Navigating primary surgical therapy for breast cancer presents complex clinical dilemmas for patients and clinicians alike. Consequently, shared decision making has emerged as an essential standard for facilitating informed and preference-aligned choices in modern oncology. Clinicians must balance medical evidence with patient values when selecting surgical and adjuvant strategies. However, psychological distress frequently impedes effective communication during initial consultations. To resolve these challenges, investigators recently evaluated a comprehensive shared decision engagement system across community oncology practices.

The Evolving Landscape of Shared Decision Making in Oncology

Modern breast cancer management offers multiple equivalent locoregional treatment pathways, such as breast-conserving surgery with radiotherapy versus mastectomy. Consequently, clinicians must actively guide patients through these nuanced preferences. Shared decision making ensures that patients thoroughly understand surgical options, recurrence risks, and cosmetic outcomes before proceeding with intervention. In addition, effective communication mitigates long-term decisional regret and fosters therapeutic alliance.

Nevertheless, acute distress often overwhelms newly diagnosed patients, impairing cognitive processing and medical comprehension. Clinicians frequently encounter individuals who struggle to absorb technical explanations during time-constrained consultations. Therefore, investigators developed digital decision support aids, such as the validated iCanDecide platform, to deliver structured, digestible treatment data. These digital tools clarify locoregional therapies, genetic testing indications, and systemic regimens outside the busy clinic room.

Furthermore, healthcare systems increasingly recognize that patient-facing aids alone cannot solve communication barriers. Multi-level interventions that simultaneously address clinician behaviors and patient preparation represent the modern frontier in cancer care delivery research. Accordingly, researchers launched the SharES trial to determine whether supplementing evidence-based decision tools with tailored emotional support components enhances patient comprehension and reduces decisional distress.

Design of the Multi-Level SharES Randomized Trial

The SharES study, conducted through the NCI Community Oncology Research Program Alliance Research Base, evaluated a crossed, multi-level intervention design. Specifically, investigators tested two interactive components across community-based surgical oncology clinics. At the patient level, researchers randomized participants to receive either the standard iCanDecide online decision tool or an emotional support enhanced version. The enhanced version incorporated dedicated stress management exercises and coping strategies alongside standard educational modules.

Simultaneously, the investigators deployed a clinic-level stepped-wedge randomized intervention featuring a specialized Clinician Dashboard. This dashboard summarized individual patient preferences, informational needs, and distress levels before surgical consultations. Consequently, surgeons could tailor discussions to address specific patient values directly. The study team enrolled 542 patients and 54 clinicians across 25 distinct community surgical practices, ultimately analyzing 403 evaluable patients.

Moreover, the research protocol established rigorous primary and secondary endpoints assessed at five weeks post-registration. The primary outcome measured objective patient knowledge regarding breast cancer locoregional treatments. Secondary outcomes captured breast cancer worry and disease-specific self-efficacy. By employing linear mixed models accounting for clinical clustering, the investigators robustly assessed both patient-level enhancements and clinician dashboard effects.

Key Findings on Knowledge, Cancer Worry, and Self-Efficacy

The primary analysis revealed unexpected results regarding the added emotional support enhancements. Specifically, confidence intervals for the primary knowledge outcome included zero, indicating no statistically significant difference between the two tool variants. Furthermore, the observed point estimates ruled out pre-specified clinically meaningful improvements in patient comprehension. Patients who utilized the enhanced emotional support module demonstrated treatment knowledge scores comparable to those using the standard tool.

Similarly, secondary outcomes showed no demonstrable superiority for the enhanced intervention. Measures of cancer-related worry and patient self-efficacy remained statistically indistinguishable between both study arms. The addition of interactive coping exercises did not significantly attenuate surgical anxiety or bolster decision confidence. However, the trial did document high fidelity to intervention protocols, confirming that participants actively engaged with the assigned digital modules.

In addition, the investigators observed considerable variation in baseline knowledge and communication outcomes across different participating surgical clinics. This institutional heterogeneity suggests that clinic culture, local demographics, and baseline clinician communication styles heavily influence patient understanding. Therefore, standardized digital enhancements may produce variable effects across diverse community oncology settings, highlighting the complexity of real-world implementation.

Interpreting the Role of Emotional Support Enhancements

These neutral findings provide critical guidance for cancer care delivery researchers and clinical oncologists. Foremost, the standard iCanDecide platform was already an established, highly effective tool designed through rigorous iterative testing. Because the baseline digital aid already optimized knowledge transmission, achieving incremental gains through emotional support modules proved challenging. Consequently, a ceiling effect likely limited further quantifiable improvements in patient comprehension.

