研究背景：早期乳癌HR+、HER2-婦女中接受輔助性化療對降低術後腫瘤復發風險未有定論，多數病人面對化療副作用與影響未來存活無法抉擇而導致決策衝突及焦慮，儘管基因檢測工具已被證實可作為選擇化療的依據，若婦女在資訊不足、知識缺乏的情況下進行化療決策，易產生自我價值觀的差異，因而加劇後續決策衝突和不良心理反應，因此如何應用基因檢測輔助工具協助病人抉擇化療之決策為重要議題。
研究目的：本研究發展基因檢測輔助化療抉擇衛教影片作為決策輔助工具，並探討此決策輔助工具對早期乳癌婦女基因檢測的知識、對術後抉擇化療決策偏好、決策衝突、決策後悔之影響。
研究方法：依據Ottawa決策支持架構設計基因檢測輔助化療抉擇衛教影片，採類實驗性、前瞻性研究設計，於南部某醫學中心乳房外科門診進行收案。選樣條件納入病理診斷為I~II期早期乳癌、生物標記為HR+、HER2-、淋巴結0~3顆轉移，且經醫師判斷需要使用基因表達分析者，排除目前或曾經有癌症、過去已做過化療、有認知功能障礙或精神相關疾病而無法自我決策者。針對符合選樣條件之早期乳癌婦女均接受輔助工具介入，研究於介入前給予前測、並於介入後一週進行後測、介入後一個月、介入後兩個月分別完成追蹤後測資料收集。使用廣義估計方程式(Generalized Estimating Equations, GEE)分析基因表達分析知識、決策衝突及決策後悔之成效。
研究結果：本研究納入31位乳癌婦女，個案的整體年齡介於41~71歲，平均年齡為53.29歲。在手術疾病相關屬性中，以I期的乳癌婦女佔最多數(67.7%)，乳房切除術式以全乳切除術佔最多數(67.7%)。研究結果顯示接受基因表達分析衛教可顯著提升乳癌婦女對基因檢測的知識(𝛽=9.88, p=.038)；超過九成之個案對化療有明確偏好，且超過八成之個案最終決策偏好與實際治療行為一致；在接受衛教後可顯著降低對抉擇化療之決策衝突(𝛽=-9.3, p=.002)，然而無法顯著降低對抉擇化療之決策後悔(𝛽=-2.24, p=.359)。
結論與臨床建議：根據本研究結果，基因表達分析衛教輔助早期乳癌婦女抉擇化療治療可顯著提升其對基因表達分析之知識，能針對化療決策上表露明確偏好，及顯著降低化療決策之決策衝突，然而在決策後悔上尚未顯著。未來研究建議可納入更多早期乳癌婦女，且進行多中心研究，並針對決策後悔之成效規劃更長期的追蹤與分析（如診斷後3至5年）。此外，本研究成果亦建議臨床照護人員在推動精準醫療共享決策時，應採取「證據與價值導向」並重的介入策略，透過結構化之衛教工具，將客觀之基因證據轉化為病人在化療決策中可實用的參考依據，藉此賦予病人更穩固的臨床決策識能。

Early-stage HR+/HER2- breast cancer patients often face uncertainty when making decisions about adjuvant chemotherapy, as the potential survival benefits must be weighed against treatment-related toxicities. Although gene expression profiling facilitates personalized treatment recommendations, inadequate understanding of genomic testing may increase decisional conflict and uncertainty. This prospective experimental study evaluated the effectiveness of a genomic test-based educational video, developed based on the Ottawa Decision Support Framework, in improving patients’ knowledge and decision-making outcomes. Thirty-one women with stage I–II HR+/HER2- breast cancer who were recommended to undergo gene expression profiling were enrolled. Participants received the educational intervention and completed assessments at baseline and at 1 week, 1 month, and 2 months post-intervention. GEE analyses were performed to examine longitudinal changes in genomic test knowledge, chemotherapy preferences, decisional conflict, and decisional regret. The intervention significantly improved participants’ knowledge of genomic testing (β = 9.88, p = .038) and reduced decisional conflict regarding chemotherapy decisions (β = −9.30, p = .002). More than 90% of participants expressed clear treatment preferences, and over 80% demonstrated concordance between their final treatment preference and the treatment ultimately received. However, no significant reduction in decisional regret was observed (β = −2.24, p = .359). These findings suggest that a genomic test-based educational decision aid can improve patients’ understanding of genomic testing, support informed decision-making regarding chemotherapy, and reduce decisional conflict among women with early-stage breast cancer. Further multicenter studies with larger samples and longer follow-up periods are warranted to evaluate its long-term effects on decision quality outcomes.

