Quality of Patient Decisions About Breast Reconstruction After Mastectomy

Abstract

IMPORTANCE Breast reconstruction has the potential to improve a person’s body image and quality of life but has important risks. Variations in who undergoes breast reconstruction have led to questions about the quality of patient decisions. OBJECTIVE To assess the quality of patient decisions about breast reconstruction. DESIGN, SETTING, AND PARTICIPANTS A prospective, cross-sectional survey study was conducted from June 27, 2012, to February 28, 2014, at a single, academic, multidisciplinary oncology clinic among women planning to undergo mastectomy for stage I to III invasive ductal or lobular breast cancer, ductal carcinoma in situ, or prophylaxis. EXPOSURES Mastectomy only and mastectomy with reconstruction. MAIN OUTCOME AND MEASURES Knowledge, as ascertained using the Decision Quality Instrument; preference concordance, based on rating and ranking of key attributes; and decision quality, defined as having knowledge of 50% or more and preference concordance. RESULTS During the 20-month period, 214 patients were eligible, 182 were approached, and 32 missed. We enrolled 145 patients (79.7% enrollment rate), and received surveys from 131 patients (72.0% participation rate). Five participants became ineligible. The final study population was 126 patients. Among the 126 women in the study (mean [SD] age, 53.2 [12.1] years), the mean (SD) knowledge score was 58.5% (16.2%) and did not differ by treatment group (mastectomy only, 55.2% [15.0%]; mastectomy with reconstruction, 60.5% [16.5%]). A total of 82 of 123 participants (66.7%) had a calculated treatment preference of mastectomy only; 39 of these women (47.6%) underwent mastectomy only. A total of 41 participants (32.5%) had a calculated treatment preference of mastectomy with reconstruction; 36 of these women (87.8%) underwent mastectomy with reconstruction. Overall, 52 of 120 participants (43.3%) made a high-quality decision. In multivariable analysis, white race/ethnicity (odds ratio [OR], 2.72; 95% CI, 1.00–7.38; P = .05), having private insurance (OR, 1.61; 95% CI, 1.35–1.93; P < .001), having a high school education or less (vs some college) (OR, 4.84; 95% CI, 1.22–19.21; P = .02), having a college degree (vs some college) (OR, 1.95; 95% CI, 1.53–2.49; P < .001), and not having a malignant neoplasm (eg, BRCA carriers) (OR, 3.13; 95% CI, 1.25–7.85; P = .01) were independently associated with making a high-quality decision. CONCLUSIONS AND RELEVANCE A minority of patients undergoing mastectomy in a single academic center made a high-quality decision about reconstruction. Shared decision making is needed to support decisions about breast reconstruction.

Psychosocial well-being at time of diagnosis of breast cancer affects the decision whether or not to undergo breast reconstruction

“…Furthermore, significantly more women who opted for breast reconstruction rated body image and sexuality important than those women who did not seek reconstruction [15]. Lee et al found that women preferring reconstruction found breast shape with or without clothes more important than women who did not seek reconstruction [21]. Nonetheless, our study did not show a significant difference in sexual well-being between the two groups at baseline, although the non-reconstruction group scored slightly higher.…”

Met and Unmet Expectations for Breast Reconstruction in Early Posttreatment Breast Cancer Survivors

“…Overall, women’s knowledge, preparedness, and decision quality related breast reconstruction is relatively low (Lee, Deal, Huh, & et al, 2017; Manne et al, 2016; Pusic et al, 2012; Pusic et al, 2017). For example, although women may view their ability to return to normal activities or avoid complications from surgery as important in their decisions, their actual knowledge of these factors as they relate to reconstruction method appears limited (Lee et al, 2011).…”

“…For example, although women may view their ability to return to normal activities or avoid complications from surgery as important in their decisions, their actual knowledge of these factors as they relate to reconstruction method appears limited (Lee et al, 2011). Of concern, a recent prospective study of over 100 women found that a majority underwent reconstruction despite endorsing preferences (e.g., desire to avoid complications) that were better aligned with mastectomy alone (Lee et al, 2017). …”

Delayed‐immediate hybrid breast reconstruction—Increasing patient input and precision in breast reconstruction

“…Numerous studies have demonstrated the beneficial effects of breast reconstruction on postoperative patient‐reported health‐related outcome measures . Clinical research has identified the importance of patient buy‐in, that is, shared decision‐making, when choosing the reconstructive modality . However, it is peculiar that after decades of breast reconstruction, patients continue to be generally offered only two options, that is, implant‐based reconstruction vs autologous reconstruction.…”