Dissecting autonomy in a resource-constrained setting: a descriptive qualitative study of women’s decisions on the surgical treatment of early breast cancer in northern Sri Lanka

Breast cancer treatment is a contested space in which therapeutic decisions often collide with women's values and preferences. In northern Sri Lanka, mastectomy remains the mainstay of surgical treatment of early breast cancer (EBC) despite evidence of equivalent survival following breast conserving surgery (BCS) and radiotherapy. This study explores autonomy in decision-making among women with EBC who were eligible for BCS and underwent mastectomy in northern Sri Lanka. A descriptive qualitative study was carried out among 15 women referred for adjuvant therapy to Tellippalai Trail Cancer Hospital in Jaffna district after having a mastectomy for EBC. Participants were recruited between January and May 2022 until data saturation was reached. Data were gathered through semi-structured interviews, which were transcribed in Tamil, translated into English, coded using QDA Miner Lite software, and analysed thematically. Women's autonomy in EBC treatment decisions is limited by various factors in northern Sri Lanka. The hospital setting is not conducive to informed decision-making, and women do not receive sufficient information. Neither survival rates nor risks/benefits of the surgical options are discussed in a systematic way. Although many women appear to be satisfied with their involvement in decision-making, their decisions are guided by incomplete information and fears of spread/recurrence communicated by treating teams. In the absence of policies and protocols to support patient autonomy, women "choose" the more invasive option: mastectomy. While it behoves medical professionals to provide evidence-based information, governments and the global health community must support strengthening healthcare systems to advance women's health and rights in lower-resource settings.