Patient-Reported Outcome Measures for Post-mastectomy Breast Reconstruction: A Systematic Review of Development and Measurement Properties

Readability of Patient-reported Outcome Measures Used in Plastic Surgery

Background

Patient-reported outcomes are essential to understanding success in plastic surgery procedures, many that aim to improve quality of life. Patient-reported outcome measures (PROMs) should be written at or below the sixth-grade reading level recommended by the American Medical Association. This study aimed to evaluate the readability of plastic surgery PROMs.

Methods

We conducted a literature review to identify validated, commonly used PROMs in plastic surgery. We extracted PROMs' text and instructions and analyzed readability using different approaches that estimate the grade level required to understand. Our primary outcome was the Simple Measure of Gobbledygook (SMOG) index, which detects word complexity and expects 100% comprehension at the grade level rating assigned. We also included the Flesch-Kincaid grade level, Coleman-Liau index, and automated readability index.

Results

Forty-three PROMs met the inclusion criteria. The mean SMOG index was 8.2 (SD = 1.3), indicating an eighth-grade reading level. Mean reading grade levels measured by the Flesch-Kincaid grade level, Coleman-Liau index, and automated readability index ranged from third to sixth grade, although these may underestimate readability difficulties. Only 6 (14%) PROMs had a SMOG index at or below the sixth-grade level. PROM instructions had significantly higher reading levels than the questions/responses for all readability indexes (P < 0.01).

Conclusions

PROMs used in plastic surgery, including the instructions, exceed the reading level recommended by the American Medical Association. This may limit comprehension and accurate completion and compromise validity and reliability. PROMs should be written and designed to be accessible to patients of all literacy levels.

Dynamics in Quality of Life of Breast Cancer Patients Following Breast-Conserving Surgery Versus Mastectomy: Protocol for Systematic Review and Meta-Analysis

Background: Quality of life (QoL) may change in female patients with breast cancer over time due to its dynamic construct. Recent studies have provided statistics on the diverse predictors of QoL in breast cancer patients. Still, the literature findings on the prognostication of QoL are scarce. Objectives: With this meta-analysis, we aim to describe the dynamics of overall QoL and its dimensions: mental status, physical functioning, and social interactions. Methods: To reach this aim, we will systematically evaluate the peer-reviewed literature on QoL of women who have undergone either mastectomy or breast-conserving surgery. The proposed study will focus on, but not be limited to, the analysis of BIRS, FACT-B, and EORTC QLQ-C30 questionnaires, which are most commonly used in the assessment of the quality of life of cancer patients. Then, we will extract the following outcome measures: The participants' age, time since surgery, type of tumor removal procedure (mastectomy or breast-conserving surgery), breast reconstruction technique, mean value, and standard deviation in a QoL score. A random-effects model will then compute the pooled QoL and construct the trend lines for scores received from each diagnostic tool. The findings will be adjusted according to the reconstruction techniques and tumor removal surgery. Finally, we will model the QoL dynamics with a set of predictors identified in the extracted studies. Conclusions: The study findings may serve as a tool for stratifying female patients with breast cancer by the risk of significant reduction in QoL.

Timing and type of breast reconstruction in SweBRO 3: long-term outcomes

BACKGROUND

Breast reconstruction after mastectomy helps women with breast cancer feel better about their bodies and lives. There is debate about the best time and type of reconstruction (immediate versus delayed, and using own tissue versus implants). Long-term studies are rare.

AIM

This study looked at long-term results of different breast reconstruction methods and timings in Swedish women who had mastectomies in 2000, 2005 or 2010. It focused on how satisfied the women were with their surgeries and their quality of life.

METHOD

The study included 5853 women from the Swedish National Breast Cancer Registry who had mastectomies in 2000, 2005 or 2010. Of these, 2904 women answered the survey, and 895 had breast reconstruction. Satisfaction and quality of life were measured using two surveys: EORTC QLQ-BRECON23 and BREAST-Q.

RESULTS

Of the women who answered the survey, 895 (31%) had breast reconstruction. Of these, 176 (20%) had immediate reconstruction, and 719 (80%) had delayed reconstruction; 58% had implant-based reconstructions, 31% had reconstructions using their own tissue, 2% had both types and 9% did not report the type of reconstruction. There were no major differences in satisfaction between immediate and delayed reconstruction. Women who used their own tissue were more satisfied with their results and breast appearance than those with implants.

