Understanding patient choices regarding breast reconstruction after mastectomy for breast cancer

Information needs in breast reconstruction after mastectomy: a qualitative analysis of free-text responses from 2077 women

BACKGROUND

For many, breast reconstruction following mastectomy (BR) forms an integral part of breast cancer survivorship. For those considering BR, provision of information is essential to allow informed decisions. Using free-text responses from a survey of breast cancer survivors, this study aims to understand current gaps in information regarding BR.

METHOD

At the end of an online survey assessing BR experiences, participants were asked the open-ended question: "Thinking about women who may experience BR in the future, is there anything you think needs to change so that they have a better experience?". Responses were analysed to identify common themes.

RESULTS

3384 people completed the survey with 2,077 (61%) responding to the open-ended question. Three themes were identified: (1) content of information, (2) managing expectations, and (3) information sources, each associated with multiple subthemes. Information wanted in theme (1) covered a range of topics including BR options, risks, recovery and 'going flat.' Information on BR's psychological impact was also needed, with comments indicating many were not prepared for this. Theme (2) stressed the importance of realistic information about BR outcomes and processes to reduce discrepancies between expectations and experiences. In theme (3), peer insights and photos were important sources of realistic information.

CONCLUSION

Multiple gaps exist in BR-related information available to women. BR information needs to be comprehensive, realistic, and provided at the right time to allow informed decision-making. Developing strategies to strengthen existing information provision as well as new resources to fill information gaps might enhance BR experiences.

The factors involved in surgical decision-making in younger women diagnosed with breast cancer in Aotearoa New Zealand: A qualitative analysis

Women diagnosed with breast cancer must make important surgical decisions. The decision-making process for younger women is complex, with this group more likely to have an advanced diagnosis and life-stage considerations that can impact on treatment. This study investigated the decision-making process of women aged <50 years who had undergone breast cancer surgery within the preceding 12 months in Aotearoa New Zealand. Twelve women participated in semi-structured qualitative interviews to explore the factors that influenced treatment decisions. Thematic analysis resulted in three themes. Fear was the main concept identified as the primary influence on initial decision-making. Good quality shared decision-making between patient and clinician was found to provide essential support during the diagnosis to treatment period. In addition, women expressed a need for multi-modal presentation of medical information and more material reflecting younger women. These findings inform provision for younger women making surgical decisions when diagnosed with breast cancer.

Key factors in the decision-making process for mastectomy alone or breast reconstruction: A qualitative analysis

Breast cancer is the most common cancer to affect New Zealand women. Women diagnosed face several decisions regarding surgical treatment, including whether to undergo lumpectomy, mastectomy, or breast reconstruction. Reconstructive surgery adds an additional layer of complexity, with several reconstructive options, each associated with differing surgical and recovery times. Furthermore, surgical decisions are often made under time-pressure and significant diagnostic distress, therefore provision of good information to support decision-making is crucial to adequately inform women of their options. We interviewed 24 women who had undergone breast surgery within the preceding 12 months to assess the key factors leading to their decision to opt for their chosen surgical procedure. Interviews revealed that decision-making was complex and involved multiple factors. Women were ultimately confronted with assessing feminine identity versus survival. Whether opting for breast reconstruction or not, women were fearful of what surgery would involve and how their reconstructed breast or mastectomy scar might look following surgery. Shared decision-making between patient and clinician can mitigate this fear and provide women with a sense of autonomy over their health decisions. Provision of visual depictions of surgical outcomes was not routinely provided to those interviewed but was expressed as important to help women manage surgical expectations. Therefore our findings support the multi-modal presentation of diagnostic and treatment information to support decision-making. Likewise, women reported feeling unsupported in their decision not to undergo breast reconstruction, suggesting a need to develop resources to provide women with positive discussions about 'going flat'.

An integrated interpreting service normalizes access to care for culturally and linguistically diverse (CALD) patients with colorectal cancer

AIM

To compare access to the initial management and overall survival with colorectal cancer for limited English proficient (LEP) patients compared with patients from an English background.

