Why Do Older Women Avoid Breast Cancer Surgery? A Qualitative Analysis of Decision-Making Factors

•Limited data exists about why older women avoid breast cancer surgery.•We report physician- and/or patient-perceived attitudes that influence avoiding surgery.•Acknowledging patient values may facilitate a patient-centered approach. Few studies have explored why older women (≥70 years old) avoid breast cancer surgery. This study aimed to identify physician- and patient-perceived attitudes that influence the decision to avoid surgery among older women with invasive breast cancer. Semi-structured in-depth interviews were conducted with multidisciplinary breast cancer specialists and older women (≥70 years old) with breast cancer who declined surgery. Transcripts were iteratively coded using a theoretical framework to guide identification of common themes. Thematic comparison was performed between patients and physicians. Ten breast cancer specialists and eleven patients participated. Physicians believed older women declined surgery because they did not perceive breast cancer as a life-threatening ailment compared to other medical comorbidities. Physicians did not discuss breast reconstruction, as it was perceived to be unimportant. Treatment side effects, length of treatment, impact on quality of life, and minimal survival benefit strongly influenced patients' decision to decline surgery. Patients valued independence and quality of life over quantity of life. Patients felt empowered to participate in the decision-making process but appreciated having support. Both phyisicians and patients had congruent beliefs with respect to age impacting treatment decision, cosmesis playing a minor factor in treatment decisions, and importance of quality of life; however, they were discordant in their perceptions about the amount of support that patients have from their families. The decision to avoid surgery in older women stems from a variety of individual beliefs. Acknowledging patient values early in treatment planning may facilitate a patient-centered approach to the decision-making process.