CONCLUSION

Autologous reconstruction leads to better satisfaction and outcomes than implants. The timing of reconstruction (immediate versus delayed) was less of an influence on quality of life.

Gothenburg Breast reconstruction (GoBreast) II protocol: a Swedish partially randomised patient preference, superiority trial comparing autologous and implant-based breast reconstruction

INTRODUCTION

Although breast reconstruction is an integral part of breast cancer treatment, there is little high-quality evidence to indicate which method is the most effective. Randomised controlled trials (RCTs) are generally thought to provide the most solid scientific evidence, but there are significant barriers to conducting RCTs in breast reconstruction, making both recruitment and achieving unbiased and generalisable results a challenge. The objective of this study is to compare implant-based and autologous breast reconstruction in non-irradiated patients. Moreover, the study aims to improve the evidence for trial decision-making in breast reconstruction.

METHODS AND ANALYSIS

The study design partially randomised patient preference trial might be a way to overcome the aforementioned challenges. In the present study, patients who consent to randomisation will be randomised to implant-based and autologous breast reconstruction, whereas patients with strong preferences will be able to choose the method. The study is designed as a superiority trial based on the patient-reported questionnaire BREAST-Q and 124 participants will be randomised. In the preference cohort, patients will be included until 62 participants have selected the least popular alternative. Follow-up will be 60 months. Embedded qualitative studies and within-trial economic evaluation will be performed. The primary outcome is patient-reported breast-specific quality of life/satisfaction, and the secondary outcomes are complications, factors affecting satisfaction and cost-effectiveness.

ETHICS AND DISSEMINATION

The study has been approved by the Swedish Ethical Review Authority (2023-04754-01). Results will be published in peer-reviewed scientific journals and presented at peer-reviewed scientific meetings.

TRIAL REGISTRATION NUMBER

NCT06195865.

Vanderbilt Mini-PROM-Breast for Breast Reconstruction: A Short-Form, Patient-Reported Outcomes Measure

BACKGROUND

Breast reconstruction procedures are among the most commonly performed plastic surgery operations. Although there are well-validated patient-reported outcomes measures (PROMs) for breast reconstruction, there are several patient-, provider-, and service-level barriers to their implementation in routine clinical settings. Therefore, we developed a short-form PROM to evaluate breast reconstruction outcomes.

METHODS

Using a mixed-methods approach, the Vanderbilt Mini-PROM-Breast (VMP-B) was constructed and validated to assess patient-reported outcomes from breast reconstruction. Classic test theory methods were used to evaluate acceptability, reliability, and validity. External validation was subsequently performed using the BREAST-Q as a reference standard.

RESULTS

The VMP-B is a 16-item instrument composed of three domains: quality of life, body image, and breast satisfaction. Psychometric properties including acceptability, reliability, and validity exceeded reference criteria. When tested with 104 patients, the authors found significant benefits of breast reconstruction on quality of life, body image, and breast satisfaction. These results were associated with sizeable effect sizes (g) (g = 0.421, g = 0.520, and g = 1.25) demonstrative of clinically meaningful results. When tested concurrently in 70 patients, the VMP-B and the BREAST-Q showed similar results, exhibiting excellent convergent validity.

CONCLUSIONS

The VMP-B is a validated short-form PROM that reliably assesses breast reconstruction outcomes. As a short form, the VMP-B decreases both patient and provider burden, which allows for routine, point-of-care collection of breast reconstruction outcomes.

Normative BREAST-Q reconstruction scores for satisfaction and well-being of the breasts and potential donor sites: what are Swedish women of the general population satisfied/dissatisfied with?

BACKGROUND

Normative data for interpreting the BREAST-Q reconstruction module are currently limited to four populations. The primary aim of this study was to create Swedish normative values for the BREAST-Q reconstruction domains. The secondary aim was to describe what aspects of the breasts and potential donor sites that women of the general population are generally satisfied or dissatisfied with.

METHODS

The BREAST-Q reconstruction module was sent to a random sample of 400 women currently living in Region Västra Götaland. Descriptive data are presented.

