Decision Regret following Breast Reconstruction: The Role of Self-Efficacy and Satisfaction with Information in the Preoperative Period

Breast cancer survivors' perceptual map of breast reconstruction appearance outcomes

Purpose

It is often hard for patients to articulate their expectations about breast reconstruction appearance outcomes to their providers. Our overarching goal is to develop a tool to help patients visually express what they expect to look like after reconstruction. We aim to comprehensively understand how breast cancer survivors perceive diverse breast appearance states by mapping them onto a low-dimensional Euclidean space, which simplifies the complex information about perceptual similarity relationships into a more interpretable form.

Approach

We recruited breast cancer survivors and conducted observer experiments to assess the visual similarities among clinical photographs depicting a range of appearances of the torso relevant to breast reconstruction. Then, we developed a perceptual map to illuminate how breast cancer survivors perceive and distinguish among these appearance states.

Results

We sampled 100 photographs as stimuli and recruited 34 breast cancer survivors locally. The resulting perceptual map, constructed in two dimensions, offers valuable insights into factors influencing breast cancer survivors' perceptions of breast reconstruction outcomes. Our findings highlight specific aspects, such as the number of nipples, symmetry, ptosis, scars, and breast shape, that emerge as particularly noteworthy for breast cancer survivors.

Conclusions

Analysis of the perceptual map identified factors associated with breast cancer survivors' perceptions of breast appearance states that should be emphasized in the appearance consultation process. The perceptual map could be used to assist patients in visually expressing what they expect to look like. Our study lays the groundwork for evaluating interventions intended to help patients form realistic expectations.

Comparison of nipple sparing and skin sparing mastectomy with immediate reconstruction based on patient reported outcomes

Nipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM) are widely accepted surgical options for breast cancer patients undergoing immediate reconstruction. However, the impact of preserving the nipple-areolar complex on patient-reported outcomes (PROs) remains uncertain, particularly in clinically matched settings. This retrospective study included patients who underwent unilateral NSM or SSM followed by immediate implant-based breast reconstruction at Hubei Cancer Hospital between January 2022 and January 2024. Patients were propensity score matched (2:1) based on age, body mass index, preoperative breast size, neoadjuvant chemotherapy, implant plane, and postmastectomy radiation therapy. PROs were assessed using the BREAST-Q (version 2.0) and the decision regret scale. Univariate and multivariate linear regression analyses were conducted to identify predictors of satisfaction and regret. A total of 87 patients were included after matching (NSM: n = 58; SSM: n = 29). NSM patients reported significantly higher satisfaction with breasts (mean 58.1 vs. 52.9, P = 0.038) and sexual well-being (mean 52.4 vs. 38.9, P = 0.035). Although psychosocial well-being and decision regret showed favorable trends in the NSM group, differences were not statistically significant. Multivariate analysis revealed that reduction in breast size was significantly associated with decreased satisfaction and psychosocial well-being, while increased breast size was linked to greater decision regret. No significant differences were observed in complication rates between groups. Notably, none of the SSM patients received nipple reconstruction during follow-up. NSM was associated with greater satisfaction in breast and sexual well-being compared to SSM in matched breast cancer patients undergoing implant-based reconstruction. These findings support prioritizing NSM when oncologically feasible and highlight the potential role of delayed nipple reconstruction and expectation management in improving postoperative satisfaction for SSM patients.

Decision-making Tools for Postmastectomy Breast Reconstruction: A Scoping Review

Background

Breast reconstruction is an essential consideration for patients with breast cancer undergoing a mastectomy. Patients commonly report inadequate education as an important cause of dissatisfaction with breast reconstructive care. Information sources for breast reconstruction vary in quality, accuracy, and validity. We sought to determine what academic and nonacademic resources exist supporting decision-making for patients undergoing breast reconstruction.

Methods

A search was conducted of both academic literature and nonacademic social media sources. Three academic databases and 5 social media platforms were searched using keywords. Three independent reviewers performed the selection and data extraction of sources that met the inclusion criteria.

Results

A total of 1172 academic articles and 1419 nonacademic records were screened, with 14 and 9 included for final review, respectively. Of the 5 nonacademic mediums searched, none were included from TikTok and Instagram. One decision-making tool (DMT) was included from Twitter, 4 from YouTube, and 4 from Google. Overall, the quality of available DMTs was very good. The one included academic DMT had a mean DISCERN score of 5, whereas the 4 DMTs from Google and Twitter had a median DISCERN score of 4. YouTube videos were ranked using the modified DISCERN tool with a median score of 5.

Conclusions

Accessibility was found to be a significant barrier for patients in academic and nonacademic platforms with significant knowledge required to effectively search these platforms for resources. Efforts must be made to improve accessibility and awareness of these DMTs, as such tools are essential in shared decision-making.

One-Year Quality of Life Outcomes of Delayed Unilateral Autologous Breast Reconstruction and Associated Patient Factors

Introduction

As breast cancer survival rates improve, the long-term quality of life (QoL) has become increasingly important. With a significant number of patients still undergoing mastectomy and experiencing its well-known negative impacts on QoL, breast reconstruction aims to mitigate this by restoring body integrity. This study aimed to evaluate the changes in QoL and satisfaction in patients after breast reconstruction and influence of various patient-related factors.

Methods

Patients who underwent delayed unilateral deep inferior epigastric perforator (DIEP) breast reconstruction at a single institution between January 2016 and April 2019 were surveyed. QoL was assessed using the BREAST-Q questionnaire preoperatively and one year postoperatively. Scores were compared between the time points, and regression analysis was conducted to identify the influence of age, body mass index, economic status, education level, and relationship status on QoL.

Results

Among the 93 patients, 55 completed the preoperative and one-year postoperative BREAST-Q questionnaires (response rate: 59%). Postoperative QoL scores significantly increased for the domains "satisfaction with breasts," physical well-being chest," "sexual well-being," and "psychosocial well-being" (p<0.001). The scores for the domain "physical well-being abdomen" remained unchanged one year postoperatively. Higher education correlated with greater satisfaction with the breasts. Lack of an intimate partnership was identified as a significant negative factor for poorer psychosocial well-being.

Conclusions

Delayed unilateral DIEP breast reconstruction significantly enhances QoL and breast satisfaction one year postoperatively without causing long-term physical discomfort at the donor site. Education level and relationship status significantly affect the postoperative outcomes. Tailored preoperative counseling and psychosocial support are essential to maximize patient satisfaction and well-being following reconstruction.

Evaluating the quality and reliability of oncologic breast reconstruction videos on youtube

Oncologic breast reconstruction (OBR) is a complex process that requires consideration of multiple factors, including chemoradiation, extent of cancer treatment, and surgical approach. Patients often feel uncertain about the numerous surgical options and may turn to popular social media platforms like YouTube for information. Thus, this study aims to assess the quality and reliability of YouTube videos related to OBR. We conducted a retrospective, cross-sectional analysis of YouTube videos related to OBR. Search terms were obtained from plasticsurgery.org and Google Trends. The first ten videos for each search term were analyzed. Videos were categorized by source and subject matter and independently reviewed by three evaluators using the DISCERN scale. This study examined 172 YouTube videos. Five video source categories were identified: Health Care Administrations, Physicians, Non-physician Providers, News Organizations, and Patients. Health Care Administration accounts received the highest overall DISCERN score of 3.6 ± 0.51, followed by Physicians at 2.98 ± 0.93, with News Organization accounts scoring the lowest at 2.22 ± 0.60 (p < 0.001). Videos from academic sources (Physicians and Health Care Administrators) had higher DISCERN scores compared to non-academic sources (News Organizations and Patients), 2.98 ± 0.95 versus 2.28 ± 0.77, respectively (p < 0.001). Our findings indicate that videos from academic sources generally exhibit higher DISCERN scores, pointing to a higher content quality and reliability standard. Given the increasing reliance on YouTube for healthcare information, our study underscores the need for healthcare professionals to engage more actively in content creation and dissemination.

