Risk communication in a patient decision aid for radiotherapy in breast cancer: How to deal with uncertainty?

D. B. Raphael, N. S. Russell, J. M. Immink, P. G. Westhoff, M. C. Stenfert Kroese, M. R. Stam, L. M. van Maurik, H. J. G. D. van den Bongard, J. H. Maduro, M. G. A. Sattler, T. van der Weijden, L. J. Boersma*

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


Background and aim: Patient decision aids for oncological treatment options, provide information on the effect on recurrence rates and/or survival benefit, and on side-effects and/or burden of different treatment options. However, often uncertainty exists around the probability estimates for recurrence/survival and side-effects which is too relevant to be ignored. Evidence is lacking on the best way to communicate these uncertainties. The aim of this study is to develop a method to incorporate uncertainties in a patient decision aid for breast cancer patients to support their decision on radiotherapy.

Methods: Firstly, qualitative interviews were held with patients and health care professionals. Secondly, in the development phase, thinking aloud sessions were organized with four patients and 12 health care professionals, individual and group-wise.

Results: Consensus was reached on a pictograph illustrating the whole range of uncertainty for local recurrence risks, in combination with textual explanation that a more exact personalized risk would be given by their own physician. The pictograph consisted of 100 female icons in a 10 x 10 array. Icons with a stepwise gradient color indicated the uncertainty margin. The prevalence and severity of possible sideeffects were explained using verbal labels.

Conclusions: We developed a novel way of visualizing uncertainties in recurrence rates in a patient decision aid. The effect of this way of communicating risk uncertainty is currently being tested in the BRASA study (NCT03375801). (C) 2020 The Author(s). Published by Elsevier Ltd.

Original languageEnglish
Pages (from-to)105-113
Number of pages9
Issue number1
Publication statusPublished - Jun 2020


  • Radiotherapy
  • Decision aid
  • Risk communication
  • Numerical uncertainty

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