RESULTS

One hundred and forty-six women answered the questionnaire (36.5%). The mean age of the cohort was 53 years, and the mean body mass index (BMI) was 25 kg/m2. Mean total scores ranged from 50 to 90. The mean score for satisfaction with breast was 57 on a 0-100 scale. Women with high BMI values seem to be less satisfied with their breasts and physical and sexual well-being. The participants were most satisfied with their breasts when clothed. Overall, the reported physical well-being related to potential donor sites was high.

CONCLUSIONS

Normative data for BREAST-Q constitute a reference point, which allows us to put another perspective on changes in scores rather than just comparing scores before and after surgery. Scores were somewhat different than scores in previously published normative populations, which indicates that there might be cultural differences in breast satisfaction.

Long-term patient-reported outcomes of immediate breast reconstruction after mastectomy for breast cancer: population-based cohort study

BACKGROUND

Breast reconstruction is offered to improve quality of life for women after mastectomy for breast cancer, but information regarding the long-term patient-reported outcomes of different reconstruction procedures is currently lacking. The Brighter study aimed to evaluate long-term patient-reported outcomes after immediate breast reconstruction (IBR) in a population-based cohort.

METHODS

Women who underwent mastectomy with IBR for breast cancer in England between 1 January 2008 and 31 March 2009 were identified from National Health Service Hospital Episode Statistics. Surviving women were invited to complete the BREAST-Q, EQ-5D-5L™, and ICECAP-A at least 12 years after the index procedure. Questionnaires were scored according to developers' instructions and compared by IBR type.

RESULTS

Some 1236 women underwent IBR; 343 (27.8 per cent) had 2-stage expander/implant, 630 (51.0 per cent) latissimus dorsi, and 263 (21.3 per cent) abdominal flap reconstructions, with a mean(s.d.) follow-up of 13.3(0.5) years. Women who underwent abdominal flap reconstruction reported higher scores in all BREAST-Q domains than those who had other procedures. These differences remained statistically significant and clinically meaningful after adjusting for age, ethnicity, geographical region, socioeconomic status, smoking, BMI, and complications. The greatest difference was seen in scores for satisfaction with breasts; women who had abdominal flap reconstructions reported scores that were 13.17 (95 per cent c.i. 9.48 to 16.87) points; P < 0.001) higher than those among women who had two-stage expander/implant procedures. Women who underwent latissimus dorsi reconstruction reported significantly more pain/discomfort on the EQ-5D-5L™, but no other differences between procedures were seen.

CONCLUSION

Long-term patient-reported outcomes are significantly better following abdominal flap reconstruction than other traditional procedure types. These findings should be shared with women considering IBR to help them make informed decisions about their surgical options.

The appropriateness and quality of patient-reported outcome measures (PROMs) in plastic surgery randomized controlled trials: A systematic review

BACKGROUND

Patient-reported outcome measures (PROMs) quantify patient perspectives to measure outcomes that matter to patients. The aim of this study was to assess the reporting of appropriateness and quality of PROM selection in plastic surgery randomized controlled trials (RCTs).

METHODS

MEDLINE, Embase, and CENTRAL were searched from January 1, 2000, to June 5, 2022, to identify published RCTs within the plastic surgery literature. Included studies were categorized as follows: 1) a clearly defined patient-reported primary outcome; 2) a primary outcome could be inferred; or 3) no clear or implied primary outcome. The Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) database was consulted to assess the available literature on the PROMs.

RESULTS

There were 130 plastic surgery RCTs identified. Of the 43 studies with a clear or inferred primary outcome, the percentage of studies that commented with supporting references on the PROM's appropriateness for the population, disease/condition, and outcome were 20.9% (n = 9/43), 18.6% (n = 8/43), and 27.9% (n = 12/43), respectively. The percentage of studies that commented on the PROM's validity, reliability, and responsiveness with supporting references were 34.9% (n = 15/43), 14.0% (n = 6/43), and 11.7% (n = 5/43), respectively. There were 21 unique PROMs identified; 28.6% (n = 6/21) were available in the COSMIN database.

CONCLUSION

The majority of plastic surgery RCTs assessing patient-reported primary outcomes lack transparency surrounding PROM selection and quality. We recommend investigators conducting plastic surgery clinical research report explicitly why they used a particular PROM and support its appropriateness and psychometric properties with supporting references. Finally, they should familiarize themselves with the COSMIN initiative.