METHODS

All newly diagnosed patients from 2017 with colorectal cancer from a single health service with a highly multicultural catchment area and a well-developed and integrated translation and language support (TALS) department were recruited. Time from referral to: biopsy, date seen by a surgeon, oncologist, discussion at a multidisciplinary meeting (MDM), and day of commencement of the first treatment modality, and overall survival were analyzed.

RESULTS

One hundred sixty-two patients were analyzed, including 57 LEP patients from 22 countries of birth. Interpreters were present at 687/782 appointments with LEP patients. There were no differences in demographics or cancer staging. There were no differences between English background and LEP patients with regard to times from referral to biopsy (1 vs. 0 days), specialist review (surgical: 4 vs. 6 days, oncological: 45 vs. 57 days), MDM discussion (23 vs. 15 days), or commencement of treatment (32 vs. 28.5 days). There were no differences in treatment for colorectal cancer, although a higher rate of stomas was noted in LEP patients. There was no difference in overall survival between groups.

CONCLUSION

Time to critical initial checkpoints and overall survival were similar in LEP and English background patients with colorectal cancer. An integrated TALS department may abrogate the language and cultural barriers that are known to disadvantage LEP patients and may contribute to normalizing care for the culturally and linguistically diverse community.

Impact of Race, Ethnicity, Primary Language, and Insurance on Reconstruction after Mastectomy for Patients with Breast Cancer at an Urban, Academic Safety-Net Hospital

BACKGROUND

Disparities in breast reconstruction have been observed in national cohorts and single-institution studies based on race, ethnicity, insurance, and language. However, little is known regarding whether safety-net hospitals deliver more or less equitable breast reconstruction care in comparison with national cohorts.

STUDY DESIGN

We performed a retrospective study of patients with either invasive breast cancer or ductal carcinoma in situ diagnosed and treated at our institution (January 1, 2009, to December 31, 2014). The rate of, timing of, and approach to breast reconstruction were assessed by race, ethnicity, insurance status, and primary language among women who underwent mastectomy. Reasons for not performing reconstruction were also analyzed.

RESULTS

A total of 756 women with ductal carcinoma in situ or nonmetastatic invasive cancer were identified. The median age was 58.5 years, 56.2% were non-White, 33.1% were non-English-speaking, and 48.9% were Medicaid/uninsured patients. A total of 142 (18.8%) underwent mastectomy during their index operation. A total of 47.9% (n = 68) did not complete reconstruction. Reasons for not performing reconstruction included patient preference (n = 22), contraindication to immediate reconstruction (ie, locoregionally advanced disease prohibiting immediate reconstruction) without follow-up for consideration of delayed reconstruction (n = 12), prohibitive medical risk or contraindication (ie, morbid obesity; n = 8), and progression of disease, prohibiting reconstruction (n = 7). Immediate and delayed reconstruction were completed in 43.7% and 8.5% of patients. The rate of reconstruction was inversely associated with tumor stage (odds ratio 0.52, 95% CI 0.31 to 0.88), but not race, ethnicity, insurance, or language, on multivariate regression.

CONCLUSIONS

At a safety-net hospital, we observed rates of reconstruction at or greater than national estimates. After adjustment for clinical attributes, rates did not vary by race, ethnicity, insurance or language. Future research is needed to understand the role of reconstruction in breast cancer care and how to advance shared decision-making among diverse patients.

Impact of Patient Primary Language upon Immediate Breast Reconstruction After Mastectomy

BACKGROUND

Preoperative decision-making in patients who speak a primary language other than English is understudied. We investigated whether patient primary language is associated with differences in immediate breast reconstruction (IBR) after mastectomy.

PATIENTS AND METHODS

This retrospective observational study analyzed female patients undergoing mastectomy in the New Jersey State Inpatient Database (2009-2014). The primary outcome was the odds of IBR with a prespecified subanalysis of autologous tissue-based IBR. We used multivariable logistic regression and hierarchical generalized linear mixed models to control for patient characteristics and nesting within hospitals.

