An exploration of patient decision-making for autologous breast reconstructive surgery following a mastectomy

Behaviour, barriers and facilitators of shared decision making in breast cancer surgical treatment: A qualitative systematic review using a 'Best Fit' framework approach

BACKGROUND

Due to the diversity and high sensitivity of the treatment, there were difficulties and uncertainties in the breast cancer surgical decision-making process. We aimed to describe the patient's decision-making behaviour and shared decision-making (SDM)-related barriers and facilitators in breast cancer surgical treatment.

METHODS

We searched eight databases for qualitative studies and mixed-method studies about breast cancer patients' surgical decision-making process from inception to March 2021. The quality of the studies was critically appraised by two researchers independently. We used a 'best fit framework approach' to analyze and synthesize the evidence.

RESULTS

Twenty-eight qualitative studies and three mixed-method studies were included in this study. Four themes and 10 subthemes were extracted: (a) struggling with various considerations, (b) actual decision-making behaviours, (c) SDM not routinely implemented and (d) multiple facilitators and barriers to SDM.

CONCLUSIONS

Patients had various considerations of breast surgery and SDM was not routinely implemented. There was a discrepancy between information exchange behaviours, value clarification, decision support utilization and SDM due to cognitive and behavioural biases. When individuals made surgical decisions, their behaviours were affected by individual-level and system-level factors. Therefore, healthcare providers and other stakeholders should constantly improve communication skills and collaboration, and emphasize the importance of decision support, so as to embed SDM into routine practice.

PATIENT AND PUBLIC CONTRIBUTION

This systematic review was conducted as part of a wider research entitled: Breast cancer patients' actual participation roles in surgical decision making: a mixed method research. The results of this project helped us to better analyze and generalize patients' views.

The relationship between immediate postmastectomy reconstruction modalities and survival benefits in patients with triple negative breast cancer

INTRODUCTION

Immediate postmastectomy reconstruction for breast cancer has been widely used due to its unique esthetic and psychological effects. However, no other population-based study has investigated the effects of different reconstruction types on the survival in patients with triple negative breast cancer (TNBC).

METHODS

We selected patients who met the eligibility criteria from the Surveillance, Epidemiology, and End Results cancer registry (N = 9760). We then assessed the effect of different reconstructive surgical approaches (implant, autologous, implant and autologous combined reconstruction) on the overall survival (OS) and breast cancer-specific survival (BCSS) by using the Kaplan-Meier survival curve and Cox proportional hazard regression analyses. The nomograms were used to predict OS and BCSS. And the competitive risk model was used to assess breast cancer-specific death (BCSD) and non-breast cancer-specific death (NBCSD).

RESULTS

Statistical analysis suggested that the three reconstruction methods had better OS and BCSS with lower hazard than mastectomy alone (log-rank test, p < 0.05). Multivariate stratified analysis showed that patients aged 40-60 years had the greatest improvement in OS (Adjusted hazard ratio [AHR], 0.646; 95% Confidence Interval [CI], 0.439-0.950; p = 0.026) with combined reconstruction. BCSS could be improved only by implant reconstruction (AHR, 0.672; 95% CI, 0.514-0.878; p = 0.004). In addition, autologous reconstruction (AHR, 0.570; 95% CI, 0.350-0.929; p = 0.024) and implant reconstruction (AHR, 0.538; 95% CI, 0.339-0.853; p = 0.008) improved OS in patients >60 years of age. The survival prediction model quantified the survival benefits of TNBC patients undergoing different surgeries. Moreover, the C-indexes showed the good predictive ability of the nomograms.

CONCLUSIONS

Our results suggest that for TNBC patients, there is a survival benefit of immediate postmastectomy reconstruction compared with mastectomy alone. Among them, implant reconstruction has the most obvious advantage.

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.

Considering the type and timing of breast reconstruction after mastectomy: Qualitative insights into women's decision-making

PURPOSE

The information women receive about the type and timing of breast reconstruction (BR) from healthcare providers is crucial to help them make an informed decision, and this is particularly important in complex cases and/or high-risk cases. This study sought to provide qualitative insights into Australian women's BR decision-making experiences.

METHOD

Twenty-nine women who had received a mastectomy and made decisions about BR, including the type (expander, implant and/or autologous) and timing (immediate, delayed or immediate-delayed), participated in semi-structured telephone interviews. Interviews were analysed thematically using the Framework method.