Trends and issues in clinical research on satisfaction and quality of life after mastectomy and breast reconstruction: a 5-year scoping review

Breast reconstruction (BR) aims to improve the satisfaction and quality of life (QOL) of breast cancer survivors. Clinical studies using patient-reported outcomes (PROs) can therefore provide relevant information to the patients and support decision-making. This scoping review was conducted to analyze recent trends in world regions, methods used, and factors investigated. The literature search was conducted in August 2022. Databases of PubMed, MEDLINE, and CINAHL were searched for relevant English-language studies published from 2017 to 2022. Studies involving women with breast cancer who underwent BR after mastectomy and investigated PROs after BR using BR-specific scales were included. Data on the country, publication year, study design, PRO measures (PROMs) used, time points of surveys, and research themes were collected. In total, 147 articles met the inclusion criteria. BREAST-Q was the most widely used, contributing to the increase in the number and diversification of studies in this area. Such research has been conducted mainly in North America and Europe and is still developing in Asia and other regions. The research themes involved a wide range of clinical and patient factors in addition to surgery, which could be influenced by research methods, time since surgery, and even cultural differences. Recent BR-specific PROMs have led to a worldwide development of research on factors that affect satisfaction and QOL after BR. PRO after BR may be influenced by local cultural and social features, and it would be necessary to accumulate data in each region to draw clinically useful conclusion.

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.

Does breast oncoplastic surgery improve quality of life?

Breast Oncoplastic Surgery (OS) has established itself as a safe procedure associated with the treatment of breast cancer, but the term is broad, encompassing procedures associated with breast-conserving surgeries (BCS), conservative mastectomies and fat grafting. Surgeons believe that OS is associated with an increase in quality of life (QOL), but the diversity of QOL questionnaires and therapeutic modalities makes it difficult to assess from the patient's perspective. To answer this question, we performed a search for systematic reviews on QOL associated with different COM procedures, and in their absence, we selected case-control studies, discussing the main results. We observed that: (1) Patients undergoing BCS or breast reconstruction have improved QoL compared to those undergoing mastectomy; (2) In patients undergoing BCS, OS has not yet shown an improvement in QOL, a fact possibly influenced by patient selection bias; (3) In patients undergoing mastectomy with reconstruction, the QoL results are superior when the reconstruction is performed with autologous flaps and when the areola is preserved; (4) Prepectoral implants improves QOL in relation to subpectoral implant-based breast reconstruction; (5) ADM do not improves QOL; (6) In patients undergoing prophylactic mastectomy, satisfaction is high with the indication, but the patient must be informed about the potential complications associated with the procedure; (7) Satisfaction is high after performing fat grafting. It is observed that, in general, OS increases QOL, and when evaluating the procedures, any preservation or repair, or the use of autologous tissues, increases QOL, justifying OS.

The BREASTrial Stage III: Acellular Dermal Matrix Breast Reconstruction Outcomes from 3 Months to 2 Years Postoperatively

BACKGROUND

The Breast Reconstruction Evaluation of Acellular Dermal Matrix as a Sling Trial (BREASTrial) is a blinded, randomized trial comparing the outcomes of tissue expander breast reconstruction using AlloDerm or DermaMatrix. In this final stage of the trial, outcomes 3 months to 2 years after definitive reconstruction are reported along with patient satisfaction data.

METHODS

A randomized trial was conducted to compare complication rates between groups of patients who underwent reconstruction with AlloDerm and DermaMatrix. Regression models were used to analyze the impact of matrix type, age, chemotherapy, radiation therapy, and reconstructive type on complication rates. Premastectomy and postmastectomy questionnaires were used to assess patient satisfaction and were also analyzed using regression models.

RESULTS

Of the 128 patients (199 breasts) who were randomized in the trial, 108 patients (167 breasts) were available for analysis in stage III. There was no difference in the overall complication rates between the AlloDerm and DermaMatrix groups (6% versus 13.2%; P = 0.3) or the severity of those complications ( P = 0.7). Obesity was a positive predictor for complications, regardless of reconstruction group ( P = 0.02). Patient satisfaction was positive overall and did not grossly vary between AlloDerm and DermaMatrix groups.

