Implementation of a Web-based Decision Aid for Breast Cancer Surgery

Routine incorporation of decision aids into oncology practice has the potential to
significantly improve patients' experiences with cancer by increasing the likelihood that
they make informed treatment decisions aligned with their values. Unfortunately, only a
minority of the more than 1.6 million patients diagnosed annually with cancer ever receive
one due to limited clinic resources for administration and challenges in timely
identification of appropriate patients. Online delivery directly to patients addresses some
of these barriers but is insufficient on its own to ensure accessibility for patients at the
time they most benefit from support.19 It is critical that active, multi-faceted
implementation strategies that target barriers to the widespread use of web-based decision
aids be identified, as these tools have the potential to significantly improve the quality of
oncologic care.

Based on strong preliminary work, the investigators have developed and piloted a package of
implementation strategies that effectively overcomes barriers to delivery of a web-based
breast cancer surgery decision aid in an academic and community clinic. Although the strategy
was successful, patients were white and educated; further investigation is imperative in
settings that provide care to underserved patients to ensure the intervention will mitigate,
rather than worsen, existing disparities in breast cancer care. This is especially critical
given that underserved patients may benefit most from shared decision-making interventions
such as the one described. To study this, the investigators propose a pilot study within a
clinic that serves a catchment area with a high proportion of African American, rural and low
income patients. The investigators will iteratively assess and enhance our implementation
package using concepts outlined in the Knowledge-to-Action Cycle, which emphasizes local
context in balancing fidelity and flexibility. The specific aims are: 1) To identify patient
and clinic level barriers to implementation of a web-based breast cancer surgery decision aid
in a clinic that cares for underserved patients, and 2) To test and expand our current
implementation package's ability to address barriers in a clinic that cares for underserved
patients. The investigators will determine the reach of implementation and acceptability of
this method of decision aid delivery to stakeholders.