Additionally, the timing of digital emotional support interventions requires careful scrutiny. While informational clarity addresses cognitive uncertainty, acute existential distress following a cancer diagnosis may demand direct interpersonal counseling rather than digital exercises. Patients often derive emotional reassurance directly from empathetic clinician interactions, oncology nurse navigators, or psycho-oncology specialists. Therefore, automated digital coping tools cannot entirely replace personalized psychological support.

Nonetheless, the trial verified that community oncology practices can successfully implement complex, multi-level digital interventions. Both clinicians and patients demonstrated substantial engagement with the web-based platforms. Accordingly, future investigators should examine whether specific patient subgroups, such as individuals with elevated baseline anxiety or low health literacy, derive greater utility from targeted emotional support features.

Clinical Implications for Surgical and Oncology Practice

For practicing surgeons and oncologists, these trial results underscore several vital lessons in cancer communication. First, clinicians should confidently adopt validated digital decision aids to facilitate pre-consultation education. Providing patients with structured information on lumpectomy, mastectomy, reconstruction, and adjuvant therapy saves consultation time while systematically improving baseline knowledge. However, surgeons must recognize that digital aids represent adjuvants rather than substitutes for compassionate clinical dialogue.

Second, the findings emphasize that managing patient anxiety requires active clinical listening during consultations. While digital tools impart foundational medical knowledge, clinicians must directly explore fears concerning body image, surgical morbidity, and cancer recurrence. When clinicians review dashboard summaries or patient preferences beforehand, they can initiate focused conversations that address specific emotional concerns. Consequently, combining digital preparatory tools with structured empathetic dialogue optimizes patient satisfaction.

Finally, health systems in diverse global settings, including resource-conscious community environments, can leverage existing standardized decision aids without over-engineering complex behavioral add-ons. Streamlined, accessible platforms that clearly articulate surgical options remain the cornerstone of patient-centered cancer care. Moving forward, multidisciplinary oncology teams should integrate validated digital tools into routine clinical workflows while maintaining robust access to dedicated psychosocial support services.

How does the SharES trial influence surgical shared decision making in breast cancer?

The SharES trial demonstrates that validated digital decision aids effectively prepare patients for complex surgical choices, such as lumpectomy versus mastectomy. However, adding automated emotional support modules to existing educational platforms does not significantly improve knowledge retention or alleviate cancer worry. Consequently, surgical oncologists should rely on standard, well-designed decision aids for cognitive education while dedicating in-person consultation time to addressing personal anxieties, values, and individualized clinical considerations.

Why did emotional support enhancements fail to significantly reduce cancer worry?

Several factors explain this outcome. First, the standard digital decision tool already provided high-quality information, creating a potential ceiling effect for measured outcomes. Second, digital stress-management exercises may not sufficiently address acute existential distress following a new breast cancer diagnosis. Patients typically require personalized, empathetic reassurance from their surgical team or specialized psycho-oncology professionals. Therefore, brief automated modules cannot substitute for comprehensive, human-delivered psychological counseling in stressful oncology settings.

What role do clinician dashboards play in multi-level oncology interventions?

Clinician dashboards summarize individual patient preferences, baseline knowledge gaps, and specific treatment concerns before surgical consultations occur. In the SharES trial, high clinician engagement proved that community practices could integrate such digital feedback into daily workflows. By alerting surgeons to specific patient priorities prior to the clinical encounter, dashboards help clinicians streamline discussions, tailor counseling, and foster meaningful collaborative deliberation regarding surgical and reconstructive pathways.

Disclaimer: This content is for informational and educational purposes only and does not constitute medical advice or establish a doctor-patient relationship. Healthcare professionals must exercise independent clinical judgment. Refer to the latest local and national guidelines for clinical practice.

References

1. Hawley ST et al. Evaluating a shared decision engagement system in the NCI community oncology research program: a multi-level RCT. JNCI Cancer Spectr. 2026 Sep 28. doi: undefined. PMID: 42804742.
2. Hawley ST, Janz NK, Lantz PM, et al. Improving patient-centered communication in breast cancer: a study protocol for a multilevel intervention of a shared treatment deliberation system (SharES) within the NCI community oncology research program (NCORP) (Alliance A231901CD). BMC Cancer. 2023;23(1):25.
3. Hawley ST, Newman L, Griggs JJ, Kosir MA, Katz SJ. Evaluating a Decision Aid for Improving Decision Making in Patients with Early-stage Breast Cancer. Patient. 2016;9(2):161-169.
4. Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361-1367.