RESULTS

Seven themes were identified: 1) information provision and needs; 2) values and preferences; 3) pressure to decide; 4) feasibility (e.g. clinical and/or financial factors); 5) social influence and support; 6) multidisciplinary team and organisational structures; and 7) decision implementation and outcomes. Breast care nurse support, as well as collaboration and communication within multidisciplinary teams were perceived by women as facilitating the BR decision-making process.

CONCLUSIONS

The identified themes offer an in-depth explanation of how a sample of Australian women make BR decisions. The current findings highlight the often limited clinician-patient information-sharing and demonstrate the overarching influence of the multidisciplinary medical team and organisational structures on BR decision-making. Development of in-consult decision-aids and strategies to improve multidisciplinary care are discussed.

Preconsultation Educational Group Intervention Can Address the Knowledge Gap in Postmastectomy Breast Reconstruction

BACKGROUND

Whether to undergo postmastectomy breast reconstruction (PMBR) is a challenging, preference-sensitive decision. It is therefore paramount to optimize decision quality through ensuring patients' knowledge and aligning treatments with their personal preferences. This study assessed the effects of a preconsultation educational group intervention (PEGI) on patient knowledge, state-trait anxiety, and decisional conflict (patient uncertainty in decision making) during the decision-making process.

METHODS

This phase 3 randomized controlled trial assessed effects of a PEGI in women without active breast cancer undergoing delayed PMBR, or prophylactic mastectomy with immediate PMBR. Both groups underwent routine education before consultation. In addition, the intervention group underwent a PEGI composed of presentations from a plastic surgeon and nurse, a value clarification exercise, and shared experiences from PMBR patients before the consultation with the plastic surgeon. Before and 1-week after consultation, outcome measures were assessed using the Decisional Conflict Scale, State-Trait Anxiety Inventory, and the BREAST-Q.

RESULTS

Of the 219 women deemed eligible, a total of 156 women were recruited and randomized. Treatment fidelity was 96% and retention was 88%. At baseline, there were no significant differences in terms of demographic or clinical status, knowledge, state-trait anxiety, and decisional conflict. Patient knowledge about PMBR improved in both groups; however, the degree of knowledge attainment was significantly greater in the PEGI group (24.5% improvement in the intervention group compared with 13.5% in the routine education group, P < 0.001). The reduction in decisional conflict from baseline to follow-up was greater in the intervention group compared with the routine education; however, the difference only approached significance (P = 0.09).

CONCLUSIONS

The provision of a preconsultation educational group intervention has been shown to significantly close the knowledge gap on PMBR in patients seeking delayed breast reconstruction or prophylactic mastectomy with immediate breast reconstruction compared with routine education alone.

Shared Decision-Making in Breast Reconstruction for Breast Cancer Patients: A Scoping Review

For most breast cancer (BC) patients who have undergone a mastectomy, the decision whether to proceed with breast reconstruction (BR) is complicated and requires deliberation. Shared decision-making (SDM) helps to address those needs and promote informed value-based decisions. However, little is known about the SDM status for BR in BC patients. This scoping review describes: 1) basic characteristics of studies on BR SDM in BC patients; 2) factors influencing BR SDM in BC patients; 3) experience and perception of BR SDM in BC patients; and 4) outcome measures reported. This review was performed in accordance with the Arksey and O'Malley methodology. A total of 5 English and 4 Chinese databases were searched, as well as different sources from grey literature. The data extraction form was developed by referring to the objectives and the Ottawa Decision Support Framework (ODSF). Data was analyzed using thematic analysis, framework analysis and descriptive statistics, with findings presented in the tables and diagrams. A total of 1481 records were retrieved and 42 of these included after screening. In 21 (21/42, 50%) of the studies, patient decision aids (PDAs) were utilized, and in 17 (17/42, 40.48%) of the studies, the factors influencing the implementation of SDM were explored. Of these 17 studies, the factors influencing the implementation of SDM were categorized into the following: the patient level (17/17, 100%), the healthcare level (2/17, 11.76%) and the organizational and system level (7/17, 41.18%). A total of 8 (19.05%) of the 42 studies focused on patients' experiences and perceptions of SDM, and all studies used qualitative research methods. Of these 8 studies, a total of 7 (7/8, 87.50%) focused on patients' experiences of SDM participation, and 4 (4/8, 50.00%) focused on patients' perceptions of SDM. A total of 24 studies (24/42, 57.14%) involved quantitative outcome measures, where 49 items were divided into three classifications according to the outcomes of ODSF: the quality of the decision (17/24, 70.83%), the quality of the decision-making process (20/24, 83.33%), and impact (13/24, 54.17%). Although researchers have paid less attention to other research points in the field of SDM, compared to the design and application of SDM interventional tools, the research team still presents some equally noteworthy points through scoping review. For instance, the various factors influencing BC patients' participation in SDM for BR (especially at the healthcare provider level and at the organizational system level), patients' experiences and perceptions. Systematic reviews (SRs) should be conducted to quantify the impact of these different factors on BR SDM. Implementation of scientific theories and methods can inform the exploration and integration of these factors.

