Four Conversations: A Randomized Controlled Trial of an Online, Personalized Coping and Decision Aid for Metastatic Breast Cancer Patients

J Palliat Med. 2020 Mar;23(3):353-358. doi: 10.1089/jpm.2019.0234. Epub 2019 Oct 22.


Background: Anticipating and making health care decisions about appropriate or preferred treatment around end-of-life care are intellectually challenging and emotionally distressing for metastatic breast cancer (MBC) patients, new interventions are needed. Objective: This study examined the effect of Four Conversations, an online and personalized coping and decision aid curriculum, on the completion of advance care directives and shared decision making among patients and their loved ones, clinicians, and spirit. Design: Participants were randomized 1:1 to Four Conversations or wait-listed usual care conditions. Setting: Adult breast cancer survivors with metastatic disease were recruited nationally. Measurements: Electronic surveys collected self-reported demographic, clinical, and outcome data at baseline and four weeks postintervention. Results: Participants (N = 252) were mean age 53.6 ± 11.0 years; 100% female; 88% Caucasian; 67% married; and 33% employed. Over half (54%) of treatment arm participants without an advance directive completed one by study end, most (62%) felt that Four Conversations helped them quite a bit or a great deal in making a better decision, and 90% would recommend to others. Difference in the change in decisional conflict scores for treatment and control conditions was not significant (p = 0.07). Conclusions: These results suggest that Four Conversations facilitated the completion of advance care directives. Given that reductions in decisional conflict scores between the treatment and control arms were not significant, we cannot conclude that program use was associated with improved decisional conflict among MBC survivors. Online programs can be a feasible and effective alternative to in-person support.

Trial registration: NCT02944344.

Keywords: advance directives; metastatic breast cancer; randomized control trial; shared decision making.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adaptation, Psychological
  • Adult
  • Breast Neoplasms*
  • Communication
  • Decision Making
  • Decision Support Techniques
  • Female
  • Humans
  • Male
  • Middle Aged

Associated data