內政部統計處（2024）．113年十五歲以上人口按年齡、教育程度及婚姻狀況．取自https://www.ris.gov.tw/app/portal/346
王蔚芸、王桂芸、湯玉英（2007）．焦慮之概念分析．長庚護理，18(1)，59-67。https://doi.org/10.6386/CGN.200703_18(1).0006
蔡宜庭、方素瓔（2022）．基因表達分析對早期乳癌婦女接受術後輔助性化療選擇之統合分析．台灣醫學，26(3)，287-301。https://doi.org/10.6320/FJM.202205_26(3).0003
蔡明霖（2021）．乳癌治療．台灣更年期醫學會會訊，(65)，17-19。https://doi.org/10.6651%2fTMS.202108_(65).03
衛生福利部國民健康署（2023，11月10日）．癌症登記報告。https://www.hpa.gov.tw/Pages/List.aspx?nodeid=269
衛生福利部國民健康署（2025，12月30日）．112年癌症登記報告。https://www.hpa.gov.tw/Pages/ashx/GetFile.ashx?lang=c&type=1&sid=19b0fbcde39a4e4da6252552cafe6176
蘇俊嘉（2007）．病患參與治療決策之探討--以乳癌婦女為例〔碩士論文，國立臺灣大學〕．華藝線上圖書館。https://doi.org/10.6342/NTU.2007.02239
American Cancer Society (2024). Breast Cancer Facts & Figures. Retrieved from https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/breast-cancer-facts-and-figures/2024/breast-cancer-facts-and-figures-2024.pdf
Andre, F., Ismaila, N., Allison, K. H., Barlow, W. E., Collyar, D. E., Damodaran, S., Henry, N. L., Jhaveri, K., Kalinsky, K., Kuderer, N. M., Litvak, A., Mayer, E. L., Pusztai, L., Raab, R., Wolff, A. C., & Stearns, V. (2022). Biomarkers for adjuvant endocrine and chemotherapy in early-stage breast cancer: ASCO guideline update. Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology, 40(16), 1816–1837. https://doi.org/10.1200/JCO.22.00069
Ben-Dror, J., Shalamov, M., & Sonnenblick, A. (2022). The history of early breast cancer treatment. Genes, 13(6), 960. https://doi.org/10.3390/genes13060960
Bombard, Y., Rozmovits, L., Trudeau, M. E., Leighl, N. B., Deal, K., & Marshall, D. A. (2014). Patients' perceptions of gene expression profiling in breast cancer treatment decisions. Current Oncology (Toronto, Ont.), 21(2), e203–e211. https://doi.org/10.3747/co.21.1524
Brehaut, J. C., O'Connor, A. M., Wood, T. J., Hack, T. F., Siminoff, L., Gordon, E., & Feldman-Stewart, D. (2003). Validation of a decision regret scale. Medical Decision Making: An International Journal of the Society for Medical Decision Making, 23(4), 281–292. https://doi.org/10.1177/0272989X03256005
Chen, J., Duan, Y., Xia, H., Xiao, R., Cai, T., & Yuan, C. (2025). Online health information seeking behavior among breast cancer patients and survivors: a scoping review. BMC Women's Health, 25(1), 1.
