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Health professional and consumer views on involving breast cancer patients in the multidisciplinary discussion of their disease and treatment plan
Article first published online: 6 SEP 2007
Copyright © 2007 American Cancer Society
Volume 110, Issue 9, pages 1937–1944, 1 November 2007
How to Cite
Butow, P., Harrison, J. D., Choy, E. T., Young, J. M., Spillane, A. and Evans, A. (2007), Health professional and consumer views on involving breast cancer patients in the multidisciplinary discussion of their disease and treatment plan. Cancer, 110: 1937–1944. doi: 10.1002/cncr.23007
- Issue published online: 18 OCT 2007
- Article first published online: 6 SEP 2007
- Manuscript Accepted: 17 JUL 2007
- Manuscript Revised: 30 MAY 2007
- Manuscript Received: 15 MAR 2007
- consumer participation;
- patient care team;
- patient-centered care;
- patient care management;
- multidisciplinary communication;
- breast neoplasms;
- multidisciplinary care
The aim was to obtain the views of health professionals and patients about the concept of involving breast cancer patients in the multidisciplinary (MD) treatment planning meeting.
Breast cancer surgeons, nurses, oncologists, and patient advocates completed a mailed questionnaire.
The majority of breast cancer health professionals and patient advocates support shared decision-making (58%–62%). However, less than a third of surgeons (32%), medical (25%), and radiation oncologists (24%) were supportive of involving women in the MD treatment planning meeting. In contrast, 93% of breast cancer advocates and 73% of breast cancer nurses were supportive of this approach. Patient advocates were significantly more in favor than all other groups (χ2 = 148.8, df = 4, P < .001). The common reasons for supporting patient involvement included that it would lead to patients being more informed and empowered, provide them with an opportunity to ask questions, facilitate decision-making, and improve communication between the patient and the medical team. Health professionals stated that attendance would make patients anxious and that they would have to modify their medical language. Suggestions about how to manage patient involvement included the patient being supported by a breast nurse and pre-education before the meeting. Patient advocates were significantly more willing to participate in a randomized controlled trial of this process compared with all other groups. (χ2 = 155.15, df = 4, P < .001).
Despite health professional's reservations, patient advocates were highly supportive of including women in the MD meeting. Such a high demand justifies consideration of this option. Cancer 2007. © 2007 American Cancer Society.
A multidisciplinary approach to the management of breast cancer is considered best practice in Australia and overseas.1–3 Multidisciplinary care (MDC) is defined as a collaborative approach to treatment planning, incorporating both clinical and supportive care input and considering all potential treatment options suitable for the individual patient.4 Internationally, attendance at multidisciplinary treatment planning meetings by core clinical and supportive care disciplines is promoted as the standard of care.5 A multidisciplinary approach is thought to foster patient-centered care and adherence to clinical practice guidelines and to improve psychosocial support and access to clinical trials.6 Other proposed benefits of MDC include consistent delivery of information to the patient, a streamlined approach to delivery of care and lack of duplication, and improved patient understanding of their disease and treatment plan, which may lead to better treatment compliance.7
Despite its widespread acceptance as best practice, a recent review of the evidence regarding the benefits of MDC4 reported that no randomized controlled trials (RCTs) of MDC have been conducted in breast cancer, few studies have formally evaluated MDC in relation to clinical outcomes, and no studies have assessed its impact on survival.4, 6 However, it is hard to imagine MDC being subjected to an RCT at this stage given its widespread endorsement by clinicians, regulatory, and representative bodies.
The optimal model of MDC is far from clear. In breast cancer care, for example, the multidisciplinary approach ranges from a “one-stop shop” that enables women with newly diagnosed breast cancer to see appropriate specialists from various disciplines at that clinic on the same day, to treatment planning meetings involving relevant specialists.8–11 In Australia the core team membership for breast cancer treatment planning meetings comprises surgery, medical and radiation oncology, radiology, pathology, and supportive care,7 although the degree to which all specialties regularly attend meetings is unknown. Rarely is the woman herself invited to attend the multidisciplinary treatment planning meeting. Thus, there is a spectrum of “multidisciplinary” approaches that vary in their position along the dimension of disease-focused versus patient-oriented breast cancer management, influenced by delivery settings and workforce issues.