Delivering Breast Reconstruction Information to Patients-Part 2: Women Report on Preferred Information Content

Purpose

To determine the type of information women want to be provided in order to make an informed decision as to whether, when, and using what technique to proceed with breast reconstruction.

Method

Using purposeful sampling, 19 patients who had recently undergone various breast reconstruction procedures were recruited to each participate in a 30- to 45-minute semi-structured interview. Participants shared their insights and beliefs regarding the type of breast reconstruction information they most valued prior to undergoing breast reconstruction surgery. Participants were also queried as to perceived information gaps. In some cases, the participants' partners or support persons were also interviewed. Grounded theory and thematic analysis assisted in interview transcript analysis.

Results

Eight topics were identified relating to women's informational needs around breast reconstruction. Examples include how to weigh the pros and cons of various breast reconstruction options to decide between flap or implant reconstruction, whether there are safety concerns with immediate breast reconstruction or nipple-sparing reconstruction, and expectations and advice on how to manage possibly unexpected intimacy issues after breast reconstruction.

Conclusions

Using mixed methods research methodology, 19 women reported on preoperative informational gaps relating to their recent breast reconstruction experiences. Patients report that adequate breast reconstruction information prior to breast reconstruction surgery helps them to manage their expectations, prepare for surgery and recovery, and improve postoperative satisfaction.

Patients' satisfaction with the reconstructive options provided to them measured 18 months after mastectomy surgery for breast cancer

INTRODUCTION

Mastectomy patients' satisfaction with reconstructive options has not been examined.

METHODS

A national study measured 18-month satisfaction with reconstructive options and collected case-mix and reconstructive offer and uptake data on breast cancer patients having mastectomy with or without immediate reconstruction (IR) in England between January 2008 and March 2009. Multivariable logistic regression examined the relationship between satisfaction, age, IR offer and uptake, and clinical suitability.

RESULTS

Of 4796 patients, 1889 were not offered IR, 1489 declined an offer and 1418 underwent it. Women not offered IR were more likely older, obese or smokers and had higher ASA grades, ECOG scores, tumour burdens and adjuvant chemotherapy and radiotherapy likelihoods (9% of lowest suitability group offered IR; 81% in highest suitability group). 83.7% were satisfied with their reconstructive options, varying significantly by IR offer and uptake (76.1% for those not offered IR; 85.8% for those who declined IR; 91.7% following IR). Older women and women deemed more suitable for IR were more often satisfied (p-values <0.001).

CONCLUSIONS

Satisfaction varied by offer and uptake status, age and suitability score. Clinicians should target equity for women deemed unsuitable by exploring their needs and desired outcomes, standardising operative fitness assessments and utilising shared decision-making aids.

Patient satisfaction and quality of life in breast reconstruction: assessment of outcomes of immediate, delayed, and nonreconstruction

Objectives

This study was conducted aiming to assess the quality of life and satisfaction of women who had mastectomy treated with and without breast reconstruction.

Results

A total of 81 women who had mastectomy were included, of whom 53 (65.4%) underwent breast reconstruction. Quality of life was not significantly better in the reconstruction group than the nonreconstruction group. Satisfaction with the surgically operated breast, whether reconstructed or not, was positively correlated with quality of life (p = 0.004). There was no significant difference in quality of life between women with immediate and late reconstruction. This study showed that the satisfaction of patients with the operated breast, reconstructed or not, is more important in quality of life than whether the breast was reconstructed or not. When we analyzed the quality of life of women who had mastectomy who were dissatisfied with their unreconstructed breasts, we observed that nonreconstruction had a negative impact on the quality of life.

