Giving meaning to patient reported outcomes in breast reconstruction after mastectomy - A systematic review of available scores and suggestions for further research

The Influence of Inset and Shaping of Abdominal-Based Free Flap Breast Reconstruction on Patient-Reported Aesthetic Outcome Scores-A Systematic Review

Background: Nowadays, multimodal cancer therapy results in very high survival rates of early-stage breast cancer and microsurgical flap-based breast reconstruction has become safe and reliable, with gradually increasing demand because of its durable and aesthetically pleasing results. This study aimed to explore the impact of different flap shaping and inset techniques on patient-reported outcome measures (PROMs) with regard to the aesthetic result in abdominal flap-based breast reconstruction. Methods: A systematic review was performed screening Pubmed, Cochrane Library and Web of Science for original articles reporting flap inset strategies, concomitantly providing PROMs on the aesthetic result. Results: Of 319 studies identified, six met the inclusion criteria. The studies described different flap rotation options according to the patient's morphology, different inset planes, and avoidance of the monitoring skin paddle, and suggested that a higher flap-to-mastectomy mass ratio was associated with better aesthetic results. In two comparative studies, according to the PROMs (BREAST-Q, Likert scale) and independent observer judgement, both higher patient satisfaction and superior aesthetic results were observed with the newly described techniques. Conclusions: Emphasis on the aesthetic outcome in terms of breast shape and symmetry, providing an individualized approach of flap inset, considering the contralateral breast's shape and volume, results in higher satisfaction scores.

Long-term patient-reported back and shoulder function after delayed breast reconstruction with a latissimus dorsi flap: case-control cohort study

BACKGROUND

Sacrifice of the latissimus dorsi (LD) muscle might entail donor site morbidity when used in delayed breast reconstruction. Previous studies are small, have short follow-up, and demonstrate diverging results. The aims of this study were to evaluate long-term patient-reported effects on shoulder and back function following LD flap harvest, and to investigate predictors for a worse outcome.

METHOD

This is a retrospective observational case-control cohort study. Cases were all patients who had undergone an LD flap reconstruction during the years 2007-2017. Controls were patients reconstructed with a deep inferior epigastric perforator (DIEP) flap during the same time period. Participants completed two validated questionnaires; the BREAST-Q reconstruction LD domains and the Western Ontario Shoulder Osteoarthritis Index (WOOS).

RESULTS

A total of 135 cases (75 per cent) and 118 controls (60 per cent) responded to the questionnaires. The mean follow-up time was 7 years. Patients reconstructed with a LD flap were significantly less satisfied with their back and shoulder function when compared to the DIEP controls, as measured with BREAST-Q and WOOS. Predictors for a poor patient-reported back and shoulder function included axillary surgery and axillary radiotherapy, especially when combined, as well as higher age at reconstruction.

CONCLUSION

Patients who have undergone LD flap for delayed breast reconstruction had a lower satisfaction with back and shoulder function, when compared to patients who had undergone a DIEP reconstruction. Delayed LD reconstruction should be used with care, especially in patients who have undergone axillary surgery and axillary radiotherapy.

Aesthetic outcomes of breast-conserving surgery and oncoplastic surgery with the new scale named Quality of Life Questionnaire Breast Reconstruction Module-23

Purpose

Oncoplastic surgery (OPS) has been developed with the aim of improving breast-conserving surgery (BCS) to provide better aesthetic and functional outcomes for breast cancer patients. We aimed to compare overall quality of life (QoL) and satisfaction with breast reconstruction in patients undergoing BCS and OPS using the Quality of Life Questionnaire Core 30 (QLQ-C30) and recently validated QLQ-Breast Reconstruction module (QLQ-BRECON23).

Methods

A total of 87 patients were included in this single-center study between January 1, 2018 and December 31, 2021; 43 underwent OPS (49.4%) and 44 underwent BCS (50.6%). The data on patient, tumor, and treatment characteristics were obtained from the prospectively collected database at the hospital. QLQ-C30 and QLQ-BRECON23 were used to evaluate psychosocial well-being, fatigue symptoms, overall QoL, sexual well-being, sensation of the operative area, and satisfaction with the reconstruction.