RESULTS

Of 13,846 discharges, 12,924 (93.3%) specified English as the patient's primary language, while 922 (6.7%) specified a language other than English. Among English-speaking patients, 6178 (47.8%) underwent IBR, including 2310 (17.9%) autologous reconstructions. Among patients with a primary language other than English, 339 (36.8%) underwent IBR, including 93 (10.1%) autologous reconstructions. Unadjusted results showed reduced odds of IBR overall [odds ratio (OR) 0.64, 95% CI 0.55-0.73], and autologous reconstruction specifically (OR 0.52, 95% CI 0.41-0.64) among patients with a primary language other than English. After adjustment for patient factors, this difference persisted among the autologous subgroup (OR 0.64, 95% CI 0.51-0.80) but not for IBR overall. A hierarchical model incorporating both patient characteristics and hospital-level effects continued to show a difference among the autologous subgroup (OR 0.75, 95% CI 0.58-0.97).

CONCLUSIONS

Primary language other than English was an independent risk factor for lower odds of autologous IBR after adjustments for patient and hospital effects. Focused efforts should be made to ensure that patients who speak a primary language other than English have access to high-quality shared decision-making for postmastectomy IBR.

Having breast reconstruction post-mastectomy: barriers and facilitators reported by Vietnamese- versus English-speaking women with breast cancer

Objective: Little is known about the experience of women of culturally and linguistically diverse (CALD) backgrounds in relation to breast reconstruction following mastectomy as treatment for their breast cancer. The aim of this study was to explore the factors that influenced Vietnamese- and English-speaking women's decisions about breast reconstruction post-mastectomy for their breast cancer, in Australia.Design: The participants in this study comprised of Vietnamese-speaking women of Vietnamese heritage, and English-speaking women from mixed ethnicities (Vietnamese included). In this qualitative study, Vietnamese-speaking and English-speaking women who had breast cancer treated by mastectomy with or without breast reconstruction participated in in-depth interviews. Interviews were undertaken in the woman's chosen language (Vietnamese or English), audio-recorded, transcribed/translated and analysed using thematic analysis.Results: Fourteen Vietnamese-speaking and 13 English-speaking patients were recruited. Participants identified age, lack of information, concerns regarding surgical procedure, fears about complications and cancer recurrence as barriers to breast reconstruction. Many more Vietnamese-speaking participants identified lack of information about breast reconstruction as a barrier compared to English-speaking participants. Both groups described the ability to wear clothing of their choice, partner influence, and the need to feel 'normal' as facilitators to having breast reconstruction. Vietnamese-speaking participants in particular identified doctor recommendation of breast reconstruction as a major facilitator.Conclusion: Lack of information about reconstruction was a persistent theme, though it was identified by more Vietnamese women as a barrier to having breast reconstruction. The results reinforce the importance of doctors' recommendations in helping particularly the Vietnamese women make an informed decision about reconstruction following mastectomy as treatment for their breast cancer.

Development of a patient decision aid for patients with breast cancer who consider immediate breast reconstruction after mastectomy

Purpose

The aim of this study was to develop a patient decision aid (pDA) that could support patients with breast cancer (BC) in making an informed decision about breast reconstruction (BR) after mastectomy.

Methods

The development included four stages: (i) Establishment of a multidisciplinary team; (ii) Needs assessment consisting of semi‐structured interviews in patients and a survey among healthcare professionals (HCPs); (iii) Creation of content, design and technical system; and (iv) Acceptability and usability testing using a think‐aloud approach in patients and interviews among HCPs and representatives of the Dutch Breast Cancer Patient Organization.

Results

From the needs assessment, three themes were identified: Challenging period to make a decision, Diverse motivations for a personal decision and Information needed to make a decision about BR. HCPs valued the development of a pDA, especially to prepare patients for consultation. The pDA that was developed contained three parts: first, a consultation sheet for oncological breast surgeons to introduce the choice; second, an online tool including an overview of reconstructive options, the pros and cons of each option, information on the consequences of each option for daily life, exercises to clarify personal values and patient stories; and third, a summary sheet with patients’ values, preferences and questions to help inform and guide the discussion between the patient and her plastic surgeon. The pDA was perceived to be informative, helpful and easy to use by patients and HCPs.

Conclusion

Consistent with information needs, a pDA was developed to support patients with BC who consider immediate BR in making an informed decision together with their plastic surgeon.

Patient or Public Contribution

Patients participated in the needs assessment and in acceptability and usability testing.