Comparing Provider and ChatGPT Responses to Breast Reconstruction Patient Questions in the Electronic Health Record

BACKGROUND

Patient-directed Electronic Health Record (EHR) messaging is used as an adjunct to enhance patient-physician interactions but further burdens the physician. There is a need for clear electronic patient communication in all aspects of medicine, including plastic surgery. We can potentially utilize innovative communication tools like ChatGPT. This study assesses ChatGPT's effectiveness in answering breast reconstruction queries, comparing its accuracy, empathy, and readability with healthcare providers' responses.

METHODS

Ten deidentified questions regarding breast reconstruction were extracted from electronic messages. They were presented to ChatGPT3, ChatGPT4, plastic surgeons, and advanced practice providers for response. ChatGPT3 and ChatGPT4 were also prompted to give brief responses. Using 1-5 Likert scoring, accuracy and empathy were graded by 2 plastic surgeons and medical students, respectively. Readability was measured using Flesch Reading Ease. Grades were compared using 2-tailed t tests.

RESULTS

Combined provider responses had better Flesch Reading Ease scores compared to all combined chatbot responses (53.3 ± 13.3 vs 36.0 ± 11.6, P < 0.001) and combined brief chatbot responses (53.3 ± 13.3 vs 34.7 ± 12.8, P < 0.001). Empathy scores were higher in all combined chatbot than in those from combined providers (2.9 ± 0.8 vs 2.0 ± 0.9, P < 0.001). There were no statistically significant differences in accuracy between combined providers and all combined chatbot responses (4.3 ± 0.9 vs 4.5 ± 0.6, P = 0.170) or combined brief chatbot responses (4.3 ± 0.9 vs 4.6 ± 0.6, P = 0.128).

CONCLUSIONS

Amid the time constraints and complexities of plastic surgery decision making, our study underscores ChatGPT's potential to enhance patient communication. ChatGPT excels in empathy and accuracy, yet its readability presents limitations that should be addressed.

Patient Decision Aids for Breast Cancer Reconstruction: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Breast cancer has surpassed lung cancer to become the most frequently diagnosed cancer in women. There has been a dramatic increase in the use of breast reconstruction after mastectomy. However, struggle in making decisions regarding breast reconstruction has existed. Thus, a study of decision aids (DAs) needs to be conducted, and further studies are needed to promote better DAs. This review discusses how DAs can be used to help women make decisions about breast reconstruction after mastectomy. In addition, the review was the first to compare different DA formats to determine which one is most effective.

METHODS

The authors searched for relevant studies published before October of 2022 in PubMed and Embase using the medical subject headings "breast reconstruction" and "decision aid." Demographic data and decision, outcomes, and instruments used for assessment were also collected. Risk of bias was measured by the Cochrane Risk of Bias 2 tool.

RESULTS

A network meta-analysis of 14 RCTs with a total of 1401 patients were included. A total of 90.9% participants presented usable results for evaluation of decisional conflict, and web-based DA (-0.3; 95% CI, -0.56 to -0.05) showed significant improvement; 50.3% of participants provided results of decisional regret, and no subgroups showed significant reduction; 60.3% of participants contributed to results for knowledge, and web-based DA (0.61; 95% CI, 0.01 to 1.21) showed the most positive effect. A total of 44.5% of participants were included for evaluation of satisfaction, and web-based DA (0.44; 95% CI, 0.15 to 0.72) revealed significant increase.

CONCLUSION

The review concluded that web-based DAs are the favorable format of DA.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Identifying research priorities for improving information and support for patients undergoing breast cancer surgery: a UK patient-centred priority setting project

PURPOSE

To use robust consensus methods with individuals with lived breast cancer experience to agree the top 10 research priorities to improve information and support for patients undergoing breast cancer surgery in the UK.

METHODS

Research uncertainties related to information and support for breast cancer surgery submitted by patients and carers were analysed thematically to generate summary questions for inclusion in an online Delphi survey. Individuals with lived breast cancer experience completed two Delphi rounds including feedback in which they selected their top 10 research priorities from the list provided. The most highly ranked priorities from the survey were discussed at an in-person prioritisation workshop at which the final top 10 was agreed.

RESULTS

The 543 uncertainties submitted by 156 patients/carers were categorised into 63 summary questions for inclusion in the Delphi survey. Of the 237 individuals completing Round 1, 190 (80.2%) participated in Round 2. The top 25 survey questions were carried forward for discussion at the in-person prioritisation workshop at which 17 participants from across the UK agreed the final top 10 research priorities. Key themes included ensuring patients were fully informed about all treatment options and given balanced, tailored information to support informed decision-making and empower their recovery. Equity of access to treatments including contralateral mastectomy for symmetry was also considered a research priority.

CONCLUSION

This process has identified the top 10 research priorities to improve information and support for patients undergoing breast cancer surgery. Work is now needed to develop studies to address these important questions.

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.

Factors influencing the decision-making process in breast reconstruction from the perspective of reconstructive surgeons: A qualitative study involving Korean plastic surgeons

BACKGROUND

Little research has been conducted on factors influencing the decision-making process for immediate breast reconstruction (IBR) options from the perspective of reconstructive surgeons, despite its significant impact on doctor-patient communication and shared decision-making. This study aims to explore the multiple factors and the mechanisms by which they interact using a qualitative methodology. We also address potential barriers to shared decision-making in IBR.

METHODS

Semistructured interviews were conducted with a purposive sample of reconstructive surgeons. Thematic analysis was used to identify key influences on IBR decision-making process from the perspective of reconstructive surgeons.

RESULTS

Four major themes were identified: 1. Patient clinical scenarios; 2. Nonclinical practice environments; 3. Reconstructive surgeon preferences; and 4. Patient consultation. Reconstructive surgeons demonstrated diverse approaches to patient clinical scenarios. High-volume centers were significantly influenced by nonclinical factors such as scheduling and operating room allocation systems. Reconstructive surgeons often had strong personal preferences for specific IBR options, shaped by their expertise, experience, and clinical environment. Based on the preliminary decision, surgeons provided information with varying degrees of neutrality. Patients varied in their knowledge and participation, resulting in variation in the final decision authority among surgeons.

CONCLUSIONS

This study highlights the need to address nonclinical environmental constraints to improve shared decision-making process in IBR. Surgeons should recognize power imbalances in the doctor-patient relationship and be aware of their biases.

Analyzing mastectomy and reconstruction weight in immediate autologous breast reconstruction: A preliminary study

BACKGROUND

This study aims to explore the ideal breast size by assessing the relationship between mastectomy to free flap weight ratio and complications as well as patient-reported outcomes in autologous breast reconstruction (ABR).