Results

According to QLQ-C30 evaluation there were significantly better outcomes for patients treated with OPS than BCS in terms of psychosocial well-being, fatigue symptoms, and overall QoL (P = 0.005, P = 0.016, and P = 0.004; respectively), according to QLQ-BRECON23 evaluation there were also significantly better outcomes in terms of sexual well-being, sensation of the operative area, and satisfaction of the reconstruction (P < 0.001, P = 0.002, and P < 0.001; respectively).

Conclusion

We found that the overall QoL and satisfaction with breast reconstruction in patients undergoing OPS are better than those undergoing BCS. Our study is critical because it is the first study comparing OPS and BCS using the QLQ-BRECON23, which was recently validated.

Breast sensorisexual function: a novel patient-reported outcome measure of sexual sensory functions of the breast

BACKGROUND

A validated measure assessing sexual sensory functions of the breast is needed to optimize sexual and other health outcomes after breast procedures.

AIM

To describe the development of a patient-reported outcome measure (PROM) to assess breast sensorisexual function (BSF).

METHODS

We applied the PROMIS standards (Patient Reported Outcomes Measurement Information System) for measure development and evaluation of validity. An initial conceptual model of BSF was developed with patients and experts. A literature review yielded a pool of 117 candidate items that underwent cognitive testing and iteration. Forty-eight items were administered to an ethnically diverse, national panel-based sample of sexually active women with breast cancer (n = 350) or without (n = 300). Psychometric analyses were performed.

OUTCOMES

The main outcome was BSF, a measure that assesses affective (satisfaction, pleasure, importance, pain, discomfort) and functional (touch, pressure, thermoreception, nipple erection) sensorisexual domains.

RESULTS

A bifactor model fit to 6 domains-excluding 2 domains with only 2 items each and 2 pain-related domains-revealed a single general factor representing BSF that may be adequately measured by the average of the items. This factor, with higher values denoting better function and with the standard deviation set to 1, was highest among women without breast cancer (mean, 0.24), intermediate among women with breast cancer but not bilateral mastectomy and reconstruction (-0.01), and lowest among those with bilateral mastectomy and reconstruction (-0.56). Between women with and without breast cancer, the BSF general factor accounted for 40%, 49%, and 100% of the difference in arousal, ability to orgasm, and sexual satisfaction, respectively. Items in each of 8 domains demonstrated unidimensionality (ie, they measured 1 underlying BSF trait) and high Cronbach's alphas for the entire sample (0.77-0.93) and the cancer group (0.71-0.95). Correlations with sexual function, health, and quality of life were positive for the BSF general factor and mostly negative for the pain domains.

CLINICAL IMPLICATIONS

The BSF PROM can be used to assess the impact of breast surgery or other procedures on the sexual sensory functions of the breast in women with and without breast cancer.

STRENGTHS AND LIMITATIONS

The BSF PROM was developed by using evidence-based standards, and it applies to sexually active women with and without breast cancer. Generalizability to sexually inactive women and other women warrants further study.

CONCLUSION

The BSF PROM is a measure of women's breast sensorisexual function with evidence of validity among women affected and unaffected by breast cancer.

Swedish Normative Scores for the BREAST-Q Reduction/Mastopexy Module

BACKGROUND

Norm values for patient reported outcomes, that is knowledge about how the general population of women rate their breast-related satisfaction and quality of life, are necessary to interpret the meaning of scores. The aims of this study were to create Swedish normative values for the BREAST-Q reduction/mastopexy module and to describe what healthy women are most satisfied/dissatisfied with regarding their breasts.

METHODS

A random sample of 400 women aged 18-80, currently living in Region Västra Götaland, were sent BREAST-Q reduction/mastopexy. Descriptive data are presented.