Cyr, A. E., & Margenthaler, J. A. (2014). Molecular profiling of breast cancer. Surgical Oncology Clinics of North America, 23(3), 451–462. https://doi.org/10.1016/j.soc.2014.03.004
Dar-Nimrod, I., & Heine, S. J. (2011). Genetic essentialism: on the deceptive determinism of DNA. Psychological Bulletin, 137(5), 800.
Davidson, J. A., Cromwell, I., Ellard, S. L., Lohrisch, C., Gelmon, K. A., Shenkier, T., Villa, D., Lim, H., Sun, S., Taylor, S., Taylor, M., Czerkawski, B., Hayes, M., Ionescu, D. N., Yoshizawa, C., Chao, C., Peacock, S., & Chia, S. K. (2013). A prospective clinical utility and pharmacoeconomic study of the impact of the 21-gene Recurrence Score® assay in oestrogen receptor positive node negative breast cancer. European Journal of Cancer (Oxford, England : 1990), 49(11), 2469–2475. https://doi.org/10.1016/j.ejca.2013.03.009
Di Nardo, P., Lisanti, C., Garutti, M., Buriolla, S., Alberti, M., Mazzeo, R., & Puglisi, F. (2022). Chemotherapy in patients with early breast cancer: clinical overview and management of long-term side effects. Expert Opinion on Drug Safety, 21(11), 1341–1355. https://doi.org/10.1080/14740338.2022.2151584
Eiermann, W., Rezai, M., Kümmel, S., Kühn, T., Warm, M., Friedrichs, K., Schneeweiss, A., Markmann, S., Eggemann, H., Hilfrich, J., Jackisch, C., Witzel, I., Eidtmann, H., Bachinger, A., Hell, S., & Blohmer, J. (2013). The 21-gene recurrence score assay impacts adjuvant therapy recommendations for ER-positive, node-negative and node-positive early breast cancer resulting in a risk-adapted change in chemotherapy use. Annals of Oncology: Official Journal of the European Society for Medical Oncology, 24(3), 618–624. https://doi.org/10.1093/annonc/mds512
Elwyn, G., Frosch, D., Thomson, R., Joseph-Williams, N., Lloyd, A., Kinnersley, P., Cording, E., Tomson, D., Dodd, C., Rollnick, S., Edwards, A., & Barry, M. (2012). Shared decision making: a model for clinical practice. Journal of General Internal Medicine, 27(10), 1361–1367. https://doi.org/10.1007/s11606-012-2077-6
Fallowfield, L., Matthews, L., May, S., Jenkins, V., & Bloomfield, D. (2018). Enhancing decision-making about adjuvant chemotherapy in early breast cancer following EndoPredict testing. Psycho-oncology, 27(4), 1264–1269. https://doi.org/10.1002/pon.4664
Fernandes-Taylor, S., & Bloom, J. R. (2011). Post-treatment regret among young breast cancer survivors. Psycho-oncology, 20(5), 506–516. https://doi.org/10.1002/pon.1749
Ferro, Y., Maurotti, S., Tarsitano, M. G., Lodari, O., Pujia, R., Mazza, E., Lascala, L., Russo, R., Pujia, A., & Montalcini, T. (2023). Therapeutic fasting in reducing chemotherapy side effects in cancer patients: A systematic review and meta-analysis. Nutrients, 15(12), 2666. https://doi.org/10.3390/nu15122666
Gradishar, W. J., Moran, M. S., Abraham, J., Aft, R., Agnese, D., Allison, K. H., Blair, S. L., Burstein, H. J., Dang, C., Elias, A. D., Giordano, S. H., Goetz, M. P., Goldstein, L. J., Hurvitz, S. A., Isakoff, S. J., Jankowitz, R. C., Javid, S. H., Krishnamurthy, J., Leitch, M., Lyons, J., … Kumar, R. (2021). NCCN Guidelines® Insights: Breast Cancer, Version 4.2021. Journal of the National Comprehensive Cancer Network : JNCCN, 19(5), 484–493. https://doi.org/10.6004/jnccn.2021.0023