METHOD

A retrospective review of patients undergoing bilateral immediate ABR with mastectomy and flap weights available was completed. Patients were divided into three groups based on the ratio of mastectomy to flap weights. The patients were grouped as "maintained" if the flap weight was within 10% of the mastectomy weight. Patients with a weight difference greater than 10% were used to declare "downsized" or "upsized." Outcomes included complications and four domains of the BREAST-Q at 1-year postoperatively.

RESULTS

Three hundred and fifty-nine patients were included in the analysis, of which 112 were downsized, 91 maintained, and 156 upsized, respectively. Presence of complications did not significantly differ among the groups. At 1-year postoperatively, Sexual Well-being significantly differed (p = 0.033). Between preoperative and 1 year, patients who upsized experienced an improvement in Satisfaction with Breasts by 16 points (p < 0.001), while patients who downsized experienced a decline in Physical Well-being of the Chest by 7 points (p = 0.016). Multivariable linear regression model showed that Sexual Well-being was 13 points lower in the downsized cohort than in the maintained cohort (β = -13, 95% confidence interval: -21 to -5.4; p = 0.001).

CONCLUSION

Although complication rates do not significantly differ between the three cohorts, patients who downsize may have lower Sexual Well-being postoperatively. Surgeons should consider our preliminary findings to counsel patients preoperatively about the predicted breast size and the impact of downsizing on sexual health.

Three-dimensional Simulation on Patient-reported Outcomes Following Oncoplastic and Reconstructive Surgery of the Breast: A Randomized Trial

Background

Three-dimensional (3D) imaging using computer simulations is an evolving technology. There is a lack of strong data on the use of this technology for oncoplastic (OP) and reconstructive surgery.

Methods

A prospective, randomized, single-center trial including breast cancer patients undergoing OP or mastectomy with immediate breast reconstruction with implant (IBR) enrolled from November 2019 to October 2021 at the Hospital Nossa Senhora das Graças, Breast Unit in Curitiba, Brazil. Both patients undergoing OP and those in the IBR group were randomized to undergo 3D imaging and simulation of postoperative results (intervention group) or 3D imaging without simulation (control group). All patients were invited to complete a patient-reported outcome (BREAST-Q) expectations module and breast reconstruction or reduction/mastopexy module before and 6 months after surgery.

Results

A total of 96 patients were enrolled. Sixty-nine patients (45 OP and 24 IBR) completed the pre- and postoperative questionnaires and were randomized for the simulation. Women in the OP group had higher expectations for breast appearance when clothed than those in the IBR implant group (93.4 ± 16.3 versus 82.9 ± 26.5; P = 0.03). The intervention group was more satisfied with information than the control group (P = 0.021). Both patients who underwent OP and IBR believed that the 3D simulation helped them understand the surgical process (86.6% and 75%, respectively).

Conclusions

Preoperative 3D simulation significantly improved patient's satisfaction with information and did not decrease postoperative satisfaction with the outcomes. The incorporation of preoperative 3D simulation may be a valuable tool in breast reconstruction.

Quality of information and decision regrets during fertility-sparing management for atypical hyperplasia and endometrial cancer in a prospective cohort study

OBJECTIVE

To evaluate satisfaction with information, treatment, and decision regret during management to preserve fertility for atypical hyperplasia (AH) or endometrial cancer (EC).

METHODS

A cohort study with standardized management using chlormadinone acetate was established through a national referral centre between January 2013 and November 2019. During this period, a questionnaire was given to 136 patients aged 19 to 43 years who were followed for fertility preservation for AH or EC. The questionnaire included the validated EORTC-QLQ-INFO25, as well as questions from the validated EVAPIL questionnaire, the Treatment Satisfaction with Medicines Questionnaire, and the Decision Regret Scales concerning treatment tolerability and general satisfaction. The main outcomes measured were the quality and satisfaction with the information and treatment received and the decision regret.

RESULTS

75 patients (55.1 %) responded to the questionnaire. Overall, patients were satisfied with the information received (median 75.0, range: 25-100) and thought it was helpful (median 100.0, range: 25-100). However, 54.7 % wished for more information. Most women (52.0 %) indicated that psychological support should be available. Patients who were less satisfied with the information received or wished to receive more information thought about stopping treatment more frequently. Decision regret was not related to treatment outcome (remission, hysterectomy, live birth), and 47 of the 56 patients who did not obtain a live birth did not regret fertility preservation. None of the nine patients who regretted fertility preservation obtained a live birth. Almost all the patients reported side effects.

CONCLUSIONS

Dedicated information tools that detail conservative treatment for AH and EC as well as its secondary effects should be provided to improve adherence to treatment and follow-up. Furthermore, psychological support should be systematically proposed.

Outcomes of posterior component separation with transversus abdominis release for repair of abdominally based breast reconstruction donor site hernias

PURPOSE

Abdominally based autologous breast reconstruction (ABABR) is common after mastectomy, but carries a risk of complex abdominal wall hernias. We report experience with posterior component separation (PCS) and transversus abdominis release (TAR) with permanent synthetic mesh repair of ABABR-related hernias.

METHODS

Patients at Cleveland Clinic Foundation and Penn State Health were identified retrospectively. Outcomes included postoperative complications, hernia recurrence, and patient-reported outcomes (PROs): Hernia Recurrence Inventory, HerQLes Summary Score, Patient-Reported Outcome Measurement Information System (PROMIS) Pain Intensity 3a Survey, and the Decision Regret Scale (DRS).

RESULTS

Forty patients underwent PCS/TAR repair of hernias resulting from pedicled (35%), free (5%), muscle-sparing TRAMs (15%), and DIEPs (28%) from August 2014 to March 2021. Following PCS, 30-day complications included superficial surgical site infection (13%), seroma (8%), and superficial wound breakdown (5%). Five patients (20%) developed clinical hernia recurrence. At a minimum of 1 year, 17 (63%) reported a bulge, 12 (44%) reported pain, median HerQLes Quality Of Life Scores improved from 33 to 63/100 (p value < 0.01), PROMIS 3a Pain Intensity Scores improved from 52 to 38 (p value < 0.05), and DRS scores were consistent with low regret (20/100).

CONCLUSION

ABABR-related hernias are complex and technically challenging due to missing abdominal wall components and denervation injury. After repair with PCS/TAR, patients had high rates of recurrence and bulge, but reported improved quality of life and pain and low regret. Surgeons should set realistic expectations regarding postoperative bulge and risk of hernia recurrence.

Machine learning analysis of online patient questions regarding breast reconstruction

BACKGROUND

Social media has become a dominant educational resource for breast reconstruction patients. Rather than passively consuming information, patients interact directly with other users and healthcare professionals. While online information for breast reconstruction has been analyzed previously, a robust analysis of patient questions on online forums has not been conducted. In this study, the authors used a machine learning approach to analyze and categorize online patient questions regarding breast reconstruction.

METHODS

Realself.com was accessed and questions pertaining to breast reconstruction were extracted. Data collected included the date of question, poster's location, question header, question text, and available tags. Questions were analyzed and categorized by two independent reviewers.

RESULTS

522 preoperative questions were analyzed. Geographic analysis is displayed in Figure 1. Questions were often asked in the pre-mastectomy period (38.3%); however, patients with tissue expanders currently in place made up 28.5%. Questions were often related to reconstructive methods (23.2%), implant selection (19.5%), and tissue expander concerns (16.7%). Questions asked in the post-lumpectomy period were significantly more likely to be related to insurance/cost and reconstructive candidacy (p < 0.01). The "Top 6″ patient questions were determined by machine learning analysis, and the most common of which was "Can I get good results going direct to implant after mastectomy?"