The National Breast Cancer Centre has developed a set of 5 Principles of Multidisciplinary Care providing a flexible approach to the implementation of MDC for patients with cancer.12, 13 The principles emphasize the importance of a team approach, good communication, access to the full range of therapies, maintenance of standards of care, and involvement of the patient in decision-making. Some have argued that for this last principle to be successful the patient should be invited to attend the treatment planning meeting.14
After repeated requests from women wishing to attend the treatment planning meeting at our center, a pilot study of this approach was conducted.14 The presence of the patient at the meeting was found to be acceptable to health professionals and valued by most breast cancer patients, without unduly raising patient anxiety. Most health professionals found the intervention to be interesting and worthwhile, whereas some reported that the exercise had caused them to be more alert and attentive during the multidisciplinary discussion. However, some team members found the intervention to be awkward and disruptive, time-consuming, and to have inhibited discussion and only half agreed that the presence of the patient in the treatment planning meeting had a positive impact overall. It is not clear from this small pilot whether such views are widespread.
Given that involving a patient in their multidisciplinary treatment planning meeting would fundamentally change how MDC is currently provided and potentially have a significant impact on how patients and their physicians interact and make treatment decisions, it was felt that it was important that views of this type of service delivery were solicited on a broader basis. The literature on system change clearly states that unless a new initiative is perceived by those who will be implementing it as having relevance and fit with organizational and practice issues, it will not succeed.15 Therefore, if such an approach is to be promoted as supporting principles of patient-centered care, it is essential to determine its acceptability in the medical and patient communities.
The aim of this study was to obtain the views of health professionals and patients about the concept of involving breast cancer patients in the multidisciplinary treatment planning meeting.
MATERIALS AND METHODS
A cross-sectional survey design was used.
Practicing health professionals were identified through their respective specialty groups, the Section of Breast Surgery at the Royal Australasian College of Surgeons, Trans-Tasman Radiation Oncology Group, Medical Oncology Group of Australia, and the Cancer Nurses Society of Australia. Patient advocates were identified through the Breast Cancer Network Australia (BCNA), a national consumer advocacy group. The decision to recruit patient advocates, rather than women recently diagnosed with breast cancer, was made because advocates would be able to give a considered opinion based on their own experience and the experience of their very large constituency. (In Australia, BCNA has a membership of over 20,000 and 175 member groups.) Non-English–speaking was the only exclusion criterion.
Development of the survey instruments was informed by the literature and the previous pilot study14 and included input from a small panel of experts and consumers. The health professional and patient advocacy surveys differed in several respects. The health professional survey elicited demographic and practice details (age, sex, specialty, year qualified, work setting, size of practice community, number of breast cancer patients seen monthly, hours worked weekly) and explored whether patients attend MDC meetings if held. The patient advocacy survey elicited demographic data (age, sex, education level, occupation, health training, and marital status), disease variables (time since diagnosis, stage of breast cancer, treatment received, treatment setting, and current breast cancer status), and explored whether they had attended a treatment planning meeting, or if not, whether they would have been interested to attend one.
In both health professional and patient advocacy surveys, views on how much involvement women with breast cancer should have in making breast cancer treatment decisions was ascertained using a modified form of the Cassileth Information Styles questionnaire16 and the current practice of involving women in the MDC meeting determined.
All participant's level of support for patient involvement in the multidisciplinary treatment planning meeting was elicited, participants were asked whether they agreed (“yes,” “no”) with the statement “Involving newly diagnosed early stage breast cancer patients in the multidisciplinary meeting for their own case discussion would benefit them.” Respondents were asked to give reasons for their answer in their own words. Health professionals' and patient advocates were then asked to respond to the same question with the provision that “sufficient resources were available.”