Graham, I. D., Logan, J., Harrison, M. B., Straus, S. E., Tetroe, J., Caswell, W., & Robinson, N. (2006). Lost in knowledge translation: time for a map?. The Journal of Continuing Education in the Health Professions, 26(1), 13–24. https://doi.org/10.1002/chp.47
Hack, T. F., Degner, L. F., & Dyck, D. G. (1994). Relationship between preferences for decisional control and illness information among women with breast cancer: a quantitative and qualitative analysis. Social Science & Medicine (1982), 39(2), 279–289. https://doi.org/10.1016/0277-9536(94)90336-0
Harris, L. N., Ismaila, N., McShane, L. M., Andre, F., Collyar, D. E., Gonzalez-Angulo, A. M., Hammond, E. H., Kuderer, N. M., Liu, M. C., Mennel, R. G., Van Poznak, C., Bast, R. C., Hayes, D. F., & American Society of Clinical Oncology (2016). Use of biomarkers to guide decisions on adjuvant systemic therapy for women with early-stage invasive breast cancer: American Society of Clinical Oncology clinical practice guideline. Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology, 34(10), 1134–1150. https://doi.org/10.1200/JCO.2015.65.2289
Holt, S., Bertelli, G., Humphreys, I., Valentine, W., Durrani, S., Pudney, D., Rolles, M., Moe, M., Khawaja, S., Sharaiha, Y., Brinkworth, E., Whelan, S., Jones, S., Bennett, H., & Phillips, C. J. (2013). A decision impact, decision conflict and economic assessment of routine Oncotype DX testing of 146 women with node-negative or pNImi, ER-positive breast cancer in the U.K. British Journal of Cancer, 108(11), 2250–2258. https://doi.org/10.1038/bjc.2013.207
Huppert, L. A., Gumusay, O., Idossa, D., & Rugo, H. S. (2023). Systemic therapy for hormone receptor-positive/human epidermal growth factor receptor 2-negative early stage and metastatic breast cancer. CA: A Cancer Journal for Clinicians, 73(5), 480–515. https://doi.org/10.3322/caac.21777
Jenkins, V., Fallowfield, L., & Saul, J. (2001). Information needs of patients with cancer: results from a large study in UK cancer centres. British Journal of Cancer, 84(1), 48-51.
Jull, J., Köpke, S., Smith, M., Carley, M., Finderup, J., Rahn, A. C., Boland, L., Dunn, S., Dwyer, A. A., Kasper, J., Kienlin, S. M., Légaré, F., Lewis, K. B., Lyddiatt, A., Rutherford, C., Zhao, J., Rader, T., Graham, I. D., & Stacey, D. (2021). Decision coaching for people making healthcare decisions. The Cochrane Database of Systematic Reviews, 11(11), CD013385. https://doi.org/10.1002/14651858.CD013385.pub2
Kuchel, A., Robinson, T., Comins, C., Shere, M., Varughese, M., Sparrow, G., Sahu, A., Saunders, L., Bahl, A., Cawthorn, S. J., & Braybrooke, J. P. (2016). The impact of the 21-gene assay on adjuvant treatment decisions in oestrogen receptor-positive early breast cancer: A prospective study. British Journal of Cancer, 114(7), 731–736. https://doi.org/10.1038/bjc.2016.48
Lam, W. W., Kwok, M., Liao, Q., Chan, M., Or, A., Kwong, A., Suen, D., & Fielding, R. (2015). Psychometric assessment of the Chinese version of the decisional conflict scale in Chinese women making decision for breast cancer surgery. Health Expectations: An International Journal of Public Participation in Health Care and Health Policy, 18(2), 210–220. https://doi.org/10.1111/hex.12021