Dissatisfaction After Post-Mastectomy Breast Reconstruction: A Mixed-Methods Study

BACKGROUND

Breast reconstruction is associated with improved patient well-being after mastectomy; however, factors that contribute to post-surgical dissatisfaction remain poorly characterized.

METHODS

Adult women who underwent post-mastectomy implant-based or autologous breast reconstruction between 2015 and 2019 were recruited to participate in semi-structured interviews regarding their lived experiences with reconstructive care. Participants completed the BREAST-Q, and tabulated scores were used to dichotomize patient-reported outcomes as satisfied or dissatisfied (high or low) for each BREAST-Q domain. A convergent mixed-methods analysis was used to evaluate interviews for content related to satisfaction or dissatisfaction with breast reconstruction.

RESULTS

Overall, we interviewed 21 women and identified 17 subcodes that corresponded with the five BREAST-Q domains. Sources of dissatisfaction were found to be related to the following domains: (a) low breast satisfaction due to asymmetry, cup size, and lack of sensation and physical feeling (n = 8, 38%); (b) poor sexual well-being due to shape, look and feel (n = 7, 78% [of 9 who discussed sexual well-being]); (c) reduced physical well-being of the chest due to persistent pain and weakness (n = 11, 52%); (d) reduced abdominal well-being due to changes in abdominal strength, numbness, and posture (n = 6, 38% [of 16 who underwent abdominally based reconstruction]); and (e) low psychosocial well-being impacted by an unexpected appearance that negatively influenced self-confidence and self-identity (n = 13, 62%).

CONCLUSION

Patients may be unprepared for the physical, sexual, and psychosocial outcomes of breast reconstruction. Targeted strategies to improve preoperative education and shared decision making are needed to mitigate unexpectedness associated with breast reconstruction and related outcomes.

Equity across the cancer care continuum for culturally and linguistically diverse migrants living in Australia: a scoping review

International evidence suggests migrants experience inequitable access, outcomes and treatment quality across the cancer care continuum. There is currently limited research assessing equity across the cancer care continuum for culturally and linguistically diverse migrants living in Australia. A detailed protocol and search strategy were developed and used to identify all relevant literature, utilising the Joanna Briggs Institute Reviewer’s Manual. Systematic searching was conducted via multiple databases and identified studies were screened against pre-identified inclusion and exclusion criteria. 71 studies met the inclusion criteria for analysis. Most studies examined cancer detection via screening. Very few studies examined cancer prevention, diagnosis, treatment or palliative care. Most studies focused on patient-sided barriers to care and there was a paucity of information regarding institutional barriers to health. Cancer-related outcomes were seldom examined, and most studies were qualitative or behavioral analysis. Results highlighted significant communication issues spanning the cancer care continuum and a context of inadequate support for both patients and clinicians. There is a demonstrable need to examine equity in access and outcomes for culturally and linguistically diverse cancer populations. This requires the identification of cancer-related disparities and an examination of institutional barriers to care. Through addressing this dearth of information, future research and health policy can support the operationalisation of health equity.

Definitions of Culturally and Linguistically Diverse (CALD): A Literature Review of Epidemiological Research in Australia

Objective: To identify how Culturally and Linguistically Diverse (CALD) communities are defined in epidemiological research in Australia and provide a definition of CALD status that aids the consistency and interpretability of epidemiological studies. Methods: Peer-reviewed literature from January 2015 to May 2020 was searched via four databases (Ovid Medline combined with PubMed, Embase, Emcare, and CINAHL) to identify quantitative studies of CALD people in Australia. Results: A total of 108 studies met the criteria for inclusion in the review. Country of birth was the most commonly used CALD definition (n = 33, 30.6%), with combinations of two or more components also frequently used (n = 31, 28.7%). No studies used all the components suggested as core to defining CALD status. including country of birth, languages other than English spoken at home, English proficiency, and indigenous status. Conclusions: There was considerable inconsistency in how CALD status was defined. The review suggests that CALD status would best be defined as people born in non-English speaking countries, and/or who do not speak English at home. Additionally, indigenous peoples should be considered separately. This recommended definition will support the better identification of potential health disparity and needs in CALD and indigenous communities.