Participants were also asked what type of breast cancer patient would benefit from attending the meeting (“all,” “none,” “those who want involvement in decision-making,” or “those who do not want involvement in decision-making”). A series of statements about factors that might either optimize and facilitate or act as barriers to involving the women in the meeting were presented. Participants were asked to consider these and state their level of agreement (“agree completely,” “agree,” “neutral,” “disagree,” “disagree completely”). Finally, the survey participants were asked if they would participate in a randomized controlled trial of this initiative if invited (“yes,” “no”).
Permission to obtain contact details of all group members was sought from each representative body. If this was granted the research team mailed potential participants a package that included a letter inviting their participation, an information sheet, a copy of the survey, and a postage-paid envelope. If contact details were not provided the packages were distributed by the representative body. Written endorsement of the survey was obtained from representative bodies, the National Breast Cancer Centre, and the Breast Cancer Network Australia. Nonreturnees were mailed a reminder letter with a replacement questionnaire at 4 and 8 weeks. Institutional ethics approval was obtained for the study to proceed.
A member of the study team (J.H.) who was unaware of participants' group status (patient advocate, surgeon, medical or radiation oncologist, and breast cancer nurse) independently performed statistical analysis. Descriptive statistics were used to describe the sample and their views. Where participants were asked to give qualitative responses, these were condensed into themes. t-tests and chi-square tests explored univariate associations between demographic, disease, and practice variables and views about involvement of women in the treatment planning meeting. Independent predictors of support for involvement and participation in an RCT of this model were assessed using logistic regression modeling. Potential predictors included in the model were those exhibiting P ≤ .25 in univariate analysis17 and these were then successively removed using a backwards, stepwise approach until all remaining predictors were significant (P < .05). Analysis was carried out using SPSS (Chicago, Ill) and SAS (Cary, NC).
Questionnaires were mailed to 155 patient advocates, 254 surgeons, 67 breast nurses, 47 radiation oncologists, and 117 medical oncologists. Subsequently, 62 surgeons, 5 radiation oncologists, and 1 breast nurse were discovered to be no longer in practice and were excluded from the study. Of the remainder, the questionnaire was returned by 135 patient advocates (87%), 142 surgeons (74%), 56 breast nurses (85%), 31 radiation oncologists (74%), and 65 medical oncologists (56%). It was not possible to obtain data on nonrespondents to allow comparison and estimation of potential bias.
Characteristics of the health professional and patient advocate samples are shown in Tables 1 and 2. The majority of medical specialists were male, whereas all breast nurses and patient advocates were female. Most health professionals had been qualified for more than 5 years and worked in a combination of public and private practice settings. Over 50% of surgeons and breast nurses practiced within a capital or major metropolitan center; this rose to over 85% for medical radiation oncologists. The majority of patient advocates were tertiary educated and 33% had had some form of health training. Only 1 woman reported having advanced cancer at diagnosis, but 36 (27%) had had a recurrence. Additional information collected from patient advocates found that 94 (70%) had been diagnosed with breast cancer within the last 10 years, with 132 (98%) having undergone surgery, 78 (58%) radiotherapy, 75 (56%) chemotherapy, and 56 (42%) hormonal treatment.