CONCLUSIONS

Findings from the BREASTrial conclude that AlloDerm and DermaMatrix exhibit similar histologic and clinical outcomes. Patient satisfaction is also similar between matrices. Obesity is a predictor of complications, and acellular dermal matrices should be used with caution in these patients. As the largest head-to-head trial comparing two acellular dermal matrices, the BREASTrial contributes to the fund of knowledge regarding acellular dermal matrix supplementation in breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

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.

Long-Term Patient Satisfaction and Quality of Life Following Breast Reconstruction Using the BREAST-Q: A Prospective Cohort Study

Background

Breast reconstruction is a promising surgical technique to improve health-related quality of life (HRQoL) in patients with breast cancer. However, the long-term risk factors associated with HRQoL after breast surgery are still unclear. Our aim was to evaluate breast satisfaction and HRQoL following breast reconstruction to identify clinical factors associated with each domain of BREAST-Q in the long-term.

Methods

Patient-reported BREAST-Q outcomes were analyzed 1 and 5 years after breast reconstruction in a single-blinded, prospective study. Multiple regression analysis was performed to identify the risk and protective factors associated with BREAST-Q scores. These scores at 1 and 5 years were also compared across three types of operation: mastectomy only, tissue expander/implant (TE/Imp), and a deep inferior epigastric perforator (DIEP) flap.

Results

Surveys were completed by 141 subjects after 1 year and 131 subjects after 5 years. Compared to mastectomy only, breast reconstruction was significantly associated with greater “Satisfaction with breasts” (TE/Imp, p &lt; 0.001; DIEP, p &lt; 0.001) and “Psychosocial well-being” (TE/Imp, p &lt; 0.001; DIEP, p &lt; 0.001), higher body mass index (BMI) resulted in lower “Satisfaction with breasts” (p = 0.004), and a history of psychiatric or neurological medication was significantly associated with “Physical well-being” at 1-year postoperatively (p = 0.02). At 5 years, reconstructive procedures were significantly positively associated with greater “Satisfaction with breasts” (TE/Imp, p &lt; 0.001; DIEP, p &lt; 0.001) and “Psychosocial well-being” (TE/Imp, p = 0.03; DIEP, p &lt; 0.001), and a bilateral procedure was a significant risk factor for lower “Psychosocial well-being” (p = 0.02).

Conclusions

The results of this study show that breast reconstruction improves “Satisfaction with Breasts” and “Psychosocial well-being” compared to mastectomy. Among all three types of operation, DIEP gave the best scores at 5 years postoperatively. Thus, autologous reconstruction is recommended for promotion of long-term HRQoL after breast surgery.

A systematic review highlighting poor-quality of evidence for Content Validity of Quality of Life (QoL) Instruments in Female Chronic Pelvic Pain (CPP)

OBJECTIVES

To evaluate the content validity of 19 Patient Reported Outcome Measures (PROMs) used to measure QoL in women with CPP DESIGN AND SETTING: We searched EMBASE, MEDLINE, PsycINFO databases and Google Scholar from inception to August 2020. We included records describing the development or studies assessing content validity of PROMs. Two reviewers independently assessed the methodological quality of PROMs using the COSMIN checklist. Evidence was synthesised for relevance, comprehensiveness and comprehensibility. Quality of evidence was rated using a modified GRADE approach.

MAIN RESULTS

PROM development was inadequate for all instruments included in this review. No high-quality evidence ratings were found for relevance, comprehensiveness and comprehensibility. QoL was measured using generic instruments (68.42%, 13/19) rather than those specific to chronic pain (21.04%, 4/19) or pelvic pain (10.53%, 2/19). Quality of concept elicitation was inadequate for 90% of PROMs. Half of PROMs did not include patients in their development and only 40% were devised using a sample representative of the target population for which the PROM was developed. Cognitive interviews were conducted in one-fifth of PROMs and were mostly of inadequate/doubtful quality.

CONCLUSION

There is poor-quality of evidence for content validity of PROMs used to measure QoL in women with CPP.

Clinical outcome measures and their evidence base in degenerative cervical myelopathy: a systematic review to inform a core measurement set (AO Spine RECODE-DCM)

OBJECTIVES

To evaluate the measurement properties of outcome measures currently used in the assessment of degenerative cervical myelopathy (DCM) for clinical research.

DESIGN

Systematic review DATA SOURCES: MEDLINE and EMBASE were searched through 4 August 2020.

