Retrospective analysis of communication with patients undergoing radiological breast biopsy
This study explored the perceptions of women after receiving breast biopsy results over the phone in order to determine patient preferences about the timing, setting, and provider they preferred when receiving biopsy results. Participants were recruited at a large university cancer center and surveyed by phone approximately 2 weeks after they received biopsy results. A 24-item survey was developed concerning how the biopsy results were communicated, the communication skills of the person reporting the diagnosis, and ways to improve the communication of results. The survey also asked about the relative importance of hearing the results quickly, from the most knowledgeable provider, from a primary care physician, or in person. We surveyed 59 patients (25 cancer, 34 benign). Patients from both groups were satisfied with the communication skills of the person who gave the results. However, patients with cancer and patients undergoing their first breast biopsy were more likely to need additional materials to understand their results (P = 0.018, P = 0.036, respectively). Both cancer and benign groups ranked hearing the results quickly as the most important aspect of communication and hearing the results in person as least important. This study suggests that patients value hearing cancer diagnoses quickly more than in person. Patients having their first biopsy or with a diagnosis of cancer would prefer to have additional materials to help them understand their diagnosis.
Correspondence to: Robert M. Arnold, MD, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, Montefiore University Hospital, 3459 Fifth Avenue Suite 932 West, Pittsburgh, PA 15213; telephone: (412) 692-4810; Fax: (412) 692-4892
Following a diagnostic or screening mammogram, patients with breast lesions are often referred for a biopsy.1 Time between the procedure and the notification of results is anxiety-provoking as women wait to find out if the lesion is malignant or benign.2
The preferences of women in this scenario regarding the method of communication and the provider who gives results are unknown. Providers try to balance different priorities: getting the information to the woman quickly,[3], [4] and [5] providing as much information as possible,[3], [4], [5], [6] and [7] having the person who talks to the woman be someone they know and trust,8 and giving the information in person rather than on the phone.3 One may not be able to maximize all of the competing variables. If the sole priority is speed, then one would develop a system where the radiologist or nurse calls as soon as the biopsy result comes back; if complete information is most important, having someone from an oncologist's office call about positive results may be best. The problem is that there is a lack of published data on women's preferences, leading different programs to be based on assumptions rather than evidence.
,Complicating this problem is that women likely have different preferences when the results are benign versus when they are malignant. To our knowledge, the communication preferences of these two groups of patients have never been compared. With evidence-based data about what women prefer, programs can develop more patient-centered programs to communicate biopsy results.
The goal of this study was to ascertain how women who have had a breast biopsy prefer to receive their test results. We also wanted to determine their satisfaction with the way they did receive their biopsy results at our cancer center and whether satisfaction differed based on patient age, race, or biopsy results. It is hoped that these data will help other programs develop communication policies.
Materials and Methods
Study Setting and Patient Recruitment
This study was based on a telephone survey of all radiologic breast biopsy patients seen at a large urban academic breast center between June 1, 2008, and July 31, 2008. The study was approved by the University of Pittsburgh Institutional Review Board. Study participants were adult females receiving a minimally invasive radiologic breast biopsy who spoke English and had a working phone. All patients fitting the inclusion criteria were approached before their procedure and given the option to participate in the study.
The center performed over 3,500 breast biopsies in 2009. At the center, two nurses gave results to an average of 30 patients a day. In addition to making calls, the nurses are responsible for admitting and discharging patients and work on rotation in order to call patients they have personally met. They make notes in patients' charts about their demeanor and concerns to help them tailor the phone calls to the patients' personalities. When patients leave after the biopsy, the nurses discuss the results call and ask the patients if they would prefer the nurse to call them or if they would like to call the nurse on their own time. No option is available for an in-person results visit except by the physician ordering the biopsy.
Study participants received biopsy results within 4 business days. Information about positive and negative results is communicated in different ways. While all results are faxed to the referring physician, positive results have a cover sheet indicating the urgency of the information. If results are positive or require further surgical biopsy, the nurses call in a room with a closed door and a “do not disturb” sign, to minimize interruptions. Nurses provide information using a standardized script that describes the result and their implications. Patients with a malignant biopsy are given a phone number to make a breast magnetic resonance imaging appointment. They are also told that they need to make a surgical appointment, but the choice of surgeon is left up to the patient and the referring physician. Patients are given time to ask questions and the direct phone number if they wish to speak to the nurse again.
Phone Survey Procedure
Two weeks were allotted between receipt of results and the study interview to allow time for patients to understand their diagnosis and seek follow-up care as necessary. After the 2-week waiting period, a study staff member contacted patients by telephone. Calls were conducted in the order in which patients received their results, and four attempts were made to call each participant, with a message left each time.
Study Survey
The phone survey consisted of four sections: an informational section, which collected data about how the patient received the results; a communication skills section, which assessed patient impressions of the person giving results; an improvement section, which assessed patient views about how to improve the communication of results; and finally, a communication priorities section, which assessed the relative importance of four distinct aspects of communication (Table 1). In addition, patients were asked “What did you like best about how you were told your results?” and “What can we do to make the process of giving results better?” The communication skills and improvement sections were scored on a five-point Likert scale, and the communication priorities section was scored on a rank scale from most to least important. (The survey is available on request.) Demographic information as well as the number of previous biopsies the woman had were also collected.
