Regret is an emotion that all of us have at one time or another. It is a feeling of remorse or sorrow for something that one wishes could be different. In medicine, in the past, when a decision was necessary between two choices, the common practice was paternalism—the doctor would take it upon him/herself to decide what course would be followed. I suppose under those circumstances, decision regret by the patient or family was rare.

Medicine has become significantly more complex in recent years with more choices that are contingent on risk/benefit ratios that require input from the patients and their family and friends. In addition, there has been a decline in the authoritative trust that we formerly placed in our physicians, and a greater reliance on outside sources for information—friends, Dr. Google, magazine and newspaper articles and blogs. This decline in reliance on the health care provider has led to an increase in patient input into decision-making or shared decision-making. For some issues, such as mastectomy versus breast conserving surgery (i.e., lumpectomy) for localized breast cancer, the guidelines of national organizations actually mandate or recommend shared decision-making.

How a physician views this may be variable. In many circumstances, this may devolve into the physician making the decision anyway for the patient (“What would you do, doc?”). In other cases, given the pressures of current medical practice and of its litigious nature, the physician may be just as happy as not to abandon his/her traditional role and welcome patient choice. Since outcomes in these circumstances are generally difficult to predict in advance, the outcomes will be what they should be either way.

I came across a recent review on this subject in the Journal of Advanced Nursing by a group of nursing faculty from Australia. They noted that decision regret often involves self-recrimination, and can be accompanied by a heavy psychological burden on the patient. It is usually also linked to dissatisfaction with the physician and health care provider team. A paper by Hawley in 2008 found among 877 American women with early breast cancer that nearly 39% reported a high degree of decision regret about their surgical treatment while an additional 30% reported a moderate amount of regret.

This review article combined data from 26 studies on decision regret, mostly related to their surgical choices in breast cancer. Several of the studies they reviewed also looked at decision regret with the decision to reject adjuvant chemotherapy after surgery. Actually, the studies varied considerably in how much decision regret they found, ranging from 2.6% to 69%—the lower levels of regret were in studies where women were provided significant decision support at the institution. Only three studies broke down whether the decision regret was greater in going from mastectomy to breast conserving surgery or vice versa—the decision regret was considerably higher for those who underwent mastectomy. Certain sociodemographic factors, such as age, race/ethnicity, mental health issues and increased education, also contributed to subsequent increased decision regret. It also seemed clear that more involvement by nurses and health care professionals in assisting the patients with these decisions was helpful in forestalling subsequent regret.

Not surprisingly, one issue that probably plays a role in the degree of regret is the outcome the patient develops. Multiple randomized and observational studies have, at least for the BCS versus mastectomy question, demonstrated that the risks of recurrence and survival should be equivalent for either option. How then would the outcome affect the occurrence of regret? Would someone who underwent breast conserving surgery and then recurred believe that the more radical surgical procedure would have prevented the negative outcome? Or would someone who underwent mastectomy and then had an extended period of being disease-free regret that she did not choose the more limited surgical procedure?

Robert Frost (1874-1963) tells us about the road that splits and offers us two paths to choose—our traveler chooses the one less trodden. We make our choices, and we (hopefully) live with the consequences:

I shall be telling this with a sigh

Somewhere ages and ages hence:

Two roads diverged in a wood, and I—I took the one less traveled by,

And that has made all the difference.

Alfred I. Neugut, MD, PhD, is a medical oncologist and cancer epidemiologist at Columbia University Irving Medical Center/New York Presbyterian and Mailman School of Public Health in New York. Email: [email protected].

 This article is for educational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment, and does not constitute medical or other professional advice. Always seek the advice of your qualified health provider with any questions you may have regarding a medical condition or treatment.