The Predictive Role of Body Image and Sexual Function in Quality of Life After Modified Radical Mastectomy Regarding the Mediating Role of Emotion; A Cross Sectional Study

Background: Mastectomy has negative effects on body image, sexual function, and quality of life (QOL). Additionally, maladaptive emotion regulation strategy is considered a trans-diagnostic mechanism underlying the psychiatric syndrome in these patients. Objectives: The predictive role of body image and sexual function in QOL regarding the mediating role of difficulty in emotion regulation has not been studied yet. Methods: In a correlational study, from March to December 2016, among patients undergoing modified radical mastectomy (MRM) at Early-stage Breast Cancer (BC), 90 patients were selected, using respondent-driven sampling (RDS). To collect the data, the Multidimensional Body-Self Relations Questionnaire (MBSRQ), the Persian language version of the Female Sexual Function Index (P-FSFI), QOL questionnaire, and Difficulties in Emotion Regulation Scales (DERS) were used. Data were analyzed through Pearson's correlation coefficient, regression analysis, and path analysis, using AMOS and SPSS software version 22 and the significance criterion was considered 0.05. Results: Data analysis showed a direct relationship between body image and sexual function with QOL, and it had an inverse relationship with difficulty in emotion regulation (P < 0.01). Also, body image, sexual function, and difficulty in emotion regulation were predictors of QOL (P < 0.01). Besides, in predicting QOL based on sexual function and body image, the difficulty in emotion regulation has a mediating role (P < 0.01). Conclusions: In patients with breast cancer under mastectomy, proper sexual function, sexual attraction depending on body image, and QOL were influenced by emotion regulation. Reducing the difficulty in emotion regulation through emotion-focused interventions can improve QOL in patients.

Effect of Perceptual Stress Reduction Control Intervention on the Level of Symptoms in Breast Cancer at Different Time Points

Background

To investigate the effect of perceptual stress reduction control intervention on the level of symptomatic groups at different time points in breast cancer.

Methods

A total of 124 breast cancer patients were divided into intervention group and control group, 62 cases in each group. Perioperative nursing and chemotherapy nursing were given to the control group, and the intervention group was given the interventional stress reduction control intervention. The level of symptom clusters of different time points were compared between the two groups.

Results

The incidence and severity of myelosuppression in the intervention group were slightly lower than those in the control group. The adverse reactions of bone marrow suppression at T3 were much lower than those in the control group, and the differences were significant (P=0.003, P=0.043). The control group had higher incidence and more severe symptoms of nausea, vomiting and diarrhea than the intervention group (P=0.002, P=0.042). The symptoms of breast pain and swelling at T1 in the intervention group were significantly lower than those in the control group (P=0.000, P=0.000). There was no significant difference in breast symptoms between the two groups at T2 and T3 (p>0.05). At the time of T2 and T3 of chemotherapy, the health promotion behavior scores of the intervention group were higher than the control group, and the difference was statistically significant (P_T2=0.000, P_T3=0.000).

Conclusion

Perceptual stress reduction control intervention can effectively relieve bone marrow suppression, digestive tract discomfort and breast symptoms, and promote health promotion behavior.

Breast reconstruction in South Western Sydney

BACKGROUND

The rates of breast reconstruction in Australian patients of culturally and linguistically diverse (CALD) backgrounds are currently unknown. This retrospective study determined the rate of breast reconstruction in women who had mastectomy as treatment for breast cancer at public hospitals in South Western Sydney Local Health District (SWSLHD) - a culturally diverse health district in New South Wales, Australia - and compared the rate of reconstruction in the CALD and non-CALD populations.

METHODS

The demographic and clinical data of all female patients who had mastectomy with or without reconstruction for treatment of breast cancer at the five public hospitals in SWSLHD between January 2006 and December 2015 were obtained from the clinical information department of each hospital and from electronic medical records.