Levine, M. N., Julian, J. A., Bedard, P. L., Eisen, A., Trudeau, M. E., Higgins, B., Bordeleau, L., & Pritchard, K. I. (2016). Prospective evaluation of the 21-gene recurrence score assay for breast cancer decision-making in Ontario. Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology, 34(10), 1065–1071. https://doi.org/10.1200/JCO.2015.62.8503
Li, Y., Fang, C., Xiong, M., Hou, H., Zhang, Y., & Zhang, C. (2024). Exploring fear of cancer recurrence and related factors among breast cancer patients: A cross-sectional study. Journal of Advanced Nursing, 80(6), 2403–2414. https://doi.org/10.1111/jan.16009
Lipkus, I. M., Vadaparampil, S. T., Jacobsen, P. B., & Miree, C. A. (2011). Knowledge about genomic recurrence risk testing among breast cancer survivors. Journal of Cancer Education: The Official Journal of the American Association for Cancer Education, 26(4), 664–669. https://doi.org/10.1007/s13187-011-0248-5
Litton, J. K., Burstein, H. J., & Turner, N. C. (2019). Molecular testing in breast cancer. American Society of Clinical Oncology Educational Book. American Society of Clinical Oncology. Annual Meeting, 39, e1–e7. https://doi.org/10.1200/EDBK_237715
Lo, S. S., Mumby, P. B., Norton, J., Rychlik, K., Smerage, J., Kash, J., Chew, H. K., Gaynor, E. R., Hayes, D. F., Epstein, A., & Albain, K. S. (2010). Prospective multicenter study of the impact of the 21-gene recurrence score assay on medical oncologist and patient adjuvant breast cancer treatment selection. Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology, 28(10), 1671–1676. https://doi.org/10.1200/JCO.2008.20.2119
Loibl, S., Poortmans, P., Morrow, M., Denkert, C., & Curigliano, G. (2021). Breast cancer. Lancet (London, England), 397(10286), 1750–1769. https://doi.org/10.1016/S0140-6736(20)32381-3
MacDonald, K. V., Bombard, Y., Deal, K., Trudeau, M., Leighl, N., & Marshall, D. A. (2016). The influence of gene expression profiling on decisional conflict in decision making for early-stage breast cancer chemotherapy. European Journal of Cancer (Oxford, England : 1990), 61, 85–93. https://doi.org/10.1016/j.ejca.2016.03.077
McArthur, H. L., & Hudis, C. A. (2007). Breast cancer chemotherapy. Cancer Journal (Sudbury, Mass.), 13(3), 141–147. https://doi.org/10.1097/PPO.0b013e318074dc6f
McDonald, E. S., Clark, A. S., Tchou, J., Zhang, P., & Freedman, G. M. (2016). Clinical diagnosis and management of breast cancer. Journal of Nuclear Medicine: Official Publication, Society of Nuclear Medicine, 57 Suppl 1, 9S–16S. https://doi.org/10.2967/jnumed.115.157834
Mishel M. H. (1990). Reconceptualization of the uncertainty in illness theory. Image--the Journal of Nursing Scholarship, 22(4), 256–262. https://doi.org/10.1111/j.1547-5069.1990.tb00225.x
National Cancer Institute. (2024). NCI dictionary of cancer terms -- Early-stage breast cancer. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/early-stage-breast-cancer
O'Connor A. M. (1993). User manual – decisional conflict scale. Ottawa Hospital Research Institute. https://decisionaid.ohri.ca/docs/develop/User_Manuals/UM_Decisional_Conflict.pdf
O'Connor A. M. (1995). Validation of a decisional conflict scale. Medical Decision Making: an International Journal of the Society for Medical Decision Making, 15(1), 25–30. https://doi.org/10.1177/0272989X9501500105
Paasche-Orlow, M. K., & Wolf, M. S. (2007). The causal pathways linking health literacy to health outcomes. American Journal of Health Behavior, 31(1), S19-S26.
