Achieving Informed Preferences: An Interactional Challenge in the Surgical Consultation for Early-Stage Breast Cancer

The American Society of Breast Surgeons urges surgeons to advocate for breast conservation and discourage contralateral prophylactic mastectomy (CPM) when consulting with early-stage breast cancer patients who are not at high risk for developing contralateral cancer. At the same time, surgeons are advised to respect the preferences and values of such early-stage patients, many of whom have been shown to exhibit a preference for CPM, choosing it over less-extensive surgical options. How are these different imperatives balanced during actual consultations? We use Conversation Analysis (CA) to examine recorded consultations for early-stage breast cancer and show how a surgeon manages this interactional challenge via a multi-component narrative that she positions at the beginning of the treatment phase of the consultation. Two illustrative cases are presented and contrasted: In the first, the surgeon is able to produce the entire narrative up front, before the patient expresses a surgical treatment preference, while in the second, the patient makes an early request for CPM. We analyze how, in this second case, the surgeon creates interactional space to table the request for now, and expand the request-response sequence in order to complete the narrative before the treatment decision is finalized. We consider the implications of our findings for the concepts of informed decision making and shared decision making for preference-sensitive treatment decisions.