RESULTS

The average rate of reconstruction in SWSLHD was 9.4% for 2006-2015. Although the reconstruction rate was higher among English-speaking women (9.9%) compared to women from a CALD background (8.6%), the difference was not statistically significant (P = 0.57). The type (autologous versus implant) and timing (immediate versus delayed) of reconstruction did not differ between groups (P = 0.19 and P = 0.22, respectively). The Index of Relative Socio-Economic Disadvantage was not significantly associated with reconstruction (P = 0.74). However, younger patients were more likely to have reconstruction (P < 0.0001) and patients with adjuvant therapy were more likely to have a delayed reconstruction (P = 0.01).

CONCLUSION

This study found a low breast reconstruction rate in public hospitals in SWSLHD. The reconstruction rate did not differ between CALD or English-speaking patients, or between patients from diverse socio-economic backgrounds.

One for two, ipsilateral reduction and contralateral reconstruction mammoplasty: A case report

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There is a considerable debate regarding implant or autologous reconstruction of breast.

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Single session reduction mammoplasty with contralateral autologous reconstruction is feasible.

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A novel procedure has been presented.

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Dividing the contralateral breast and creating a myocutaneous flap for reconstruction.

Introduction

The aim of this paper is to introduce a novel procedure for concomitant contralateral reduction and ipsilateral reconstruction mammoplasty by dividing the contralateral breast and creating a pectoralis myocutaneous flap for reconstruction.

Presentation of case

A 34-year-old female, with a history of left side mastectomy presented for reconstruction. Under general anesthesia, the scar of the previous operation was resected in an elliptical shaped incision, the right breast was divided in middle, leaving the flap (pectoralis myocutaneous flap) with pectoralis branch of thoracoacromial artery. The superiomedial part of right breast (the flap) was rotated under the bridge of intermammary skin into the left incision. Ten days after the operation, the flap was viable and healthy.

Discussion

The aim of breast reconstruction is to provide psychosocial support and improve quality of life in the long term by restoring the shape of the breast surgically. New techniques have emerged constantly, and each comes with its list of advantages and risks. The benefits of reconstruction are clear, yet often it is not found as a part of breast cancer treatment routinely.

Conclusion

In single session reduction mammoplasty in one breast and using the resected piece as a flap to reconstruct the contralateral breast is possible whenever indication.

Psychological Aspects of Breast Reconstruction after Breast Cancer

Even though breast cancer mortality is declining, the diagnosis still poses a huge threat for the affected woman and her close family. Breast cancer surgery, which often includes reconstructive procedures, can help restoring a satisfactory body image. The decision on the type of surgery should always be made together with the patient and should focus on her psychosocial needs. This review describes the psychological aspects of breast cancer for the patient and her social environment and offers ideas for a patient-oriented treatment plan.

The impact of an online patient decision aid for women with breast cancer considering immediate breast reconstruction: study protocol of a multicenter randomized controlled trial

Background

Most breast cancer patients undergoing mastectomy are candidates for breast reconstruction. Deciding about breast reconstruction is complex and the preference-sensitive nature of this decision requires an approach of shared decision making between patient and doctor. Women considering breast reconstruction have expressed a need for decision support. We developed an online patient decision aid (pDA) to support decision making in women considering immediate breast reconstruction. The primary aim of this study is to assess the impact of the pDA in reducing decisional conflict, and more generally, on the decision-making process and the decision quality. Additionally, we will investigate the pDA’s impact on health outcomes, explore predictors, and assess its cost-effectiveness.

Methods

A multicenter, two-armed randomized controlled trial (1:1) will be conducted. Women with breast cancer or ductal carcinoma in situ who will undergo a mastectomy and are eligible for immediate breast reconstruction will be invited to participate. The intervention group will receive access to the online pDA, whereas the control group will receive a widely available free information leaflet on breast reconstruction. Participants will complete online questionnaires at: baseline (T0), 1 week after consultation with a plastic surgeon (T1), and 3 (T2) and 12 months (T3) after surgery. The primary outcome is decisional conflict. Secondary outcomes include other measures reflecting the decision-making process and decision quality (e.g., decision regret), patient-reported health outcomes (e.g., satisfaction with the breasts) and costs.

Discussion

This study will provide evidence about the impact of an online pDA for women who will undergo mastectomy and are deciding about breast reconstruction. It will contribute to the knowledge on how to optimally support women in making this difficult decision.

Trial registration

This study is retrospectively registered at ClinicalTrials.gov (NCT03791138).