|Surgeon N = 142||Breast nurses N = 56||Radiation oncologists N = 31||Medical oncologists N = 65|
|Male||129 (91)||0||22 (71)||43 (66)|
|Female||12 (9)||55 (98)||9 (29)||19 (29)|
|<5 y||0||20 (36)||1 (3)||2 (3)|
|5–10 y||21 (15)||17 (30)||2 (7)||19 (29)|
|10–20 y||46 (32)||11 (20)||20 (65)||24 (37)|
|>20 y||71 (50)||3 (5)||7 (23)||17 (26)|
|Public hospital||125 (88)||43 (77)||23 (74)||40 (62)|
|Private practice||107 (75)||12 (21)||19 (61)||36 (55)|
|Cancer center||10 (7)||12 (21)||16 (52)||18 (28)|
|University clinic||8 (6)||2 (4)||6 (19)||5 (8)|
|Other||2 (1)||14 (25)||2 (7)||0|
|Major city/metropolitan||76 (54)||30 (54)||29 (94)||55 (85)|
|Regional||46 (32)||13 (23)||1 (3)||5 (8)|
|Rural||17 (12)||13 (13)||0||2 (3)|
|Cases per annum|
|0||1 (1)||1 (2)||1 (3)||1 (2)|
|1–5||12 (9)||4 (7)||1 (3)||4 (6)|
|6–20||39 (28)||10 (18)||3 (10)||10 (15)|
|21–50||25 (18)||6 (11)||3 (10)||19 (29)|
|51–150||51 (36)||20 (36)||19 (61)||21 (32)|
|>150||13 (9)||14 (25)||4 (13)||4 (6)|
|Patient base breast cancer|
|<25%||79 (56)||11 (20)||10 (32)||20 (31)|
|26–50%||32 (23)||8 (14)||13 (42)||28 (43)|
|51–75%||14 (10)||5 (9)||2 (7)||8 (12)|
|>75%||16 (11)||30 (54)||6 (20)||5 (8)|
|Time devoted to breast cancer patients|
|≤20 hrs a week||89 (63)||22 (40)||21 (68)||37 (57)|
|>20 hrs a week||52 (37)||33 (59)||10 (32)||24 (37)|
|Prior school certificate||5 (4)|
|School certificate||14 (10)|
|Tertiary (non-university)||36 (27)|
|Occupation /past occupation|
|De facto||7 (5)|
Views on Decision-Making
Most participants (58%–62%) supported shared decision-making (Table 3). A minority supported modified paternalism (the physician making the decision after considering the patient's views), with slightly more surgeons (n = 16, 11%) supporting this view than other health professionals (1%–4%). However, no health professional and only 1 patient advocate supported full paternalism (the physician making the decision without reference to patient views). Most health professionals (85%) reported eliciting patient preference for involvement in decision-making in over 50% of their patients
|Patient advocates N = 135||Surgeons N = 142||Nurses N = 56||Radiation N = 31||Medical N = 65|
|Cancer specialist should make the decision||1 (1)||0||0||0||0|
|Cancer specialist decides after considering patients views||7 (5)||16 (11)||1 (2)||0||4 (6)|
|Cancer specialist and patient decide together||83 (62)||94 (66)||37 (66)||18 (58)||39 (60)|
|Patient decides after considering cancer specialists opinion||26 (20)||19 (13)||10 (18)||8 (26)||16 (25)|
|Patient decides after learning all she knows or has learnt about treatment||18 (13)||10 (7)||7 (13)||3 (10)||5 (8)|
Current Practice Regarding Patient Involvement in MDC Meetings
Only 12 health professionals (4%) reported that their work setting allowed women with breast cancer to attend the MDC meeting. No advocates reported being invited to attend such meetings, with only 47 (35%) reporting knowing whether a meeting had been held in which their case was discussed.
Views on Patient Involvement in MDC Meetings
There was a significant difference between groups inthe proportion agreeing with the statement “Involving newly diagnosed breast cancer patients in the multidisciplinary meeting for their own case discussion would benefit them” (χ2 = 148.8, df = 4, P≤ .001). Ninety-three percent of patient advocates agreed with the statement. Of the health professionals, more nurses agreed with the statement compared with other specialties (73% of nurses compared with 32% of surgeons and 25% of medical and 24% of radiation oncologists). The majority of participants felt women who did not want involvement in decision-making should not be offered participation in the MDC meeting, but 43 (34%) of advocates, 10 (24%) of breast nurses, and 12% to 14% of other health professionals felt that all women should be offered this option, regardless of their initial involvement preference.