Quality of life, patient satisfaction and cosmetic outcome after delayed breast reconstruction using DIEP flap: a 10 years' follow-up survey

Autologous breast reconstruction (BR) aims to restore body image and improve health-related quality of life in women undergoing mastectomy due to breast cancer. We wanted to explore patient-reported cosmetic results and satisfaction 10 or more years post BR surgery, using deep inferior epigastric perforator flap (DIEP). This is a follow-up study based on the same patient population of 34 patients undergoing delayed DIEP-flap procedure during 2001-2004 at Oslo University Hospital investigated by our group and published in 2008; Four patients died during the 10 years' follow-up time and four patients with total or partial flap failure were excluded. The average age for reconstruction was 51.4 years (SD 5.8). The participants answered study-specific questions based on the first study, evaluated cosmetic results using the visual analog scale (VAS) and BREAST-Q post-mastectomy reconstruction module. The response rate was 85% (22/26). A significantly reduced number of patients reported satisfaction with the appearance of breasts (p = .035). The consistency of the reconstructed breast was significantly better evaluated with VAS score (p = .039). The patients reported overall satisfactory results based on Q-scores using the BREAST-Q post-mastectomy reconstruction module. Patients reported a generally high level of satisfaction with BR and cosmetic results 10 or more years after delayed DIEP-flap procedure. Although a significantly decreased number of patients reported satisfaction with the appearance of the breast, almost all patients would have chosen BR again, and the consistency of the reconstructed breast was evaluated as improved.

Delivering Breast Reconstruction Information to Patients: Women Report on Preferred Information Delivery Styles and Options

Purpose

To discover missed opportunities for providing information to women undergoing breast reconstruction in an effort to decrease regret and improve patient education, teaching modalities, and satisfaction.

Method

Thirty- to 45-minute semi-structured interviews were conducted exploring patient experiences with information provision on breast reconstruction. Purposeful sampling was used to include women with a variety of reconstruction types at different time points along their recovery. Using grounded theory methodology, 2 independent reviewers analyzed the transcripts and generated thematic codes based on patient responses. BREAST-Q scores were also collected to compare satisfaction scores with qualitative responses.

Results

Patients were interested in a wide variety of topics related to breast reconstruction including the pros and cons of different options, nipple-sparing mastectomies, immediate breast reconstruction, oncological safety/monitoring and the impact of chemotherapy and radiotherapy, secondary procedures (balancing, nipple reconstruction), post-operative recovery, and long-term expectations. Patients valued accessing information from multiple sources, seeing numerous photographs, being guided to reliable information online, and having access to a frequently asked questions file or document. Information delivery via interaction with medical personnel and previously reconstructed patients was most appreciated. Compared with BREAST-Q scores for satisfaction with the plastic surgeon (mean: 95.7, range: 60-100), informational satisfaction scores were lower at 74.7 (50-100), confirming the informational gaps expressed by interviewees.

Conclusions

Women having recently undergone breast reconstruction reported key deficiencies in information provided prior to surgery and identified preferred information delivery options. Addressing women's educational needs is important to achieve appropriate expectations and improve satisfaction.

Making decisions about breast reconstruction: A systematic review of patient-reported factors influencing choice

PURPOSE

Many studies have explored women's reasons for choosing or declining a particular type of breast reconstruction (BR) following mastectomy for breast cancer. This systematic review synthesises women's reasons for choosing a range of BR options, including no BR, in different settings and across time.

METHODS

Thirteen databases were systematically searched, with 30 studies (4269 participants), meeting the selection criteria. Information on study aim and time frame, participation rate, design/methods, limitations/bias, reasons and conclusions, as well as participant clinical and demographic information, was reported. An overall quality score was generated for each study. Reasons were grouped into eight domains.

RESULTS

While study methodology and results were heterogeneous, all reported reasons were covered by the eight domains: Feeling/looking normal; Feeling/looking good; Being practical; Influence of others; Relationship expectations; Fear; Timing; and Unnecessary. We found a strong consistency in reasons across studies, ranging from 52% of relevant publications citing relationship expectations as a reason for choosing BR, up to 91% citing fear as a reason for delaying or declining BR. Major thematic findings were a lack of adequate information about BR, lack of genuine choice for women and additional access limitations due to health system barriers.

CONCLUSIONS

Understanding women's reasons for wanting or not wanting BR can assist clinicians to help women make choices most aligned with their individual values and needs. Our thematic findings have equity implications and illustrate the need for surgeons to discuss all clinically appropriate BR options with mastectomy patients, even if some options are not available locally.

Predictors of satisfaction and quality of life following post-mastectomy breast reconstruction

OBJECTIVE

Breast reconstruction is associated with multiple psychological benefits. However, few studies have identified clinical and psychological factors associated with improved satisfaction and quality of life. This study examined factors, which predict satisfaction with breast appearance, outcome satisfaction and quality of life following post-mastectomy breast reconstruction.

METHODS

Women who underwent post-mastectomy breast reconstruction between 2010 and 2016 received a postal questionnaire consisting of The BREAST-Q Patient Reported Outcomes Instrument, The European Organisation for Research and Treatment of Cancer QLQ-30 Questionnaire, The Patient and Observer Scar Assessment Scale, and a series of Visual-Analogue Scales. One hundredforty-eight women completed the questionnaire, a 56% response rate.