ELIGIBILITY CRITERIA

Primary clinical research published in English and whose primary purpose was to evaluate the measurement properties or clinically important differences of instruments used in DCM.

DATA EXTRACTION AND SYNTHESIS

Psychometric properties and clinically important differences were both extracted from each study, assessed for risk of bias and presented in accordance with the Consensus-based Standards for the selection of health Measurement Instruments criteria.

RESULTS

Twenty-nine outcome instruments were identified from 52 studies published between 1999 and 2020. They measured neuromuscular function (16 instruments), life impact (five instruments), pain (five instruments) and radiological scoring (five instruments). No instrument had evaluations for all 10 measurement properties and <50% had assessments for all three domains (ie, reliability, validity and responsiveness). There was a paucity of high-quality evidence. Notably, there were no studies that reported on structural validity and no high-quality evidence that discussed content validity. In this context, we identified nine instruments that are interpretable by clinicians: the arm and neck pain scores; the 12-item and 36-item short form health surveys; the Japanese Orthopaedic Association (JOA) score, modified JOA and JOA Cervical Myelopathy Evaluation Questionnaire; the neck disability index; and the visual analogue scale for pain. These include six scores with barriers to application and one score with insufficient criterion and construct validity.

CONCLUSIONS

This review aggregates studies evaluating outcome measures used to assess patients with DCM. Overall, there is a need for a set of agreed tools to measure outcomes in DCM. These findings will be used to inform the development of a core measurement set as part of AO Spine RECODE-DCM.

PROM a contemporary approach to assessing the quality of life of patients with cancer

PRO (patient reported outcomes) is a patient's subjective assessment of health and quality of life, without interpretation by a specialist. PROM (patient reported outcomes measure) questionnaires are used to analyzing this data. Assessment of the quality of life is a perspective direction, which allows to improve the quality of medical care and treatment results. Today, there are many questionnaires PROM, their reliability and validity has been proven in numerous studies. Unified standards and methods for developing and evaluating questionnaires have been developed. Interest in the use of quality of life questionnaires is increasing constantly. However, studies analyzing the data of the PROM questionnaires are rarely found in the national literature. Quality of life is also poorly researched in clinical practice. The aim of the literature review is to present modern methods for assessing the quality of life of patients, especially with cancer. A review of the most widespread and reliable questionnaires and assessment instruments for the quality of life of a patient has been carried out. The analysis of world experience of their use in clinical practice, for patients with cancer has been performed. Examples of both general and specific questionnaires are given. PROM questionnaires are widely used among patients with cancer. However, incorrect use of PROMs is found in the literature, and in patients with certain nosologies PROM data studied poorly. Further analysis of the potential of PROM questionnaires implementation is required, as well as their translation and adaptation for use in Russian health care.

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

Background

There are three patient reported outcome measure instruments (PROMs) that have adequate content validity for breast reconstruction, BREAST-Q, BRECON-31 and EORTC QLQ-BRECON-23, and they all have been robustly validated. The aim of this study was to systematically review scores giving meaning to validated PROMs for breast reconstruction after mastectomy and discuss methods to enable interpretation of them.

Methods

A systematic review was performed according to the recommendations of PRISMA. Prospero CRD42021255874. Included articles had to meet criteria defined in a SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type). The included studies were critically appraised using the GRADE approach.

Results

Three articles were finally included in the review: two studies on scores for healthy controls and one on minimally important differences (MIDs), both of BREAST-Q. All of the studies were performed in North America. Only MIDs based on statistical characteristics, and not on what constitutes a relevant change for the patient, exist. The risk of bias was evaluated as very high and moderate, respectively, of inconsistencies as low, of indirectness as high, of imprecisions as low, and of publication bias as probably low.

Conclusions

The overall certainty of evidence for scores giving meaning to PROMs for breast reconstruction is low (GRADE ƟƟОО). More studies are needed to establish relevant healthy control scores and what constitutes a relevant clinical difference for patient-reported outcome measures for breast reconstruction after mastectomy. Clinical implications of the findings and suggestions for further research are suggested in the article.

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Patient reported outcome measurements have to be clinically interpretable to make sense.

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Three articles on scores giving meaning to PROMs for breast reconstruction post-mastectomy exist.