CONCLUSIONS

Analysis of online questions provides valuable insights and may help inform our educational approach toward our breast reconstruction patients. Our findings suggest that questions are common throughout the reconstructive process and do not end after the initial consultation. Patients most often want more information on the reconstructive options, implant selection, and the tissue expansion process.

Patient Preferences for Postmastectomy Breast Reconstruction

Importance

Up to 40% of women experience dissatisfaction after breast reconstruction due to unexpected outcomes that are poorly aligned with personal preferences. Identifying what attributes patients value when considering surgery could improve shared decision-making. Adaptive choice-based conjoint (ACBC) analysis can elicit individual-level treatment preferences.

Objectives

To identify which attributes of breast reconstruction are most important to women considering surgery and to describe how these attributes differ by those who prefer flap vs implant reconstruction.

Design, Setting, and Participants

This web-based, cross-sectional study was conducted from March 1, 2022, to January 31, 2023, at Duke University and between June 1 and December 31, 2022, through the Love Research Army with ACBC analysis. Participants were 105 women at Duke University with a new diagnosis of or genetic predisposition to breast cancer who were considering mastectomy with reconstruction and 301 women with a history of breast cancer or a genetic predisposition as identified through the Love Research Army registry.

Main Outcomes and Measures

Relative importance scores, part-worth utility values, and maximum acceptable risks were estimated.

Results

Overall, 406 women (105 from Duke University [mean (SD) age, 46.3 (10.5) years] and 301 from the Love Research Army registry [mean (SD) age, 59.2 (11.9) years]) participated. The attribute considered most important was the risk of abdominal morbidity (mean [SD] relative importance [RI], 28% [11%]), followed by chance of major complications (RI, 25% [10%]), number of additional operations (RI, 23% [12%]), appearance of the breasts (RI, 13% [12%]), and recovery time (RI, 11% [7%]). Most participants (344 [85%]) preferred implant-based reconstruction; these participants cared most about abdominal morbidity (mean [SD] RI, 30% [11%]), followed by the risk of complications (mean [SD], RI, 26% [11%]) and additional operations (mean [SD] RI, 21% [12%]). In contrast, participants who preferred flap reconstruction cared most about additional operations (mean [SD] RI, 31% [15%]), appearance of the breasts (mean [SD] RI, 27% [16%]), and risk of complications (mean [SD] RI, 18% [6%]). Factors independently associated with choosing flap reconstruction included being married (odds ratio [OR], 2.30 [95% CI, 1.04-5.08]; P = .04) and higher educational level (college education; OR, 2.43 [95% CI, 1.01-5.86]; P = .048), while having an income level of greater than $75 000 was associated with a decreased likelihood of choosing the flap profile (OR, 0.45 [95% CI, 0.21-0.97]; P = .01). Respondents who preferred flap appearance were willing to accept a mean (SD) increase of 14.9% (2.2%) chance of abdominal morbidity (n = 113) or 6.4% (4.8%) chance of complications (n = 115).

Conclusions and Relevance

This study provides information on how women value different aspects of their care when making decisions for breast reconstruction. Future studies should assess how decision aids that elicit individual-level preferences can help tailor patient-physician discussions to focus preoperative counseling on factors that matter most to each patient and ultimately improve patient-centered care.

Direct-to-implant versus autologous tissue transfer: A meta-analysis of patient-reported outcomes after immediate breast reconstruction

BACKGROUND

The effect of immediate implant and autologous breast reconstruction on complication rates has been studied extensively; however, the patient-reported outcomes for these procedures during immediate, one-stage reconstruction has yet to be comprehensively investigated.

OBJECTIVE

This study compared the patient-reported outcomes for immediate implant reconstruction with those associated with immediate autologous reconstruction to determine the advantages and disadvantages for each modality from the patient's perspective.

METHODS

A literature search of PubMed between 2010 and 2021 was performed, and 21 studies containing patient-reported outcomes were selected for the analysis. A meta-analysis of patient-reported outcome scores was performed separately for immediate breast reconstruction using autologous tissue transfer and synthetic implants.

RESULTS

Nineteen manuscripts were included, representing data on a total of 1342 patients across all studies. The pooled mean of patients' satisfaction with their breasts was 70.7 (95% CI, 69.4-72.0) after immediate autologous reconstruction and 68.5 (95% CI, 67.1-69.9) after immediate implant reconstruction, showing a statistically significant difference in outcomes (p < 0.05). The pooled mean of patients' sexual well-being was 59.3 (95% CI, 57.8-60.8) after immediate autologous reconstruction and 62.8 (95% CI, 60.7-64.8) after immediate implant reconstruction (p < 0.01). The pooled mean of patients' satisfaction with their outcome was 78.8 (95% CI, 76.2-81.3) after immediate autologous reconstruction and 82.3 (95% CI, 80.4-84.1) after immediate implant reconstruction (p < 0.05). The results of each meta-analysis were summarized on forest plots depicting the distribution of patient-reported outcome scores from each study.

CONCLUSIONS

Immediate reconstruction with implants may have a similar or greater capacity to achieve patient satisfaction and improve patients' QoL compared to those associated with immediate reconstruction with autologous tissue transfer when both procedures are available.

Health Literacy in Oculofacial Plastic Surgery: A Literature Review

Patient satisfaction following oculofacial cosmetic procedures depends on preoperative expectations, which may be influenced by online material. Patients with poor health literacy are particularly vulnerable to misinformation and low-quality resources. However, few studies have evaluated the quality of online information on common oculofacial plastic surgeries and procedures. This study aimed to review the literature on the readability and quality of online material related to oculofacial plastic surgery. We conducted a systematic search of the PubMed/MEDLINE database and included 10 studies in our review. Among the readability scores reported in these studies, the lowest was 10, representing a tenth-grade reading level. Furthermore, the online materials were often rated as "poor" quality based on multiple grading scales. Our systematic review of the literature demonstrates that online materials covering common oculofacial plastic surgery procedures are consistently of poor quality and exceed the recommended readability level. Therefore, considering these online materials that influence patient expectations could enable oculofacial plastic surgeons to better tailor their preoperative counseling.

Decision Regret in Plastic Surgery: A Summary

Patient decision regret can occur following elective healthcare decisions. The current era is focused on patient-reported outcomes, and decision regret is another metric by which surgeons can and should measure postoperative results. Patients who experience decision regret after elective procedures can often blame themselves, the surgeon, or the clinical practice, and this can lead to downstream psychological and economic consequences for all parties involved.

Methods

A literature search was conducted on PubMed using the following search terms: (aesthetic surgery) AND (decision regret), (rhinoplasty) AND (decision regret), (face-lift) AND (decision regret), (abdominoplasty) AND (decision regret), (breast augmentation) AND (decision regret), (breast reconstruction) AND (decision regret), (FACE-Q) AND (rhinoplasty), (BREAST-Q) AND (breast augmentation). The following article types were included in the search: randomized controlled trials, meta-analysis, and systematic reviews.

Results

After review of the literature, preoperative education, decisional tools, and postoperative complications were found to be the most important factors affecting decision regret after surgery.