The most common reasons participants gave for supporting patient involvement in the MDC meeting were that it would lead to patients being more informed and empowered, provide them with an opportunity to ask questions, facilitate their involvement in decision-making, and improve communication between the medical team and the patient. However, many of those who supported the idea, when asked to give reasons for their response, tempered their support with statements such as “only if the patient wants it,” “only if the patient is adequately supported,” “but with concerns about the process making the patient feeling confused or intimidated,” and “only if it doesn't slow down the meeting.” These comments were in addition to the list of barriers that participants were asked to consider (Table 4), in which physicians commonly reported concern that attendance at the MDC meeting would be overwhelming and anxiety-provoking for patients, but also that it would inhibit their discussion, force them to change their language, and take up too much time. Patient advocates and breast nurses also identified the personality of some clinicians and the nature of team dynamics within the meeting as potential barriers to implementing this strategy. Furthermore, when asked if they would support this approach “provided sufficient resources were available,” the proportion of respondents who would support it did not increase.
|Patient advocates N = 135||Surgeons N = 142||Nurses N = 56||Radiation N = 31||Medical N = 65|
|Attending would make the patient too anxious||35 (26)||88 (62)||28 (50)||20 (65)||45 (69)|
|Attending would be too overwhelming for the patient||35 (26)||91 (64)||29 (52)||18 (58)||49 (75)|
|Attending would leave the patient confused||29 (21)||79 (56)||20 (36)||16 (52)||47 (72)|
|I would feel awkward during the whole discussion process||29 (21)||27 (19)||12 (21)||3 (10)||15 (23)|
|I would feel inhibited in discussing certain aspects of the patients disease and/or treatment||52 (39)||69 (49)||18 (32)||11 (35)||34 (52)|
|I would have to modify my medical language/jargon to accommodate the presence of the patient||112 (83)||87 (61)||45 (80)||16 (52)||46 (71)|
|I would find it disruptive to have patients included||36 (27)||48 (34)||8 (14)||7 (23)||30 (46)|
|There would be insufficient time||22 (16)||82 (58)||26 (46)||22 (71)||50 (77)|
|The patient would not understand the information delivered in this format||23 (17)||72 (51)||26 (46)||13 (42)||41 (63)|
|Cultural differences would make it particularly difficult||92 (68)||59 (42)||28 (50)||18 (58)||22 (34)|
|Patient information overload could result from attendance.||47 (35)||96 (68)||29 (52)||17 (55)||45 (69)|
|The patient would develop misconceptions about the disease and/or the treatment plan||13 (10)||49 (35)||15 (27)||10 (32)||22 (34)|
Suggestions about how to manage patient involvement in a meeting found that most participants supported premeeting education in the form of a plain English summary of the purpose of the MDC meeting for the patient; the patient being supported by a breast nurse, and/or family or friend during the meeting and by staff immediately after the meeting; the patient being an active participant during the meeting; and staff limiting use of jargon during the meeting. However, of those who supported involving patients in the treatment planning meeting, 4 oncologists (25%), 5 surgeons (11%), and 9 patient advocates (7%) thought the patient should not be allowed to speak during the meeting. Most respondents agreed that patients wanting to participate in decision-making and in the meeting would assist the process. The majority thought emotional readiness to hear the discussion and patient trust of their treatment team were also important, although the latter was emphasized more by advocates (74%) and breast nurses (76%) and less by surgeons (49%), radiation (29%), and medical oncologists (38%). Breast nurses also thought it very important that the woman knew her diagnosis before the meeting.