RESULTS

Hierarchical multiple regression analyses revealed psychosocial factors accounted for 75% of the variance in breast satisfaction, 68% for outcome satisfaction, and 46% forquality of life. Psychosocial well-being emerged as a significant predictor of satisfaction with breast appearance (β = .322) and outcome satisfaction (β = .406). Deep inferior epigastric perforator flap patients reported greater satisfaction with breast appearance (β = .120) and outcome satisfaction (β = .167).

CONCLUSIONS

This study extends beyond the limited research by distinguishing between satisfaction with breast appearance and outcome satisfaction. The study provides evidence for the role of psychosocial factors predicting key patient reported outcomes and demonstrates the importance of psychosocial well-being and reconstruction type. The findings also highlight the need for healthcare providers to consider the psychosocial well-being of patients both preoperatively and post operatively and provide preliminary evidence for the use of deep inferior epigastric perforator reconstructions over other types of reconstructive procedures.

Factors influencing the decision to pursue immediate breast reconstruction after mastectomy for breast cancer

BACKGROUND

Immediate breast reconstruction (IBR) after mastectomy has shown to be oncologically safe and to improve quality of life in breast cancer patients. However, most women undergoing mastectomy do not undergo IBR. In this study, we aim to identify breast surgeon-related factors in considering IBR and factors affecting patients' decision to choose for IBR.

METHODS

Retrospective analysis of the records of breast cancer patients who underwent mastectomy with or without IBR between 2010 and 2013. We documented all information whether or not a patient underwent IBR after mastectomy.

RESULTS

Of 437 patients, 97 (22.2%) underwent IBR, 89.8% of which received tissue expanders. Patient who did not undergo IBR had a higher age (62.2 versus 51.9 years, P<0.001) and higher body mass index (BMI) (27.0 versus 24.3, P<0.001). Hundred three patients declined IBR, mainly because considering reconstruction as too much trouble. In 128 cases the breast surgeon did not offer IBR, mostly because of the predicted need for post mastectomy radiation. Approximately 11% of the patients were not informed about IBR.

CONCLUSIONS

Anticipated radiation therapy, higher age and higher BMI were important breast surgeon-related factors in refraining from IBR. Almost one third of all patients declined IBR. In almost 10% of all patients, IBR was not discussed.

[Evaluation of the impact of breast reconstruction in women in couple through a community-based research tool: The Seintinelles]

This preliminary study explores the psychological and marital impact of breast reconstruction (or lack thereof) in women who had a mastectomy due to breast cancer. The study was carried out through an innovative and French community-based research tool on cancer: the Seintinelles. Sixty-nine partnered women treated for breast cancer participated, divided into 3 groups: 19 without breast reconstruction, 24 with immediate breast reconstruction and 26 with delayed breast reconstruction. They completed online questionnaires measuring both satisfaction and regret about the decision related to breast reconstruction, quality of life after breast surgery (EORTC-BRR), emotional state (POMS) and marital intimacy (PAIR). Recruitment through the Seintinelles had the advantage of being quick and national, but the profile of participants deviated from the mean population in the sense that our subjects were on average younger than women affected by breast cancer and had faced more breast cancer in their family. The results revealed that women are satisfied with their choice (little regret), have a similar emotional experience and good marital intimacy. However, women without breast reconstruction would less recommend their decision to others and were less satisfied with the aesthetic result, compared to women with breast reconstruction. These results highlight that psychological and marital impact seems comparable in women with and without reconstruction. Future studies are needed to better understand the role of the partner in the recourse of breast reconstruction.

An evaluation of factors affecting preference for immediate, delayed or no breast reconstruction in women with high-risk breast cancer

OBJECTIVE

Women with locally advanced breast cancer face many conflicting issues affecting their choice of immediate versus delayed versus no breast reconstruction (BR). This single-centre pilot study assessed high-risk women's reasons and priorities in choosing the timing and type of BR in a setting where all clinically feasible options were discussed with all women.

METHODS

Fifty-one women from a metropolitan breast oncology practice, who were likely to require post-mastectomy radiotherapy (PMRT), were recruited after making their decision about BR. Participants completed a questionnaire (69% preoperatively), adapted from Reaby (1998), evaluating the factors affecting their decision. Responses were subsequently classified into eight issue-based domains (feeling normal, feeling good, being practical, influence of others, expectations, fear, timing and unnecessary). Demographic and clinical data were also collected.