Conclusions

A better understanding of the factors associated with decision regret can help surgeons provide more effective preoperative counseling and prevent postoperative decision regret. Plastic surgeons can use these tools within a context of shared decision-making and ultimately increase patient satisfaction. Decision regret for plastic surgical procedures was mainly in the context of breast reconstruction. The differences in medical necessity create unique psychological challenges, emphasizing the need for more studies and a better understanding of the topic for other elective and cosmetic surgery procedures.

Financial Implications of Enhanced Recovery After Surgery Protocols in Microsurgical Breast Reconstruction

INTRODUCTION

Surgical advancements in breast reconstruction have allowed a shift toward optimizing patient-reported outcomes and efficiency measures. The enhanced recovery after surgery (ERAS) protocol has been instrumental in improving outcomes, but the effect of these protocols on health care spending has not been examined. This study aims to assess the effect of ERAS protocols on the length of hospital stay and costs associated with microsurgical breast reconstruction.

METHODS

In 2018, the authors implemented an ERAS protocol for patients undergoing microsurgical breast reconstruction that included perioperative procedures involving patient education and care. Subjects included patients who underwent deep inferior epigastric perforator flap breast reconstruction at the authors' institution between 2016 and 2019. Data were gathered from the electronic medical record and the hospital system's finance department, and patients were divided into pre-ERAS and ERAS cohorts. A 2-sample t test was used for statistical analysis.

RESULTS

The study included 269 patients with no statistically significant differences in demographic data between the cohorts. The average length of hospitalization was 3.46 days for the pre-ERAS group and 2.45 days for the ERAS group ( P = 0.000). In a linear regression, the ERAS protocol predicted a 1.04-day decrease in the length of stay ( P = 0.000). Overall, total direct cost decreased by 7.5% with the ERAS protocol.

CONCLUSION

The rising cost of health care presents a challenge for providers to reduce the cost burden placed on our health system while providing the highest-quality care. This study demonstrates that the use of standardized ERAS protocols can achieve this 2-fold goal.

Effects of decision aids on breast reconstruction: A systematic review and meta-analysis of randomised controlled trials

AIMS AND OBJECTIVES

To systematically evaluate the effects of decision aids for women facing breast reconstruction decision on decision conflict, decision regret, knowledge, satisfaction, anxiety and depression.

BACKGROUND

Breast reconstruction decision is not good or bad and should be guided by clinical evidence and patient preferences. Decision aids can increase the patient's decision-making enthusiasm and ability, improve the quality of decision and promote shared decision-making between patients and medical staff.

DESIGN

Systematic review and meta-analysis.

METHODS

Eight databases were conducted from the establishment of the database until October 2021. The PRISMA checklist was selected for analysis in this paper. The meta-analysis was conducted in Review Manager 5.3. The quality of the studies was assessed using the Cochrane risk-of-bias tool. The result is decision conflict, decision regret, knowledge and other secondary outcomes. Sensitivity analysis and subgroup analysis were also conducted.

RESULTS

A total of twelve randomised controlled trials (RCTs) were included in the systematic review and meta-analysis. Meta-analysis revealed that decision aids could significantly reduce decision conflict and decision regret, improve knowledge, satisfaction and depression and had no influence on anxiety.

CONCLUSIONS

The results of the systematic review and meta-analysis reviewed the positive effect of decision aids on the decision-making of women facing postmastectomy breast reconstruction. In the future, more well-designed RCTs are needed to confirm the effects of decision aids on the decision-making of breast reconstruction and nurses should be encouraged to take part in the development of decision aids in accordance with strict standards and apply them to breast cancer patients considering postmastectomy breast reconstruction.

RELEVANCE TO CLINICAL PRACTICE

Our study provides evidence for the effectiveness of decision aids on breast reconstruction and points to the important role of healthcare providers in the use of decision aids and in facilitating shared decision-making.

Patient-Reported Outcomes of Breast Reconstruction: Does the Quality of Decisions Matter?

BACKGROUND

Little is known about how the quality of decisions influences patient-reported outcomes (PROs). We hypothesized that higher decision quality for breast reconstruction would be independently associated with better PROs.

METHODS

We conducted a prospective cohort study of patients undergoing mastectomy with or without reconstruction. Patients were enrolled before surgery and followed for 18 months. We used BREAST-Q scales to measure PROs and linear regression models to explore the relationship between decision quality (based on knowledge and preference concordance) and PROs. Final models were adjusted for baseline BREAST-Q score, radiation, chemotherapy, and major complications.

RESULTS

The cohort included 101 patients who completed baseline and 18-month surveys. Breast reconstruction was independently associated with higher satisfaction with breasts (β = 20.2, p = 0.0002), psychosocial well-being (β = 14.4, p = 0.006), and sexual well-being (β = 15.7, p = 0.007), but not physical well-being. Patients who made a high-quality decision had similar PROs as patients who did not. Among patients undergoing mastectomy with reconstruction, higher decision quality was associated with lower psychosocial well-being (β = -14.2, p = 0.01).

CONCLUSIONS

Breast reconstruction was associated with better PROs in some but not all domains. Overall, making a high-quality decision was not associated with better PROs. However, patients who did not have reconstruction had a trend toward better well-being after making a high-quality decision, whereas patients who did have reconstruction had poorer well-being after making a high-quality decision. Additional research on the relationship between decision quality and PROs is needed.

Decision regret related to urinary diversion choices after cystectomy among Chinese bladder cancer patients

AIM

To explore factors associated with decision regret after cystectomy among Chinese bladder cancer patients.

METHODS

This cross-sectional study involved 112 patients, who had received radical bladder cancer resection. Participants were recruited from August 2021 until January 2022. The decision regret scale (DRS), decision conflict scale (DCS), and the Functional Assessment of Cancer Therapy-Bladder cancer (FACT-BL) form were used to measure decision regret, decision conflict, and quality of life. Investigator-designed items further explored perceptions involved in decision-making participation and outcomes.

RESULTS

The average score for decision regret was 26.21 (SD 15.886), while decision conflict was 20.27 (SD 13.375) and quality of life was 94.74 (SD 20.873). 57.1% of our participants had a little knowledge about the quality of life of patients who chose an alternate urinary diversion method; however, only 13.4% reported having a clear understanding. In addition, 8.9%, 26.8%, and 36.6% thought that quality of life related to alternate decisions was poor, average, or good, respectively. Multiple regression analysis suggested that decision regret is associated with decision conflict, quality of life, and the perceptions that others (who took alternate urinary diversion decisions) had a better quality of life.

CONCLUSION

Decision regret is common among Chinese bladder cancer patients, after cystectomy. The prevalence of regret appears to be much higher in Chinese bladder cancer patients compared to similar studies from other regions. Decisions in mainland China are often made by the treating physician or by family members which may cause more profound regret. However, education and economic status are positively related to higher levels of regret which creates questions around knowing, participation, and expectations, which must be explored.

Development of a Risk Prediction Model for Complications Following Forehead Flaps for Nasal and Periorbital Reconstruction

BACKGROUND

Forehead flaps are a workhorse for nasal reconstruction, but complications occur in up to 30% of patients and risk factors are not well characterized. This study aimed to identify risk factors for complications, and provide clinicians a method to stratify patient risk to facilitate shared decision-making.

MATERIALS AND METHODS

This retrospective study included patients who underwent forehead flaps between 2007 and 2020. Demographic and treatment characteristics were abstracted, in addition to clinical outcomes data. Multivariable regression was conducted, with step-wise variable elimination to determine inclusion in the final model. From the final regression, a risk-stratification scheme was developed.

