Relationship Between Decision Conict and Decision Regret Among Postoperative Breast Cancer Patients in China: The Regulating Role of Decision-Making Preparation

Objective: Different surgical methods have different risks and benets. The Chinese breast cancer(BC) patients’ decision-making of surgical treatment become a critical research question. Patients are often offered several options before surgery, and decision preparation play an important role in decision process. However some patients regret the original decision afterward. To understand the current situation, this study explore mainly explores the status of decision regret among newly diagnosed BC patients,and tests the relationship between decision conicts, decision-making preparation, and decision regrets. Methods: A cross-sectional survey was conducted. Totally 320 postoperative BC patients were studied using a self-made general data scale, Decision Regret Scale, Decision Conict Scale, and Preparation for Decision Making Scale. Basic descriptive analyses, Pearson’s correlation analyses and regression analyses were performed. Results: The average score of decision regret among BC patients after surgery was 34.28. Decision regret was positively associated with decision conict (r=0.853, p<0.01), and negatively associated decision preparation (r=-0.404, p<0.01). Decision-making preparation plays a regulatory role for the emergence of decision conicts and regrets. The correlation between decision conicts and decision regrets increases with the increase of decision-making preparation. Conclusion: The adverse effects of decision conicts on decision regrets gradually increase with the increase of decision-making preparation. Results indicate that reducing decision preparation can be expected to improve the level of decision regret among Chinese BC patients.Thus, Clinical staffs should encourage patients to actively participate in decision-making, provide specialized information support, and improve the level of decision regret among Chinese BCpatients after surgery.


Introduction
Breast cancer is the most common cancer in women worldwide. According to global cancer data in 2020, there are more than 2.26million new cases of breast cancer each year, accounting for 11.7% of all tumors [1].In China, the median age of diagnosis is 48-50 years old, and the 5-year survival rate has reached 85% to 88% [2]. Surgical treatment is one of the important methods for comprehensive treatment of breast cancer patients.The surgical decision-making is a complex and di cult progress for Chinese BC. Breast-conserving surgery and breast reconstruction have become milestones in surgical treatment.
The rate of breast-conserving in USA was 64.5% [3,4]and the rate of breast reconstruction was 40%, however, The majority of BC patients in China are still dominated by mastectomy, and 20-40% chose breast-conserving and only 10.7% chose breast reconstruction [3,5].Different surgical methods proved to have an impact on the quality of life [6]..Therefore, the Chinese BC patients' decision-making of surgical treatment become a critical research question.
In china, cancer is a family event. Facing with complicated treatment decisions, BC patients always require to weigh e cacy, safety, post-operation complications, cost, quality of life and follow-up treatment. A qualitative research have reveal the decision-making progress were in uenced by many factors, such as nancial burden, family factors, traditional culture and faltalism in china [7].When confronted with surgical decision, BC patients always experienced anxiety, illness uncertainty , depress, hesitation and decision con ict [8].Facing with many treatment options, BC patients experienced moods uctuate and always given the decision-making right to physicians ,which just considered survival time and didn't consider patients' preference . A survey showed 6-23% of cancer patients experience decision regret [9]. Therefore, different surgical decision-making may contribute to different quality of life and body image.
Decision regrets is a measure of the quality of decision making. Regrets was often considered to be negative psychological and emotional feelings related with considering a past or future choice [9,10].Prior studies have shown that the active involvement in treatment decision can get more satisfaction about decision-making process [11,12] . In uenced by traditional medical environment, more patient play a passive role in decision-making progress and tend to let the physicians or family members make treatment decision in China [7]. The decision regret associated with various factors including lack of treatment information, individual value, personality traits, decision con ict, decision attitudes and culture factors [13,14]. Berry et al.'s research has shown that if patients make decisions with insu cient participation, in the long run the probability of regret will increase and the quality of decision-making will decrease [15]. Share decision-making is the peak form of patient-centered care, which encourage patients actively participate in their own treatment decisions [16]. The surgical options is a challenging and perplexing process and largely depend on each patient's personal values and preferences. Even though some research conducted in other countries, little is known about the decision regret, in uencing factor and mechanism among newly diagnosed BC patients in China.
This study mainly explores the status of decision regret among newly diagnosed BC patients,and tests the relationship between decision con icts, decision preparation, and decision regrets. The hypothetical model is shown in Figure 1, which details treatment decisions for breast cancer patients. New information will provide a theoretical basis for improving patients' ability to make relevant decisions.