RESULTS

There were 32 immediate BR (IBR = 63%), seven delayed BR (DBR = 13%) and 12 no BR (NBR = 23%). Analysis using the chi square test showed women over 60 were more likely to choose NBR (p = 0.005), while women living with a partner were more likely to choose IBR (p = 0.032). The most relevant domains for both IBR and DBR were 'feeling good' and 'feeling normal'; and for NBR were 'unnecessary' and 'being practical'. Although all women understood pre-operatively the potential aesthetic limitations of PMRT, 63% still chose IBR.

CONCLUSIONS

These data will enable clinicians, researchers and women with breast cancer to gain a clearer understanding of the factors that impact on the choice and timing of BR in women requiring PMRT, a major breast cancer survivorship decision. Copyright © 2016 John Wiley & Sons, Ltd.

Psychosocial Predictors and Outcomes of Delayed Breast Reconstruction in Mastectomized Women in Mainland China: An Observational Study

Background

The aim of the present study was to evaluate potential psychosocial factors that impact Chinese female breast cancer patients to select breast reconstruction (BR), and potential connection of psychosocial outcomes with their satisfaction with BR.

Methods

A total of 264 female breast cancer patients with mastectomy were recruited from 2012 to 2014. All patients were informed with BR options at their first visit. Personal and medical profiles were collected. Body image, self-esteem, depression and anxiety were assessed using validated scales. Patients who were selected to undergo BR after the first visit were followed up for six months. The same assessment was performed at 6 months post BR, and their satisfaction with BR was evaluated using the Alderman scale. Multivariate linear and logistic regressions were performed.

Results

Forty-seven percent of the patients (126/264) opted to undergo BR within six months after the initial visit. Multivariate logistic regression analysis revealed that self-esteem (P < 0.05), body image (P < 0.01), education level (P < 0.05), and their husband’s recommendation (P < 0.05) were highly related to the patients’ decision to undergo BR. In addition, multivariate linear regression analysis showed that patient satisfaction with BR was significantly associated with preoperative body image (P < 0.01), postoperative improvement in self-esteem (P < 0.01), improvement in body image (P < 0.01), reduction in depression (P < 0.05), pain (P < 0.05), and scarring (P < 0.01).

Conclusions

The psychosocial factors including self-esteem and body image are highly related to selecting the BR option and post-BR satisfaction in Chinese female breast cancer patients.

Influence of Patient and Hospital Characteristics on the Performance of Direct Reconstruction after Mastectomy

Aim: International studies have shown that the performance of a direct (or immediate) reconstruction (DR) after mastectomy is associated with patient (e.g., socio-economic status, insurance status, age) and hospital (number of cases, teaching status) characteristics. The present article addresses the question if such relationships also exist in Germany. Material and Methods: The results of a nationwide questionnaire to the patients of certified breast cancer centres were coupled with the clinical features of the patients and the characteristics of the hospital. Predictors for receiving a DR (vs. delayed or no reconstruction) were estimated by means of a logistic multilevel model for a sample of 1165 patients from 105 certified locations. Results: Substantial differences between the treating hospitals were found (intraclass correlation coefficient null model: 0.195) which can in part be explained by the total model (total model: 0.169). Patients with the following features are more likely to receive a DR: younger age, private health insurance, secondary school leaving certificate (vs. primary school leaving certificate), lower stage and acquisition of more information about reconstruction. ASA and partnership status are not statistically significantly related with DR. DR is more likely to be performed in hospitals with higher caseload of patients with primary breast cancer. Teaching status, operations per surgeon and urbanity of the location are not related to receiving a DR. Conclusions: Non-clinical features of the patients and the primary case number are associated with the performance of a DR, this poses questions concerning reasons and the equality of health care.

Helping patients make choices about breast reconstruction: a decision analysis approach

Decision analysis can help breast reconstruction patients and their surgeons to methodically evaluate clinical alternatives and make hard decisions. The purpose of this article is to help plastic surgeons guide patients in making decisions though a case study in breast reconstruction. By making good decisions, patient outcomes may be improved. This article aims to illustrate decision analysis techniques from the patient perspective, with an emphasis on her values and preferences. The authors introduce normative decision-making through a fictional breast reconstruction patient and systematically build the decision basis to help her make a good decision. The authors broadly identify alternatives of breast reconstruction, propose types of outcomes that the patient should consider, discuss sources of probabilistic information and outcome values, and demonstrate how to make a good decision. The concepts presented here may be extended to other shared decision-making problems in plastic and reconstructive surgery. In addition, the authors discuss how sensitivity analysis may test the robustness of the decision and how to evaluate the quality of decisions. The authors also present tools to help implement these concepts in practice. Finally, the authors examine limitations that hamper adoption of patient decision analysis in reconstructive surgery and health care in general. In particular, the authors emphasize the need for routine collection of quality-of-life information, out-of-pocket expense, and recovery time.