RESULTS

One hundred ninety-seven patients underwent forehead flap reconstruction, with a mean age of 68.5 years. Mean follow-up time was 42 months. There were 50 (25.4%) patients who developed a complication, including impaired nasal function (18.8%), flap congestion (5.1%), infection (2.5%), poor donor site healing (2.5%) wound dehiscence (2.0%), and flap congestion (1.5%). On univariate analysis, female sex, immunosuppression, prior radiotherapy, and larger resection area were associated with complications ( P <0.05). On multivariable analysis, female sex [odds ratio (OR): 3.89, P <0.001], hypoalbuminemia (OR: 3.70, P =0.01), and prior wide local excision (OR: 3.62, P =0.04) were predictors of complications. A clinical calculator was developed incorporating these risk factors, with a C-statistic of 0.85, indicating strong predictive value.

CONCLUSIONS

We conducted the most comprehensive review of risk factors for the development of complications after forehead flap reconstruction. From this analysis, a novel, implementable, risk-stratification scheme was developed to equip surgeons with the ability to provide individualized risk assessment to patients and address preoperative comorbidities to optimize outcomes.

Best Practices for BREAST-Q Research: A Systematic Review of Study Methodology

BACKGROUND

Data heterogeneity and methodologic errors hinder the ability to draw clinically meaningful conclusions from studies using the BREAST-Q Reconstruction Module patient-reported outcome measure. In this systematic review, the authors evaluate the quality of BREAST-Q Reconstruction Module administration in relation to the BREAST-Q version 2.0 user's guide and the reporting of key methodology characteristics. The authors also describe a framework for improving the quality of BREAST-Q data analysis and reporting.

METHODS

The authors conducted a systematic search of PubMed, Embase, Cochrane CENTRAL, and Ovid HAPI databases to identify articles on the BREAST-Q Reconstruction Module to assess postmastectomy breast reconstruction outcomes. The authors registered the protocol before study implementation on Open Science Framework ( https://osf.io/c5236 ) and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data on mode of BREAST-Q administration, time horizon justification, and sample size calculation were collected.

RESULTS

The authors included 185 studies in the analysis. Errors in BREAST-Q administration were identified in 36 studies (19.5 percent). Appropriate administration of the BREAST-Q could not be determined in 63 studies (34.1 percent) because of insufficient reporting. Time horizon for the primary outcome was reported in 71 studies (38.4 percent), with only 17 (9.2 percent) reporting a sample size calculation.

CONCLUSIONS

The authors identified important yet actionable shortcomings in the BREAST-Q literature. Researchers are encouraged to review the BREAST-Q user's guide in the study design phase to mitigate errors in patient-reported outcome measure administration and reporting for future trials using the BREAST-Q Reconstruction Module. Adhering to these guidelines will allow for greater clinical utility and generalizability of BREAST-Q research.

The Impact of Reconstructive Modality and Postoperative Complications on Decision Regret and Patient-Reported Outcomes following Breast Reconstruction

Shared decision-making gives patients greater autonomy in their healthcare decisions; however, decisions that result in negative outcomes may lead to decision regret. The complexity of reconstructive options makes post-mastectomy breast reconstruction particularly prone to decision regret. This study's purpose was to explore the relationship between breast reconstruction modalities and degree of postoperative decision regret. Patients who had undergone either implant-based or autologous breast reconstruction with a minimum of 12 months of follow-up were invited to complete the Decision Regret Scale and the BREAST-Q Satisfaction with Breasts module. The impact of reconstructive modality and occurrence of postoperative complications on decision regret and satisfaction with breasts was examined. Sixty-three patients completed the questionnaires-25 patients with implant-based reconstruction and 38 patients with autologous reconstruction. The average Decision Regret score was 84.6 ± 23.6; thirty-one patients experienced no decision regret. The average score for the BREAST-Q module was 81.9 ± 18.8. Neither satisfaction with breasts nor decision regret were impacted by the reconstructive modality. The occurrence of postoperative complications was strongly correlated with lower Decision Regret scores (91.6 vs. 74.6, p=0.004) but was not correlated with lower Satisfaction with Breasts scores (84.6 vs. 78.2, p=0.18). Patients had relatively low levels of decision regret and relatively high levels of satisfaction with breasts, irrespective of reconstructive modality. Having a postoperative complication led to significantly greater levels of decision regret without impacting satisfaction with breasts. Patients may benefit from additional preoperative education on possible complications to mitigate decision regret. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Invited Discussion on: The Impact of Reconstructive Modality and Postoperative Complications on Decision Regret and Patient-Reported Outcomes following Breast Reconstruction

One in eight women will have a lifetime diagnosis of confirmed breast cancer, and one in three of these women will undergo a mastectomy. About half of women undergoing mastectomies will opt for some type of breast reconstruction. Breast cancer itself and breast reconstruction bring physical changes that are accompanied by psychological changes of varying degrees. The decision process about cancer treatment and whether or not to perform breast reconstruction brings suffering. In the case of choosing to perform the reconstruction, deciding when to perform it and which surgical technique to choose from among several available is quite complex, and may result in regret. The author provides a brief literature review on this subject and comments on the work carried out by Cai and Momeni, comparing data and results.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Health Literacy in Plastic Surgery: A Scoping Review

Health literacy of plastic surgery patients may affect surgical decision-making and perioperative outcomes. In addition to consulting a plastic surgeon, patients often refer to online-based resources to learn about surgical options. The aim of this scoping review was to identify evidence detailing the state of health literacy of plastic surgery patients and available resources to highlight areas of improvement for clinical practice and future research.

Methods

Utilizing PubMed and Web of Science databases, 46 eligible studies that analyzed health literacy in plastic surgery patients and readability of plastic surgery resources were included. Extracted characteristics from eligible studies included study size, type of analysis, findings, and conclusions.

Results

Regardless of plastic surgery procedure or subspecialty, resources presenting plastic surgery information to patients exceeded the American Medical Association and National Institutes of Health recommended sixth- to eighth-grade reading level. Plastic surgery patients demonstrated greater knowledge of preoperative indications and surgical benefits compared with postoperative outcomes and surgical risks.

Conclusions

Most health literacy research in plastic surgery focuses on readability of written internet-based resources as opposed to direct assessment of health literacy in plastic surgery patients. Plastic surgery resources exceed the recommended mean reading grade level. Dedicated efforts to recognize and accommodate a patient's level of health literacy in plastic surgery should be considered.

Satisfaction With Expectations-Based Education in Women Undergoing Breast Reconstruction

Women undergoing breast reconstruction sometimes have unrealistic or unformed expectations regarding the reconstructive process and outcomes. The objectives of this study were to assess preoperative expectations in women undergoing mastectomy and initial breast reconstruction, provide expectations-based education, and evaluate satisfaction with education. Fifty-one women undergoing mastectomy and breast tissue expander placement participated in this study. At a preoperative education appointment, participants completed a questionnaire to determine whether their expectations were realistic, unrealistic, or unformed. A nurse practitioner reviewed the results and provided patient-centered, expectations-based education to modify expectations from unrealistic to realistic or to set expectations from unformed to realistic. Four to 6 weeks after surgery, a second questionnaire was provided to assess perceived satisfaction with education. Unrealistic and unformed expectations were identified related to complications, pain, scarring, sensation, symmetry, and aesthetic results. After receiving patient-centered, expectations-based preoperative education, participants agreed they had received the appropriate amount of information and felt well prepared for their surgery and recovery. Most participants reported they were aware of possible complications, had effective tools to manage their pain, and had received adequate information about scarring and sensation changes. Some participants continued to have unrealistic or unformed expectations related to aesthetic results. Women undergoing breast reconstruction often have unrealistic or unformed expectations before surgery. Identifying these expectations and proving expectations-based education resulted in satisfaction with information provided.