Predictors of Support for Patient Attendance at the MDC Meeting
Patient advocates who were health trained (medical, nursing, or allied health) were significantly less likely to support this approach (Table 5). After adjusting for health training, patient advocates who were diagnosed originally with localized breast cancer were more than 6 times more likely to support this approach compared with those who were originally diagnosed with regional or advanced disease. Finally, after adjusting for health training and stage of disease at primary diagnosis, patient advocates who currently had active disease were significantly more likely (adjusted odds ratio [AOR] 9.78, 95% CI, 1.99–48.16) to support this approach compared with women who were currently disease-free.
|Univariate association, n/N (%)||Multivariate analysis AOR* (95% CI)|
|Yes||38/44 (86)||0.20 (0.04-0.92)|
|Stage of disease at primary diagnosis|
|Localized||80/83 (96)||6.51 (1.33-31.87)|
|Regionalized or advanced||42/49 (86)||1.00|
|Current status of disease|
|Active disease||112/118 (95)||9.78 (1.99-48.16)|
|Disease free||9/13 (69)||1.00|
|Surgeons||43/136 (32)||0.15 (0.07-0.31)|
|Medical oncologists||7/28 (25)||0.15 (0.05-0.45)|
|Radiation oncologists||15/62 (24)||0.14 (0.06-0.32)|
|Major city||58/182 (32)||0.54 (0.30-0.98)|
|Regional or rural||47/93 (51)||1.00|
Compared with breast nurses, all other health professionals were less likely to agree with the concept of involving women in the multidisciplinary meetings. After adjusting for clinical role, clinicians who were based in major capital cities were significantly less likely (AOR 0.54, 95% CI, 0.30–0.98) to be supportive of this initiative compared with clinicians based in regional or rural centers.
Participation in a Randomized Trial
Significantly more patient advocates indicated that they would participate in an RCT of this process than the health professional groups (χ2 = 155.15, df = 4, P ≤ .001; 93% of patient advocates; 28% of medical oncologists; 27% of surgeons; 23% of radiation oncologists; and 21% of nurses). Clinicians working in a public hospital setting were more likely to say they would participate in an RCT of the process than those in other settings (AOR = 2.03; 95% CI, 0.99–4.17). After adjusting for public hospital setting, clinicians who agreed with the concept of involving women in the meeting were significantly more likely to indicate that they would participate in a trial (AOR 4.40, 95% CI, 2.44–7.93).
This survey demonstrates support by the majority of breast cancer health professionals and patient advocates for shared decision-making. However, achieving this goal through attendance of the patient at the multidisciplinary treatment planning meeting currently rarely occurs in Australia and less than a third of surgeons and oncologists surveyed were supportive of this approach. In contrast, the majority (93%) of breast cancer advocates and breast nurses (73%) supported attendance by patients at treatment planning meetings, suggesting some discordance between patient and medical views. There was further disparity between patient advocates and health professionals in their willingness to participate in an RCT of this intervention, with 93% of patient advocates but just 22% of health professionals expressing interest in participating in such a trial.
What does this discordance mean, and how should it be resolved? Is the medical profession out of step with community thinking, or do they have a more expert, or “wiser” view of this issue? Are physicians' time and ease within their own professional meetings more important than patients feeling empowered by observing the basis for professional recommendations for their care? If some patients would feel overwhelmed and anxious after participating in such an approach, should it be denied to all? To some extent these are ethical and philosophical issues, but they could also be informed by evidence. An RCT of this approach with careful documentation of the characteristics of patients who refuse and agree to be randomized, differences between MDC meetings with and without patient attendees, and patient outcomes could provide extremely useful data on which to make evidence-based decisions regarding the utility of this approach.
Limitations of this study is that the patients surveyed were members of a patient advocacy organization and are not necessarily representative of the “average woman” in the breast cancer patient population. Our pilot study14 identified that women with higher information needs or a higher education level were more likely to wish to attend the treatment planning meeting. This is the group most likely to go on to be patient advocates. Nevertheless, two-thirds of eligible patients involved in the pilot study wanted the opportunity to attend the MDC meeting. Such a high level of demand justifies consideration of this option.
Shared decision-making is espoused in several documents within Australia1, 18, 19 and internationally2, 3, 20, 21; for example, a Patient Charter19 states that “You should be fully involved in decisions about your care and be given the opportunity to ask questions and discuss treatments so you understand what is happening.” However, resources clearly linked to MDC meetings have only just become available22 and there is no funding available for interventions targeting shared decision-making. A high value placed on the promotion of patient understanding and shared decision-making by health services, and their willingness to adequately resource interventions to achieve these outcomes, would both be critical to implementation.