Breast cancer diagnosis and factors influencing treatment decisions in Ghana

Researchers in this study explored the reactions of women with breast cancer and identified factors influencing treatment decisions. A qualitative exploratory approach was employed. Participants were recruited from a tertiary hospital and a breast cancer support group. Purposive sampling recruited 12 women. It was found that women identified breast lesions accidentally or intentionally and that diagnosis was delayed. Emotional reactions to diagnosis included shock and sadness. Factors that influenced treatment were the influence of other people, alternative sources of treatment, faith and support, knowledge, "tuning the mind," and effects on intimacy. Health professionals should develop effective communication and counseling skills for clients.

Plastic Surgeon Expertise in Predicting Breast Reconstruction Outcomes for Patient Decision Analysis

BACKGROUND

Decision analysis offers a framework that may help breast cancer patients make good breast reconstruction decisions. A requirement for this type of analysis is information about the possibility of outcomes occurring in the form of probabilities. The purpose of this study was to determine if plastic surgeons are good sources of probability information, both individually and as a group, when data are limited.

METHODS

Seven plastic surgeons were provided with pertinent medical information and preoperative photographs of patients, and were asked to assign probabilities to predict number of revisions, complications, and final aesthetic outcome using a questionnaire designed for the study. Logarithmic strictly proper scoring was used to evaluate the surgeons' abilities to predict breast reconstruction outcomes. Surgeons' responses were analyzed for calibration and confidence in their answers.

RESULTS

As individuals, there was variation in surgeons' ability to predict outcomes. For each prediction category, a different surgeon was more accurate. As a group, surgeons possessed knowledge of future events despite not being well calibrated in their probability assessments. Prediction accuracy for the group was up to six-fold greater than that of the best individual.

CONCLUSIONS

The use of individual plastic surgeon-elicited probability information is not encouraged unless the individual's prediction skill has been evaluated. In the absence of this information, a group consensus on the probability of outcomes is preferred. Without a large evidence base for calculating probabilities, estimates assessed from a group of plastic surgeons may be acceptable for purposes of breast reconstruction decision analysis.

Patient motivations for choosing postmastectomy breast reconstruction

INTRODUCTION

The number of women who undergo postmastectomy breast reconstruction is reported to be around 40% and, although increased from previous decades, seems lower than expected. The purpose of this report is to investigate and improve our understanding of women's motivations for choosing reconstruction.

METHODS

We prospectively surveyed consecutive patients referred for possible reconstructive surgery at Emory University Hospital between December 2008 and September 2010. A Likert-scale (1-5) questionnaire was used evaluating body image, femininity and sexuality, and influences regarding reconstruction. Demographic information was collected and analyzed. A PubMed search was also performed evaluating national rates of reconstruction, the demographic disparities, and the decision-making process behind undergoing reconstruction.

RESULTS

Among the 155 women surveyed, most (63%, n = 99) were 40 to 60 years old, 54.8% (n = 85) were African American, and 41.3% (n = 64) were white. Overall, patients agreed more strongly with questions related to body image as a motivating factor for breast reconstruction than they did with questions related to sexuality or femininity (mean score, 2.85 vs 3.26). When asked about their primary motivation for breast reconstruction, 76% of women agreed it was to maintain a balanced appearance, 34% agreed it was to continue to feel feminine, and 7.7% agreed it was to maintain sexual functioning. When asked about outside influences in pursuing breast reconstruction, the 51.6% of patients reported that they were urged by their referring physician to consider it, and most of the patients (58%) discussed the surgery with other breast cancer patients considering breast reconstruction.

CONCLUSIONS

Women pursuing breast reconstruction are motivated more by concerns of body image than issues of sexuality or femininity, which is independent of any demographic characteristics. It is important for referring physicians to recognize their role in initiating the discussion on reconstruction, and women would benefit from being referred to support groups to discuss their treatment and reconstruction with other breast cancer patients.

Skin-sparing mastectomy and immediate reconstruction with DIEP flap after breast-conserving therapy

BACKGROUND

Currently about 70% of women who suffer from breast cancer undergo breast-conserving therapy (BCT) without removing the entire breast. Thus, this surgical approach is the standard therapy for primary breast cancer. If corrections are necessary, the breast surgeon is faced with irritated skin and higher risks of complications in wound healing. After radiation, an implant-based reconstruction is only recommended in selected cases. Correction of a poor BCT outcome is often only solved with an additional extended operation using autologous reconstruction.