Development of a patient decision aid for patients with breast cancer who consider immediate breast reconstruction after mastectomy

Purpose

The aim of this study was to develop a patient decision aid (pDA) that could support patients with breast cancer (BC) in making an informed decision about breast reconstruction (BR) after mastectomy.

Methods

The development included four stages: (i) Establishment of a multidisciplinary team; (ii) Needs assessment consisting of semi‐structured interviews in patients and a survey among healthcare professionals (HCPs); (iii) Creation of content, design and technical system; and (iv) Acceptability and usability testing using a think‐aloud approach in patients and interviews among HCPs and representatives of the Dutch Breast Cancer Patient Organization.

Results

From the needs assessment, three themes were identified: Challenging period to make a decision, Diverse motivations for a personal decision and Information needed to make a decision about BR. HCPs valued the development of a pDA, especially to prepare patients for consultation. The pDA that was developed contained three parts: first, a consultation sheet for oncological breast surgeons to introduce the choice; second, an online tool including an overview of reconstructive options, the pros and cons of each option, information on the consequences of each option for daily life, exercises to clarify personal values and patient stories; and third, a summary sheet with patients’ values, preferences and questions to help inform and guide the discussion between the patient and her plastic surgeon. The pDA was perceived to be informative, helpful and easy to use by patients and HCPs.

Conclusion

Consistent with information needs, a pDA was developed to support patients with BC who consider immediate BR in making an informed decision together with their plastic surgeon.

Patient or Public Contribution

Patients participated in the needs assessment and in acceptability and usability testing.

Dissatisfaction After Post-Mastectomy Breast Reconstruction: A Mixed-Methods Study

BACKGROUND

Breast reconstruction is associated with improved patient well-being after mastectomy; however, factors that contribute to post-surgical dissatisfaction remain poorly characterized.

METHODS

Adult women who underwent post-mastectomy implant-based or autologous breast reconstruction between 2015 and 2019 were recruited to participate in semi-structured interviews regarding their lived experiences with reconstructive care. Participants completed the BREAST-Q, and tabulated scores were used to dichotomize patient-reported outcomes as satisfied or dissatisfied (high or low) for each BREAST-Q domain. A convergent mixed-methods analysis was used to evaluate interviews for content related to satisfaction or dissatisfaction with breast reconstruction.

RESULTS

Overall, we interviewed 21 women and identified 17 subcodes that corresponded with the five BREAST-Q domains. Sources of dissatisfaction were found to be related to the following domains: (a) low breast satisfaction due to asymmetry, cup size, and lack of sensation and physical feeling (n = 8, 38%); (b) poor sexual well-being due to shape, look and feel (n = 7, 78% [of 9 who discussed sexual well-being]); (c) reduced physical well-being of the chest due to persistent pain and weakness (n = 11, 52%); (d) reduced abdominal well-being due to changes in abdominal strength, numbness, and posture (n = 6, 38% [of 16 who underwent abdominally based reconstruction]); and (e) low psychosocial well-being impacted by an unexpected appearance that negatively influenced self-confidence and self-identity (n = 13, 62%).

CONCLUSION

Patients may be unprepared for the physical, sexual, and psychosocial outcomes of breast reconstruction. Targeted strategies to improve preoperative education and shared decision making are needed to mitigate unexpectedness associated with breast reconstruction and related outcomes.

Assessing the Influence of Failed Implant Reconstruction on Patient Satisfaction and Decision Regret after Salvage Free-Flap Breast Reconstruction

BACKGROUND

 Free-flap breast reconstruction after failed implant reconstruction is associated with improved patient outcomes. How the level of satisfaction achieved compares between patients with and without previously failed implant reconstruction remains unknown. The aim of this study was to assess the influence of prior failed implant-based reconstruction on long-term patient-reported outcomes after free-flap breast reconstruction.

METHODS

 All patients undergoing free-flap breast reconstruction between 2015 and 2019 were identified. Patient satisfaction using the BREAST-Q and decisional regret using the Decision Regret Scale were compared between patients with and without a history of implant breast reconstruction.

RESULTS

 Overall, 207 patients were contacted and 131 completed the BREAST-Q and Decision Regret Scale. A total of 23 patients had a history of failed implant-based reconstruction requiring free-flap-flap salvage, most commonly due to infection (39.1%), chronic pain (34.8%), capsular contracture (26%), and implant malposition (26.1%). Following definitive free-flap reconstruction, patients with prior failed implant reconstruction had significantly lower BREAST-Q scores for satisfaction with breast (61.2 ± 16.7 vs. 70.4 ± 18.7; p = 0.04) and sexual well-being (38.5 ± 18.2 vs. 52.8 ± 24.7; p = 0.01) and reported higher decision regret (19.1 ± 18.6 vs. 9.6 ± 15.6, respectively). There were no significant differences for psychosocial well-being (p = 0.67), physical well-being (chest; p = 0.27), and physical well-being (abdomen; p = 0.91).

CONCLUSION

 A history of failed implant-based reconstruction is associated with reduced satisfaction and increased decision regret with the final reconstructive outcome. This data underscores the importance of appropriate patient selection at the initial consultation, and informed preoperative counseling regarding long-term outcomes in patients presenting for free-flap reconstruction after a failed implant-based reconstruction.

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.

Satisfaction With Expectations-Based Education in Women Undergoing Breast Reconstruction

Women undergoing breast reconstruction sometimes have unrealistic or unformed expectations regarding the reconstructive process and outcomes. The objectives of this study were to assess preoperative expectations in women undergoing mastectomy and initial breast reconstruction, provide expectations-based education, and evaluate satisfaction with education. Fifty-one women undergoing mastectomy and breast tissue expander placement participated in this study. At a preoperative education appointment, participants completed a questionnaire to determine whether their expectations were realistic, unrealistic, or unformed. A nurse practitioner reviewed the results and provided patient-centered, expectations-based education to modify expectations from unrealistic to realistic or to set expectations from unformed to realistic. Four to 6 weeks after surgery, a second questionnaire was provided to assess perceived satisfaction with education. Unrealistic and unformed expectations were identified related to complications, pain, scarring, sensation, symmetry, and aesthetic results. After receiving patient-centered, expectations-based preoperative education, participants agreed they had received the appropriate amount of information and felt well prepared for their surgery and recovery. Most participants reported they were aware of possible complications, had effective tools to manage their pain, and had received adequate information about scarring and sensation changes. Some participants continued to have unrealistic or unformed expectations related to aesthetic results. Women undergoing breast reconstruction often have unrealistic or unformed expectations before surgery. Identifying these expectations and proving expectations-based education resulted in satisfaction with information provided.

Decision aid for women with newly diagnosed breast cancer seeking breast reconstruction surgery: A prospective, randomized, controlled, single-blinded, pilot study

BACKGROUND

Women undergoing immediate breast reconstruction for breast cancer often experience anxiety when faced with reconstruction and the type of reconstruction to choose. The purpose of this study is to analyze the impact of a decision aid on decisional conflict in women with newly diagnosed breast cancer seeking breast reconstruction.

