The decision board is a method of transferring information on treatment options to patients with early-stage breast cancer [1]. The instrument was tested for validity, reliability, clarity, patient acceptance, and satisfaction and was found to be extremely useful. We use it in our clinic, and it works.

Although we advocated a randomized, controlled trial to compare the board to usual practice, there are major methodologic and ethical obstacles to be overcome. Llewellyn-Thomas and colleagues' suggestion that the probability trade-off method combined with the decision board might be even more effective at communicating information should be tested empirically. However, when a patient with breast cancer first presents to an oncologist, she is often anxious and afraid. Thus, unlike the case of a hypothetical cancer trial (as in studies by Llewellyn-Thomas and associates), the manipulation of recurrence probabilities at the decision-making point (that is, with a real patient) could present problems.

We do not agree that a trial is necessary "before the decision board alone is disseminated into the clinical setting". This confuses two issues: the question of whether the decision board is an improvement on current practice and the need to further improve the process of information transfer. As we noted, "we hope that our decision board will encourage others to develop more innovative ways of transferring information to the patient in a clear and nonbiased way".

Dr. Callahan notes that more cancer patients than healthy volunteers opted for chemotherapy. It is important to emphasize again that the objective of our research was not to determine what proportion of women opted for treatment. Validity testing was done in healthy volunteers because we had great discomfort regarding the manipulation of probabilities and scenarios at the decision-making point in real patients. The success of the pilot work in healthy volunteers encouraged us to proceed with the use of the board at the decision-making point.

Dr. Callahan argues that fear and anxiety, combined with the human elements of denial and anger, may block a rational decision-making process. Because of our concern about the patient's ability to comprehend at the initial meeting, we have introduced a take-home version of the Board. Patients have time to think and ask questions before stating their preference for treatment. Finally, it is also important to emphasize that on Earth, in contrast to the planet Vulcan, emotional factors such as fear and anxiety are seen as legitimate parts of the patient's preference system and thus are an integral part of (rather than a barrier to) any rational decision-making process.