Measures
The demographic questionnaire was self-designed by researcher to collect patients' demographic and clinical characteristics. The information collected was age, religious beliefs, occupational status, educational level, marital status, medical expenses, surgical decision-makers, and disease details.

Decision Regret
The Decision Regret Scale was developed by Brehaut [17]in 2003 to assess the level of regret of a patient's treatment-related decision after surgery. The scale consist of 5 items and each item was rated on a 5-point Likert scale, with 1 for complete agreement and 5 for complete disagreement. The scores of item is subtracted from the raw score and the result is multiplied by 25. The total(mean) scores range from 0 to 100, with a higher score indicating patient's more decision regret. The Chinese scale has good reliability and validity, with a Cronbach's α of 0.86 [18]. It has been widely used in breast cancer patients.The Cronbach's α coe cient in this study was 0.834.

Decision Con ict
The Decision Con ict Scale was used to assess the uncertainty about choices, factors that lead to decision con icts, and perceptions of effective decision-making [19]. The study used Chinese version of Decision Con ict Scale by Li [20].The scale consists of 16 items and 16 items are divided into 3 dimensions : decision uncertainty (3 items), factors leading to decision uncertainty (9 items), and perceived effectiveness of decisions (4 items). The scale uses the 5-point Likert scale from 0-4 (from strongly agree to strongly disagree). the total score ranges from 0-64. The converted total score rstly were summed all item scores, then was divided by 16 and multiplied by 25. The converted total scores range from 0 to 100, with a higher score indicating a higher level of decision con ict [21]. A total scores of less than 25 is considered as absence of a decision-making dilemma. More than 37.5 indicated the presence of a decision-making dilemma, which often delays decisions.The Chinese scale has good reliability and validity, with a Cronbach's alpha of 0.941. And the Cronbach's α coe cient in this study was 0.926.

Decision Preparation
The Preparation for Decision Making Scale (PrepDM) was developed by Bennett [22]in 2010 to assess patients' perceptions during the decision-making process. The Chinese version of Decision Preparation Scale [20] was translated by Li. The scale consists of 10items . Each item used 5-point Likert scale. The Chinese version of the Preparation for Decision Making questionnaire contained 10 items. The scores of each item are added to the mean value, multiplied by 20, and converted to 0-100 points. A total score of more than 60 points indicates better decision preparation. The Cronbach's α coe cient in this study was 0.916.

Data collection method
The researchers instructed the patients to carefully read the questionnaire instructions and explained the purpose and signi cance of the research. Each patient completed the questionnaire independently and the questionnaire were collected on the spot. All the participants signed informed consent. All the 330 potential patients completed the questionnaires, and 320 included in the nal analysis.

Statistical Analysis
Data analysis were performed by SPSS 20.0 and STATA 15.0. Statistical signi cance was set as P <0.05. The means (standard deviations) and frequencies (percentages) were used to describe the characteristics of the participants. Pearson's correlation analyses were used to exam the relationship among decision regrets, decision con ict and decision preparation. Multivariate stepwise regression analysis was used to nd the in uencing factors of decision regret, and to exam whether decision-making preparation moderate the relationship between decision con ict and decision regrets when demographic and clinical characteristics were controlled in regression model . If the moderation effect of decision-making preparation exists, then the Johnson-Neyman technic was applied to explore the conditional effect of decision regrets on decision con ict across the range of decision-making preparation.

Decision regret scores of post-operation breast cancer patients
The average score of the 320 participants' postoperative decision regret was 34.28 SD=20.18).