RESULTS

One hundred and forty-six women answered the questionnaire (36.5%). Mean total scores ranged from 48 to 78. No clear changes in scores could be seen with age and women with a high BMI seem to be less satisfied with their breasts. The participants were most satisfied with the appearance of the breasts when dressed, the appearance in the mirror dressed, the shape of the breasts with bra, and symmetry of size and most dissatisfied with appearance in the mirror naked and the shape of the breasts without a bra. Thirty to forty-five per cent of healthy women never or almost never feel sexually attractive. Among physical symptoms often described in breast hypertrophy, the most common among healthy women were lack of energy, pain in the neck, arms and shoulders, headache and difficulty performing intense physical activity.

CONCLUSION

The norms for BREAST-Q reduction/mastopexy add another piece to the puzzle to what constitutes normal breast satisfaction and how surgical outcomes can be evaluated.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Donor-Site Satisfaction of DIEP and Latissimus Dorsi Flaps-A Comparative Cohort Study

BACKGROUND

 Understanding of donor-site morbidity and satisfaction after breast reconstruction is limited. There are few previous studies comparing satisfaction with different donor sites in breast reconstruction. This study aimed to examine the long-term patient-reported satisfaction with the donor site of latissimus dorsi (LD) flaps in comparison to the deep inferior epigastric artery perforator (DIEP) flaps. Further, a systematic review of previously published studies was conducted.

METHODS

 In this retrospective cross-sectional study, all women who underwent breast reconstructions with either LD or DIEP flap following mastectomy and radiotherapy between 2007 and 2017 were included; patient-reported satisfaction was assessed using the BREAST-Q reconstruction module. For the systematic review, studies examining patient-reported abdominal satisfaction and well-being, and meeting the PICO (Population, Intervention, Comparison, and Outcome) criteria were included.

RESULTS

 Eligible and responding participants were divided into the LD (n = 135 patients) and DIEP (n = 118 patients) flap groups. Impairment due to muscular weakness of the donor site was more common in the LD group than that of the DIEP group. Bulging was common in the DIEP group and increased over time. Regarding the esthetic appearance of the donor site, the patients in the DIEP group were less satisfied than the LD group. The systematic review showed that most of the patients were dissatisfied with their abdomen after the operation.

CONCLUSION

 Patients who have undergone DIEP flap for breast reconstruction are less satisfied with the donor-site esthetics than those who have undergone LD flap. Patient-reported abdominal bulging was common in the DIEP group and the number seemed to increase over time. Most patients were not satisfied with their abdominal scarring postoperatively, as per the systematic review. These results may indicate a need for more nuanced preoperative patient information, as well as improvements in the surgical management of the donor site, for DIEP flap reconstructions.

Patient Reported Outcome and Quality of Life After Delayed Breast Reconstruction - An RCT Comparing Different Reconstructive Methods in Radiated and Non-radiated Patients

BACKGROUND

Health-related quality of life (HRQoL) is one of the core outcomes for breast reconstruction. The aim of this study was to evaluate whether the method of delayed breast reconstruction affects long-term HRQoL.

METHODS

Participants were divided into 2 arms depending on previous radiotherapy, and subsequently randomized between 2 methods of breast reconstruction: a latissimus dorsi flap or a deep inferior epigastric artery perforator flap in the radiated arm and a thoracodorsal flap and implant or an expander in the non-radiated arm. Validated HRQoL instruments were used: BREAST-Q to evaluate breast specific HRQoL and satisfaction, RAND-36 and EQ-5D to evaluate generic HRQoL, and BDI-21 to measure symptoms of depression and anxiety.

RESULTS

During the recruitment period (2009-2015), 233 patients were randomized. After opt-outs and exclusions, the remaining 107 participants comprise the study sample. Postoperative HrQoL was measured on average 7to 8years post-operatively. Response rates varied between 60 and 82 per cent. The BREAST-Q scores were higher after the reconstruction than before for the great majority of domains in both arms; albeit statistically significant only between the 2 methods for physical well-being chest in the radiated arm. Most participants in both arms had minimal or mild depression both before and after the operation.

CONCLUSION

No distinct differences in long-term HrQoL could be seen for different methods There was a clear improvement in HrQoL compared to pre-reconstruction in all groups, but the effect of specific reconstructive methods on scores could not be reliably demonstrated.