In a recent issue of Nursing Research, Lee and Knobf (2015) presented their findings relating medical decision-making for cancer treatment to satisfaction or regret in a Chinese American community in Primary Breast Cancer Decision-making Among Chinese American Women. The authors examined factors that lead to treatment decisions for breast cancer and correlated lower levels of satisfaction with decisional conflict, especially in socially or economically disadvantaged women who experience difficulty communicating with their physicians. I thoroughly enjoyed reading the paper and am pleased to learn of the progress regarding research in sparsely studied ethnic groups such as the Chinese American population.

The theoretical framework centered on the Ottawa decision support framework (Legare, O'Connor, Graham, Wells, & Tremblay, 2006), with emphasis on the expectancy value model, decisional conflict theory, and social support theory. The authors referred to the breast Cancer Decision-Making Questionnaire with Decisional Conflict and Regret scales that was made available in the Chinese language. This raises a question for me surrounding the use of this tool, which in its origin was validated with test subjects in Ottawa, Canada, with educated test subjects residing in a nation where healthcare is publicly funded. This leads me to question if a theoretical framework rooted in Westernized thought and experiences is fit for the population in this study. In addition, was the Chinese version of this tool validated in the population of interest? In my attempt to find this answer, I located two papers that addressed validation of this tool: one, in the United States regarding genetic testing (Katapodi, Munro, Pierce, & Williams, 2011) and another in Hong Kong (Lam et al., 2012) conducted among breast cancer patients. Both reported limitations of transferability, as the first studied a primarily homogenous, affluent, White population, and the second, although conducted in Chinese, removed the element of language barrier between patients and their respective providers. Lam et al. (2015) verified its reliability, but not its external validity, even stating, "The original proposed factor structure measuring decisional conflict may not be applicable across different populations (p. 218)." We learned from Walker and Avant (2011) that many theoretical models emerged from a Westernized point of view, which does not necessarily guarantee generalizability to more international communities. Thus, the word "conflict" may actually be considered a misnomer in situations where the female patient does not view her decision as merely her own, but as one that serves the needs of the family-negating the internal, emotional conflict. This tool uses questions that focus on shared decision-making with the dyad, the provider and the patient. However, ethnic groups from a Confucian background place more emphasis on shared decision-making as a community and family unit (Shek, 2006). Therefore, this tool could lack transference across Chinese American populations. Use of the Ottawa decision support framework ought to be tested in the population of interest to increase its meaningfulness and usefulness across diverse populations.

As Lee and Knobf pointed out, many Chinese American women elected to undergo mastectomies, which were perceived as a safer option. However, for our patients who rely on family support as a key role in the shared decision-making process, an informed consent process that includes families may also increase satisfaction for our patients. Therefore, the social support aspect of the theoretical framework deserves greater mention because it grounds decision-making more toward the support network and personal resources (Shorey & Lakey, 2006). Regarding resources, the authors mentioned that dissatisfaction following medical decision-making occurred at higher numbers for ethnic minorities and women with less financial independence-a source of reduced autonomy, but for different reasons. I applaud the authors for their acknowledgement of multiple confounders, such as recall bias from a retrospective viewpoint 3-12 months posttreatment and survivorship, and pointing out the relationship between dissatisfaction and language barriers that remain between provider and patient despite use of translation services.

In closing, this study increased my understanding surrounding medical decision-making in breast cancer patients, and I am excited to see forthcoming work from Lee and Knobf, especially in a population that has not yet been extensively studied. In addition, I would be very interested in learning more about validation of existing tools for diverse communities. Continued work is warranted for improved translation services, especially for the patients like the ones mentioned in Lee and Knobf's work, where true, informed consent could be enhanced when the patients have opportunities to have their questions answered to their satisfaction, in the language they understand, and with the necessary support people.

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