Bivariate Correlations Among the main variables
Pearson correlation analysis showed that decision regret was positively associated with decision con ict (r=0.853, p<0.01), and negatively associated decision preparation (r=-0.404, p<0.01). Further, decision con ict was negatively related with decision preparation (r=-0.524, p<0.01).
The regulating effect of decision preparation on the relationship between decision con ict and decision regrets Controlling all demographic and clinical characteristics in the analysis process, the results showed that decision-making preparation played a regulatory role in the emergence of decision con ict and decision regret (decision-making preparation × decision con ict: β=1.408, p<0.05), the detailed results are shown in Table 2.
Note: All demographic variables were adjusted. *p 0.05 **p 0.01 The Johnson-Neyman technique was used to further explore the boundary value of the decision-making preparation adjustment effect and the range of the statistically signi cant decision-making preparation.
Analysis found that the correlation between decision con icts and decision regrets increases with the increase of decision-making preparation, indicating that the adverse effects of decision con icts on decision regrets gradually increase with the increase of decision-making preparation. The 95% con dence interval does not include 0, as shown in Figure 2.

Discussion
To date, the interplay between decision regret, decision con ict and decision preparation has not been indirectly tested via a mediation model. Several studies have found that decision regret was related with decision con ict, but there are no research to exam the possible mechanism for this correlation. We found decision regret BC patients more negatively engage in decision progress, and this was related with less decision preparation and developed more decision con ict.
The results of this study show that the postoperative decision regret score of 320 breast cancer patients was 34.28 SD=20.18),which is higher than the decision regret level in Chinese American women with BC[18]. The reasons could be that the inclusion population live in different countries and share a different medical service. In China, BC patients play a passion role in decision progress, and they didn't have enough time to do a preferred decision because of the heavy patient's burden [7], In USA, the decision regret is associated with nancial barriers and consultation limitation by language. Our nding is similar with several investigation [9,23]which are carried on BC patients aiming to exam the level of decision regret after surgery. With the spread of Shared decision making, the physicians encourage patients to participant in treatment decision aiming to meet patients' needs and preference [24].Most Chinese patients still prefer survival rate rather than quality of life. Because of traditional culture and patients' perception, the mastectomies is the best treatment in economic cost and survival [25]. Meanwhile, one research found that age affects decision regret among breast cancer patients, especially among patients after total mastectomy, such that younger patients experienced more decision regret [9]. The high incidence of young patients' decision regrets is related to fertility, and the reason why the results of this study are inconsistent with the results of Japanese research may be due to the fact that 83.75% of the subjects included in the present study were older than 40 years old and had fewer fertility concerns [9].In addition, the types of surgical procedures and different occupational types affect patients' decision regret. Because of women who engage in contract or part-time work have a lower probability of experiencing decision regret than women with working full-time. A previous research in German [26] found that patients were more inclined to consult doctors and think their doctors would show more sympathy. In our study,55% BC patients do surgical options with family. The reasons is that BC patients build a poor communication with clinicians and have no time to discuss the type of cancer, its treatment, and a person's preferences and perceptions of treatment choices [27][28][29][30]. Therefore, health professionals build a systematic shared decision-making model to provide adequate information and enough decision-making time,do a high-quality decision and relieve the level of decision regret.
In this study, decision-making preparation had a regulatory effect between decision con icts and decision regrets. The prerequisite for patients to participant in treatment decision-making included 2 basic conditions: 1) patients are willing to participate in treatment decisions and 2) patients have the ability to participate in decision-making [32]. Decision-making preparation manifests as participation competence in decision-making process with their doctor [22]. In China, caner patients are highly motivated to participate in treatment decision, but more than 40% patients depend on physicians to make treatment decision and 62.8% patients make decision with family actually [32]. One explanation is traditional Chinese cultural centered on family since ancient times.In addition, Ottawa's decision support theory based on decision con ict theory and social support theory [16] have determined that participation competence is a prerequisite for the decision-making process. Decision-making is a complex processes, and there are many in uenced factor such as social statistics and clinical characteristics, expectations, values, decision con icts, social support, decision-making roles, and personal resources [24]. When BC patients actively participate in treatment decision,they will seek the amount of information about available options and reduce decision regret [33].However, this study found the in uence of decision con icts on decision regrets increases with decision-making preparation increases.One possible explanation is that the source of information mainly relies on the internet in Chinese medical environment.Network information is not strictly screened and often causes greater decision con icts in decision-making. Thus, medical staff shouldn't blindly pursue the increase of patient participation and should provided specialization information support for breast cancer patients to increase decision preparation and eliminate decision con ict.
Our nding also has an important clinical implication for relieve the level of decision regret.We found that greater decision con ict predicted a higher level of decision regret, and similar result also found in a previous study [34]. The reason is that different breast surgical operation have different risks and bene ts.Because of there are no adequate information support to introduce costs, surgical sites, potential complications , and femininity with post-operation.These results are similar with the share decisionmaking model [23,35],which determine the importance of patients' information needs before decisionmaking, and encourage patients actively participating in decision-making experience less regret than women who delegate treatment decision-making to their physicians. A research shown that breast cancer treatment was widely selective and active. Because of various medical advice may make patients feel overwhelmed and they have a di culty to understanding medical information [36,37].A study in Australia showed that the Breast Reconstruction Decision Support Program signi cantly reduced decision con icts and increased satisfaction with information [38]. The overall cost of breast reconstruction decision support programs was less than that of other medical interventions. This suggests that in the process of intervention, we cannot blindly pursue the increase of patient participation and, more importantly, must improve patients' understanding during the process of assisting decision-making in order to improve interventions. For Chinese American women, providers need to develop decision support interventions to support breast cancer patients in making high-quality decisions, but these interventions must also identify established socio-demographic factors [39]. Meanwhile,our prior study found decision aids also reduce the level of decision regret by guiding decision-making and clarifying value preference [ 40]. Future studies should focus on the impact of caregivers on decision-making with breast cancer patients.