Panattoni, L., Lieu, T. A., Jayasekera, J., O'Neill, S., Mandelblatt, J. S., Etzioni, R., Phelps, C. E., & Ramsey, S. D. (2019). The impact of gene expression profile testing on confidence in chemotherapy decisions and prognostic expectations. Breast Cancer Research and Treatment, 173(2), 417–427. https://doi.org/10.1007/s10549-018-4988-3
Parker, G., Hunter, S., Ghazi, S., Hayeems, R. Z., Rousseau, F., & Miller, F. A. (2023). Decision impact studies, evidence of clinical utility for genomic assays in cancer: A scoping review. PloS One, 18(3), e0280582. https://doi.org/10.1371/journal.pone.0280582
Rajan, K. K., Fairhurst, K., Birkbeck, B., Novintan, S., Wilson, R., Savović, J., Holcombe, C., & Potter, S. (2024). Overall survival after mastectomy versus breast-conserving surgery with adjuvant radiotherapy for early-stage breast cancer: meta-analysis. BJS Open, 8(3), zrae040. https://doi.org/10.1093/bjsopen/zrae040
Richman, A. R., Tzeng, J. P., Carey, L. A., Retèl, V. P., & Brewer, N. T. (2011). Knowledge of genomic testing among early‐stage breast cancer patients. Psycho‐Oncology, 20(1), 28-35.
Schwartz, B. (2015). The paradox of choice. Positive Psychology in Practice: Promoting Human Flourishing in Work, Health, Education, and Everyday Life, 121-138
Sørensen, K., Van den Broucke, S., Fullam, J., Doyle, G., Pelikan, J., Slonska, Z., Brand, H., & (HLS-EU) Consortium Health Literacy Project European (2012). Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health, 12, 80. https://doi.org/10.1186/1471-2458-12-80
Sparano, J. A., Gray, R. J., Makower, D. F., Pritchard, K. I., Albain, K. S., Hayes, D. F., Geyer, C. E., Jr, Dees, E. C., Goetz, M. P., Olson, J. A., Jr, Lively, T., Badve, S. S., Saphner, T. J., Wagner, L. I., Whelan, T. J., Ellis, M. J., Paik, S., Wood, W. C., Ravdin, P. M., Keane, M. M., … Sledge, G. W., Jr (2018). Adjuvant chemotherapy guided by a 21-gene expression assay in breast cancer. The New England Journal of Medicine, 379(2), 111–121. https://doi.org/10.1056/NEJMoa1804710
Stacey, D., Légaré, F., Boland, L., Lewis, K. B., Loiselle, M. C., Hoefel, L., Garvelink, M., & O'Connor, A. (2020). 20th Anniversary Ottawa Decision Support Framework: Part 3 overview of systematic reviews and updated framework. Medical Decision Making: An International Journal of the Society for Medical Decision Making, 40(3), 379–398. https://doi.org/10.1177/0272989X20911870
Stacey, D., Légaré, F., Lewis, K., Barry, M. J., Bennett, C. L., Eden, K. B., Holmes-Rovner, M., Llewellyn-Thomas, H., Lyddiatt, A., Thomson, R., & Trevena, L. (2017). Decision aids for people facing health treatment or screening decisions. The Cochrane Database of Systematic Reviews, 4(4), CD001431. https://doi.org/10.1002/14651858.CD001431.pub5
Stacey, D., Lewis, K. B., Smith, M., Carley, M., Volk, R., Douglas, E. E., Pacheco-Brousseau, L., Finderup, J., Gunderson, J., Barry, M. J., Bennett, C. L., Bravo, P., Steffensen, K., Gogovor, A., Graham, I. D., Kelly, S. E., Légaré, F., Sondergaard, H., Thomson, R., Trenaman, L., … Trevena, L. (2024). Decision aids for people facing health treatment or screening decisions. The Cochrane Database of Systematic Reviews, 1(1), CD001431. https://doi.org/10.1002/14651858.CD001431.pub6
Trayes, K. P., & Cokenakes, S. E. H. (2021). Breast cancer treatment. American Family Physician, 104(2), 171–178.