Although the majority of patient advocates surveyed were supportive of patients attending the treatment planning meeting, those who were initially diagnosed with locally advanced or advanced disease were less supportive of the intervention. This suggests that patients perceive that bad news may be harder to hear in this context than relatively good news. Furthermore, only one-third of patient advocates and 12% to 14% of medical professionals felt that women who preferred their physician to make treatment decisions should be offered involvement in the meeting. However, in our pilot study14 stage of disease and involvement preference were not associated with the decision to attend, suggesting that these variables should not influence the decision about whether to offer meeting attendance to the woman. Nevertheless, care to “do no harm” and allow choice should clearly be a priority in this intervention as in others.
Survey participants had many suggestions about how to optimize this model of the multidisciplinary treatment planning meeting, including evaluation of a patient's motivational and emotional readiness to participate, time and effort put in to develop trust between the patient and healthcare team before the meeting, a plain English statement to inform patients of the purpose and outcome of the meeting, and adequate patient support before, during, and after the meeting. Future evaluation of this model should incorporate these suggestions.
The impact of this practice on patient outcomes, positive and negative, can only be assessed by an RCT despite health professionals' reservations and is justified considering patient advocates high level of support. Such a trial could ascertain the impact of this MDC model on both patients and breast cancer specialists.
The authors thank all patient advocates and clinicians who took part in this study and the executive committees of the clinical interest groups involved: the Section of Breast Surgery at the Royal Australasian College of Surgeons, Trans-Tasman Radiation Oncology Group, Medical Oncology Group of Australia, and the Cancer Nurses Society of Australia. We also the Breast Cancer Network Australia.
- 1National Health & Medical Research Council (NHMRC). Clinical Practice Guidelines for the Management of Early Breast Cancer. 2nd ed. Canberra, Australia: NHMRC; 2001.
- 2National Comprehensive Cancer Network (NCCN) & American Cancer Society (ACS). Breast Cancer Treatment Guidelines for Patients: Version VIII. Jenkintown, PA: NCCN & ACS; 2006.
- 5European Society of Mastology. Breast Unit Guidelines. Available at URL: http://www.eusoma.org/Engx/Breast Units/Guideline.aspx?cont=sub7 Accessed on May 21, 2007.
- 7National Breast Cancer Centre. Multidisciplinary Meetings for Cancer Care: A Guide for Health Service Providers. New South Wales Australia: National Breast Cancer Centre; 2005. Available at URL: www.nbcc.org.au
- 12National Breast Cancer Centre (NBCC). Multidisciplinary Care in Australia: A National Demonstration Project in Breast Cancer. New South Wales, Australia: NBCC; 2003. Available at URL: www.nbcc.org.au
- 17Applied Logistic Regression. New York: John Wiley & Sons; 1989., .
- 18National Health & Medical Research Council. General Guidelines for Medical Practitioners on Providing Information to Patients. Canberra, Australia: NHMRC; 2004. Available at URL: http://www.nhmrc.gov.au/publications/_files/e57.pdf
- 19State Government of Victoria. Victorian public hospital patient charter. Available at URL: http://www.health.vic. gov.au/patientcharter/patient.htm Accessed on May 21, 2007.
- 20Health Care Quality Commission. Consumer Bill of Rights and Responsibilities. Available at URL: http://www. hcqualitycommission.gov/cborr/chap4.html Accessed on May 21, 2007.
- 21American Cancer Society (ACS). Breast Cancer Facts & Figures 2005–2006. Atlanta: ACS; 2005.
- 22National Breast Cancer Centre. Information about the new MBS items for multidisciplinary cancer care. Available at URL: http://www.nbcc.org.au/bestpractice/resources/MDCC_informationaboutthen.pdf Accessed on May 21, 2007.