Are Patients Making High-Quality Decisions about Breast Reconstruction after Mastectomy? [Outcomes Article]

Abstract

Background Variation in rates of breast reconstruction after mastectomy has raised concerns about the quality of decisions about reconstruction. We sought to evaluate patient decision making about reconstruction, using a validated measure of knowledge and preferences related to reconstruction. Methods A cross-sectional survey of early-stage breast cancer survivors from four university medical centers was conducted. The survey included measures of knowledge about specific reconstruction facts, personal goals and concerns, and involvement in decision making. A multivariable linear regression model of characteristics associated with knowledge and a logistic regression model of factors associated with having reconstruction were developed. Results 84 patients participated (59% response rate). Participants answered 37.9% of knowledge questions correctly. Higher education (beta 15%, p=0.003) and having reconstruction (beta 21%, p<0.0001) were associated with higher knowledge. The goals “use your own tissue to make a breast” (OR 1.53, 95% CI 1.15, 2.05) and “wake up after mastectomy with reconstruction underway” (OR 1.66, 95% CI 1.30, 2.12) were associated with reconstruction. The goal “avoid putting foreign material in your body” was associated with no reconstruction (OR 0.64, 95% CI 0.48, 0.86). Most patients reported they mainly made the decision or made the decision with the doctor equally (93%, 95%CI 85-97%), and that their degree of involvement was about right (85%, 95%CI 75-91%). Conclusion Women treated with mastectomy in this study were not well-informed about breast reconstruction. Treatments were associated with patients' goals and concerns, however, and patients were highly involved in their decisions. Knowledge deficits suggest that breast cancer patients would benefit from interventions to support their decision making.

Patient Motivations for Choosing Postmastectomy Breast Reconstruction

“…Surveys of women after breast reconstruction have found women feel strongly about having a natural appearance in clothing and are motivated by the idea of improving their body image. 11,27,28 We similarly found women to be more motivated by body image than sexual relations or concerns of femininity. In fact, only 20% of women reported being worried about their relationship or their sexual relations if they did not choose breast reconstruction.…”

The option of delayed reconstructive surgery following mastectomy for invasive breast cancer: Why do so few patients embrace this offer?

“…19 We do not support this assessment. We think that the group of patients who are open for BR will be given the opportunity to talk about their needs during their follow-up (in our study cohort, the vast majority of patients reported that they received information regarding BR, both preoperatively and during aftercare.).…”

How Informed Is the Decision About Breast Reconstruction After Mastectomy?

“…In our prior retrospective study, which also used the Decision Quality Instrument, overall knowledge about reconstruction 2.5 years after mastectomy was 37.9%. 13 Knowledge about breast cancer surgery (mastectomy versus breast conserving surgery) has also been limited in prior studies, with patients correctly answering about half of questions about the pros and cons of surgery. 14–16 Patients also have incomplete knowledge about systemic therapy, with frequent overestimation of the survival benefit of chemotherapy.…”

“…In our prior retrospective study, knowledge about complication risk was even lower, at 3%. 13 The DQI question on complication risk was developed using the best available evidence about long-term complications of reconstruction. 13, 19 That evidence has found complication rates in the range of 20–33%.…”

“…13 The DQI question on complication risk was developed using the best available evidence about long-term complications of reconstruction. 13, 19 That evidence has found complication rates in the range of 20–33%. 20–22 Although other studies have reported complication rates in the 5–15% range, they have been limited to short-term (usually 30-day) complications 21, 23, 24 or have not reported follow-up duration.…”