van Steenhoven, J. E. C., den Dekker, B. M., Kuijer, A., van Diest, P. J., Nieboer, P., Zuetenhorst, J. M., Imholz, A. L. T., Siesling, S., & van Dalen, T. (2020). Patients' perceptions of 70-gene signature testing: commonly changing the initial inclination to undergo or forego chemotherapy and reducing decisional conflict. Breast Cancer Research and Treatment, 182(1), 107–115. https://doi.org/10.1007/s10549-020-05683-6
Varnier, R., Sajous, C., de Talhouet, S., Smentek, C., Péron, J., You, B., Reverdy, T., & Freyer, G. (2021). Using breast cancer gene expression signatures in clinical practice: unsolved issues, ongoing trials and future perspectives. Cancers, 13(19), 4840. https://doi.org/10.3390/cancers13194840
Wilson, T. D., & Gilbert, D. T. (2003). Affective forecasting. Advances in Experimental Social Psychology, 35(35), 345-411.
World Health Organization. (2023). Breast cancer. https://www.who.int/news-room/fact-sheets/detail/breast-cancer
Wuerstlein, R., Kates, R., Gluz, O., Grischke, E. M., Schem, C., Thill, M., Hasmueller, S., Köhler, A., Otremba, B., Griesinger, F., Schindlbeck, C., Trojan, A., Otto, F., Knauer, M., Pusch, R., Harbeck, N., & WSG-PRIMe investigators in Germany, Austria, Switzerland (2019). Strong impact of MammaPrint and BluePrint on treatment decisions in luminal early breast cancer: results of the WSG-PRIMe study. Breast Cancer Research and Treatment, 175(2), 389–399. https://doi.org/10.1007/s10549-018-05075-x
Wuerstlein, R., Sotlar, K., Gluz, O., Otremba, B., von Schumann, R., Witzel, I., … Harbeck, N. (2016). The west German study group breast cancer intrinsic subtype study: A prospective multicenter decision impact study utilizing the Prosigna assay for adjuvant treatment decision-making in estrogen-receptor-positive, HER2-negative early-stage breast cancer. Current Medical Research and Opinion, 32(7), 1217–1224. https://doi.org/10.1185/03007995.2016.1166102
Yamauchi, H., Nakagawa, C., Takei, H., Chao, C., Yoshizawa, C., Yagata, H., Yoshida, A., Hayashi, N., Hell, S., & Nakamura, S. (2014). Prospective study of the effect of the 21-gene assay on adjuvant clinical decision-making in Japanese women with estrogen receptor-positive, node-negative, and node-positive breast cancer. Clinical Breast Cancer, 14(3), 191–197. https://doi.org/10.1016/j.clbc.2013.10.017
Zafar, S. Y., Peppercorn, J. M., Schrag, D., Taylor, D. H., Goetzinger, A. M., Zhong, X., & Abernethy, A. P. (2013). The financial toxicity of cancer treatment: a pilot study assessing out-of-pocket expenses and the insured cancer patient's experience. The Oncologist, 18(4), 381–390. https://doi.org/10.1634/theoncologist.2012-0279
Zhang X. (2023). Molecular classification of breast cancer: Relevance and challenges. Archives of Pathology & Laboratory Medicine, 147(1), 46–51. https://doi.org/10.5858/arpa.2022-0070-RA
Zhang Y. (2017). Uncertainty in illness: Theory review, application, and extension. Oncology Nursing Forum, 44(6), 645–649. https://doi.org/10.1188/17.ONF.645-649