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More studies are needed to establish relevant controls and clinical differences in scores.

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Clinical implications and suggestions for further research are discussed.

Long-Term Quality of Life (BREAST-Q) in Patients with Mastectomy and Breast Reconstruction

(1) Background: Mastectomy is the surgical treatment of choice in 20-30% of women with breast cancer. In addition, more women are undergoing risk-reducing mastectomies. It is necessary to study these women's quality of life and satisfaction after surgery, as studies report high percentages of dissatisfaction with the results. The publication of the BREAST-Q© questionnaire in 2009 provided a valuable tool to measure these results. (2) Methods: Descriptive, cross-sectional study of 70 patients who underwent mastectomy and breast reconstruction, both therapeutic and prophylactic, in the last 10 years to whom the BREAST-Q© 2.0-Reconstruction Module questionnaire was provided for completion. (3) Results: The sexual satisfaction scale was the lowest score of the entire questionnaire (51.84 ± 21.13), while the highest score was obtained on the satisfaction with the surgeon scale (91.86 ± 18.11). The satisfaction with care scales showed the importance of the evaluation of these items for future studies. More than half of the patients of the study (51.5%) underwent at least one reoperation after the first surgery, with an average of one (1.15) intervention per patient and a maximum of five. (4) Conclusions: Mastectomy and breast reconstruction have a high negative impact on the sexual well-being of patients. The high percentage of reoperations is a factor to consider because of its possible influence on these patients' quality of life and satisfaction.

Innovations for the future of breast surgery

BACKGROUND

Future innovations in science and technology with an impact on multimodal breast cancer management from a surgical perspective are discussed in this narrative review. The work was undertaken in response to the Commission on the Future of Surgery project initiated by the Royal College of Surgeons of England.

METHODS

Expert opinion was sought around themes of surgical de-escalation, reduction in treatment morbidities, and improving the accuracy of breast-conserving surgery in terms of margin status. There was emphasis on how the primacy of surgical excision in an era of oncoplastic and reconstructive surgery is increasingly being challenged, with more effective systemic therapies that target residual disease burden, and permit response-adapted approaches to both breast and axillary surgery.

RESULTS

Technologies for intraoperative margin assessment can potentially half re-excision rates after breast-conserving surgery, and sentinel lymph node biopsy will become a therapeutic procedure for many patients with node-positive disease treated either with surgery or chemotherapy as the primary modality. Genomic profiling of tumours can aid in the selection of patients for neoadjuvant and adjuvant therapies as well as prevention strategies. Molecular subtypes are predictive of response to induction therapies and reductive approaches to surgery in the breast or axilla.

CONCLUSION

Treatments are increasingly being tailored and based on improved understanding of tumour biology and relevant biomarkers to determine absolute benefit and permit delivery of cost-effective healthcare. Patient involvement is crucial for breast cancer studies to ensure relevance and outcome measures that are objective, meaningful, and patient-centred.

Psychometric properties of patient-reported outcome measures of self-management for cancer survivors: a systematic review protocol using COSMIN methodology

INTRODUCTION

Self-management is an important strategy for cancer survivors. Evaluating self-management is essential for planning nursing interventions that promote self-management and for measuring the contribution of nursing to health outcomes. Many patient-reported outcome measures (PROMs) have been designed and used to assess self-management in cancer survivors. However, it is unclear which PROM has the best reliability and validity. Therefore, the goal is to systematically review the psychometric properties of existing self-management PROMs and determine which PROM is best for cancer survivors.

METHODS AND ANALYSIS

This systematic review will be conducted according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines for systematic reviews of PROMs. Ten electronic literature databases (PubMed, EMBASE and so on) and two websites for PROMs will be searched from inception to 1 March 2020. Studies testing the psychometric properties of PROMs assessing self-management for cancer survivors, published in either English or Chinese, will be included. Two independent reviewers determined the eligibility of the studies and will independently extract the data. Risk of bias will be assessed using the COSMIN risk-of-bias checklist, and the quality of the results will be assessed using specific COSMIN quality criteria.

ETHICS AND DISSEMINATION

It is not necessary to obtain ethical approval for this systematic review protocol. The results will be published in a peer-reviewed journal and presented at a relevant conference.

PROSPERO REGISTRATION NUMBER

CRD42020149120.