MATERIAL/METHODS

In our plastic surgery unit, which focuses on breast reconstruction, we offer a skin-sparing or subcutaneous mastectomy, followed by primary breast reconstruction based on free autologous tissue transfer to correct poor BCT outcomes. Between July 2004 and May 2011 we performed 1068 deep inferior epigastric artery perforator (DIEP) flaps for breast reconstruction, including 64 skin-sparing or subcutaneous mastectomies, followed by primary DIEP breast reconstruction procedures after BCT procedures.

RESULTS

In all free flap-based breast reconstruction procedures, we had a total flap loss in 0.8% (9 cases). Within the group of patients after BCT, we performed 41 DIEP flaps and 23 ms-2 TRAM flaps after skin-sparing or subcutaneous mastectomies to reconstruct the breast. Among this group we had of a total flap loss in 1.6% (1 case).

CONCLUSIONS

In cases of large tumour sizes and/or difficult tumour locations, the initial oncologic breast surgeon should inform the patients of a possibly poor cosmetic result after BCT and radiation. In our opinion a skin-sparing mastectomy with primary breast reconstruction should be discussed as a valid alternative.

Clinical Practice Guideline

Objective

Thyroidectomy may be performed for clinical indications that include malignancy, benign nodules or cysts, suspicious findings on fine needle aspiration biopsy, dysphagia from cervical esophageal compression, or dyspnea from airway compression. About 1 in 10 patients experience temporary laryngeal nerve injury after surgery, with longer lasting voice problems in up to 1 in 25. Reduced quality of life after thyroid surgery is multifactorial and may include the need for lifelong medication, thyroid suppression, radioactive scanning/treatment, temporary and permanent hypoparathyroidism, temporary or permanent dysphonia postoperatively, and dysphagia. This clinical practice guideline provides evidence-based recommendations for management of the patient’s voice when undergoing thyroid surgery during the preoperative, intraoperative, and postoperative period.

Purpose

The purpose of this guideline is to optimize voice outcomes for adult patients aged 18 years or older after thyroid surgery. The target audience is any clinician involved in managing such patients, which includes but may not be limited to otolaryngologists, general surgeons, endocrinologists, internists, speech-language pathologists, family physicians and other primary care providers, anesthesiologists, nurses, and others who manage patients with thyroid/voice issues. The guideline applies to any setting in which clinicians may interact with patients before, during, or after thyroid surgery. Children under age 18 years are specifically excluded from the target population; however, the panel understands that many of the findings may be applicable to this population. Also excluded are patients undergoing concurrent laryngectomy. Although this guideline is limited to thyroidectomy, some of the recommendations may extrapolate to parathyroidectomy as well.

Results

The guideline development group made a strong recommendation that the surgeon should identify the recurrent laryngeal nerve(s) during thyroid surgery. The group made recommendations that the clinician or surgeon should (1) document assessment of the patient’s voice once a decision has been made to proceed with thyroid surgery; (2) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, if the patient’s voice is impaired and a decision has been made to proceed with thyroid surgery; (3) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, once a decision has been made to proceed with thyroid surgery if the patient’s voice is normal and the patient has (a) thyroid cancer with suspected extrathyroidal extension, or (b) prior neck surgery that increases the risk of laryngeal nerve injury (carotid endarterectomy, anterior approach to the cervical spine, cervical esophagectomy, and prior thyroid or parathyroid surgery), or (c) both; (4) educate the patient about the potential impact of thyroid surgery on voice once a decision has been made to proceed with thyroid surgery; (5) inform the anesthesiologist of the results of abnormal preoperative laryngeal assessment in patients who have had laryngoscopy prior to thyroid surgery; (6) take steps to preserve the external branch of the surperior laryngeal nerve(s) when performing thyroid surgery; (7) document whether there has been a change in voice between 2 weeks and 2 months following thyroid surgery; (8) examine vocal fold mobility or refer the patient for examination of vocal fold mobility in patients with a change in voice following thyroid surgery; (9) refer a patient to an otolaryngologist when abnormal vocal fold mobility is identified after thyroid surgery; (10) counsel patients with voice change or abnormal vocal fold mobility after thyroid surgery on options for voice rehabilitation. The group made an option that the surgeon or his or her designee may monitor laryngeal electromyography during thyroid surgery. The group made no recommendation regarding the impact of a single intraoperative dose of intravenous corticosteroid on voice outcomes in patients undergoing thyroid surgery.