Limitations and Future Direction
This study investigated t the regulatory role of decision-making preparation between decision con icts and decision regrets. However, this study also had several limitations. On the one hand, this study utilized a cross-sectional design and it is not possible to infer a causal relationship. Further research should focus on qualitative study to deeply mini the relationship between decision con ict and decision regret. On the other hand,, this study only collected questionnaires in one hospital in which participants were recruited from an cancer institute in northern part of China. thus.more patients from various parts of the country make the research object more diverse and extensive and facilitate national comparison in future research. Lastly, there were few variables included in this study. Further research should focus on testing what other in uenced factors between decision con ict and decision regret.

Conclusion
In summary, this study demonstrated the relationship among the three variables (decision preparation,decision con ict, and decision regret). Decision-making preparation was negatively associated with decision-con icts and decision regrets, and Decision preparation have a regulatory effect between decision con icts and decision regrets.. As decision-making preparation increases, so did in uence of decision con icts on decision regrets. Results indicate that reducing decision preparation can be expected to improve the level of decision regret among Chinese BC patients, by the regulatory role of decision preparation. Authors' contributions: Yan Wang is responsible for the entire design and writing of the paper.Qingyue Zhang is responsible for part of the design and writing of the paper. Jianmei pang is responsible for the data analysis and writing of the paper.Liyuan Shi Xiaoyuan Wang and Di Yan are responsible for data collection. Jian Yin is responsible for expert consultation on paper.Wanmin Qiang guides the design and writing of papers. Consent to participate: N/A Consent for publication: All authors expressed the authenticity of the data and agreed to be published in this journal.The work described has not been published previously, that it is not under consideration for publication elsewhere, that its publication is approved by all authors and tacitly or explicitly by the responsible authorities where the work was carried out, and that, if accepted, it will not be published elsewhere in the same form, in English or in any other language, including electronically without the written consent of the copyright-holder.  Figure 1 Hypothetical model Figure 2 Conditional Effect of Decision Preparation to Regulate Decision Con ict on Decision Regret