooses lumpectomy, there is a greater chance the cancer will recur locally, requiring further treatment (but not affecting survival).

"Here you can divide women into two groups," says Wennberg, "those who are most concerned about preserving the breast and those most concerned about preventing local recurrence of the disease. The second group is likely to prefer the more aggressivemastectomy—these are patients who just want to get it over with."

For women who choose mastectomy, there's yet another decision to be made—whether to wear a breast prosthesis after the operation or to have breast reconstruction surgery. Those who choose the latter option then need to decide whether to have the reconstruction done at the same time as the mastectomy or later. And there are, of course, different risks and benefits associated with each of those choices.

In the past, women traditionally followed their doctors' preferences. Some physicians recommended lumpectomy; others felt strongly that mastectomy was the safest course—even though there was no solid medical evidence to back up their belief. Over time, the predilections of physicians in each community created a medical culture that favored one treatment over another.

In the early 1990s, Dartmouth researchers investigating geographic variations in patient care discovered that the rate of mastectomies fluctuated widely from one part of the country to another, and even one part of a state to another. For example, Medicare records for patients near Elyria, Ohio, revealed that 48% of breast-cancer patients had lumpectomies. But 30 miles away, in Cleveland, only 23% wound up with the less invasive procedure. Meanwhile, a mere 1% of women in Rapid City, S.D., had

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