METHODS

Newly diagnosed breast cancer patients seeking breast reconstruction at a single center were prospectively randomized into two groups. Comparisons were made between two groups using the decisional conflict scale (DCS): women who reviewed the standard educational materials prior to initial consultation (control) and women who reviewed standard materials prior to initial consultation and then reviewed a decision aid brochure at initial consultation and two-week post-consultation (intervention). Pre-to-post-consultation DCS scores were compared within and between the control groups and intervention groups to assess which group had lower DCS scores.

RESULTS

A total of 20 patients, mean age 53±9 years were included. Median differences between pre-to-post-consultation DCS total scores in the control and intervention groups lowered from 32 to 22 and 28 to 16, respectively. Significant differences in subscores were control group: uncertainty: 54-21 (p = 0.030), and intervention group: uncertainty: 46-29 (p = 0.036) and values clarity: 29-25(p = 0.042). Pre-to-post-consultation differences between DCS scores and subscores did not demonstrate any statistical significance.

CONCLUSION

Decision aids did not significantly reduce pre-operative DCS total scores compared to current educational materials. More educational materials may not always be helpful for patients.

The nature and importance of women's goals for immediate and delayed breast reconstruction

OBJECTIVES

Increasingly, women undergo breast reconstruction (BR) surgery to restore health-related and psychosocial quality of life after mastectomy. Most research focuses on BR outcomes rather than women's pre-surgical expectations of, and goals for, immediate (IBR) or delayed (DBR) procedures, yet such information could support women's decision-making. This study aimed to investigate women's BR goals, whether they differed according surgery timing (IBR or DBR), and the importance women placed on them.

METHODS

Seventy-six women considering DBR (n = 50) or IBR (n = 26) at a UK hospital were encouraged to clarify their BR goals and rate the importance of achieving each one. Content analysis categorised and counted the frequency of the goals they reported.

RESULTS

Fifteen goal categories (7 surgical, e.g. scarring; 8 psychosocial/lifestyle, e.g. feeling feminine) were identified. Many (e.g. scarring, intimacy) were reported by a similar percentage of women in each surgical group, however, differences were identified (e.g. breast sensation was not mentioned by women considering IBR). Women reported more psychosocial (n = 206) than surgical goals (n = 160). Further, an independent t-tests revealed that women in both groups placed significantly more importance on the psychosocial (M = 9.4) than surgical goals (M = 8.5).

CONCLUSIONS

This study highlights the variety of goals women have for BR, the importance they attach to them, and differences and similarities between those seeking IBR and DBR. Future research should consider whether BR goals are met, how goal achievement influences satisfaction with outcome over time and how best to incorporate goals into pre-surgical treatment decision-making.

The Influence of Functional Shoulder Biomechanics as a Mediator of Patient-Reported Outcomes following Mastectomy and Breast Reconstruction

BACKGROUND

Postmastectomy breast reconstruction techniques differentially influence patient-reported physical and psychosocial well-being. Objective measures of shoulder biomechanics, which are uniquely influenced by reconstruction technique, may provide insight into the influence of reconstruction technique on patient-reported outcomes.

METHODS

Robot-assisted measures of shoulder strength and stiffness, and five validated patient-reported outcomes surveys were obtained from 46 women who had undergone mastectomy and a combined latissimus dorsi flap plus subpectoral implant, subpectoral implant, or DIEP flap breast reconstruction. Mediation analyses examined the role of functional shoulder biomechanics as a mediator between reconstruction technique and patient-reported outcomes.

RESULTS

Reconstruction technique affected shoulder biomechanics, with latissimus dorsi flap plus subpectoral implant patients exhibiting reduced shoulder strength and stiffness compared with subpectoral implant and DIEP flap patients. Increasing external rotation strength was predictive of improved upper extremity function (p = 0.04). Increasing shoulder stiffness while at rest was predictive of worsened upper extremity function (p = 0.03). Increasing shoulder stiffness at rest and during contraction was indicative of worsened psychosocial well-being (all p ≤ 0.02). Reconstruction technique did not predict survey scores of function directly, or when mediated by functional shoulder biomechanics.

CONCLUSIONS

In the current cohort, latissimus dorsi plus subpectoral implant breast reconstructions significantly reduced shoulder strength and stiffness when compared with the other techniques. In addition, objective measures of shoulder biomechanics were predictive of patient-reported physical and psychosocial well-being. The results emphasize the need for improved perioperative screening for shoulder functional deficits in patients undergoing breast reconstruction.

CLINICAL QUESITON/LEVEL OF EVIDENCE

Therapeutic, II.

Pain Management in Breast Surgery: Recommendations of a Multidisciplinary Expert Panel-The American Society of Breast Surgeons

Opioid overdose accounted for more than 47,000 deaths in the United States in 2018. The risk of new persistent opioid use following breast cancer surgery is significant, with up to 10% of patients continuing to fill opioid prescriptions one year after surgery. Over prescription of opioids is far too common. A recent study suggested that up to 80% of patients receiving a prescription for opioids post-operatively do not need them (either do not fill the prescription or do not use the medication). In order to address this important issue, The American Society of Breast Surgeons empaneled an inter-disciplinary committee to develop a consensus statement on pain control for patients undergoing breast surgery. Representatives were nominated by the American College of Surgeons, the Society of Surgical Oncology, The American Society of Plastic Surgeons, and The American Society of Anesthesiologists. A broad literature review followed by a more focused review was performed by the inter-disciplinary panel which was comprised of 14 experts in the fields of breast surgery, anesthesiology, plastic surgery, rehabilitation medicine, and addiction medicine. Through a process of multiple revisions, a consensus was developed, resulting in the outline for decreased opioid use in patients undergoing breast surgery presented in this manuscript. The final document was reviewed and approved by the Board of Directors of the American Society of Breast Surgeons.

A Randomized Controlled Trial Evaluating the BREASTChoice Tool for Personalized Decision Support About Breast Reconstruction After Mastectomy

OBJECTIVE

To evaluate a web-based breast reconstruction decision aid, BREASTChoice.

SUMMARY AND BACKGROUND DATA

Although postmastectomy breast reconstruction can restore quality of life and body image, its morbidity remains substantial. Many patients lack adequate knowledge to make informed choices. Decisions are often discordant with patients' preferences.

METHODS

Adult women with stages 0-III breast cancer considering postmastectomy breast reconstruction with no previous reconstruction were randomized to BREASTChoice or enhanced usual care (EUC).

RESULTS

Three hundred seventy-six patients were screened; 120 of 172 (69.8%) eligible patients enrolled. Mean age = 50.7 years (range 25-77). Most were Non-Hispanic White (86.3%) and had a college degree (64.3%). Controlling for health literacy and provider seen, BREASTChoice users had higher knowledge than those in EUC (84.6% vs. 58.2% questions correct; P < 0.001). Those using BREASTChoice were more likely to know that reconstruction typically requires more than 1 surgery, delayed reconstruction lowers one's risk, and implants may need replacement over time (all ps < 0.002). BREASTChoice compared to EUC participants also felt more confident understanding reconstruction information (P = 0.009). There were no differences between groups in decisional conflict, decision process quality, shared decision-making, quality of life, or preferences (all ps > 0.05). There were no differences in consultation length between BREASTChoice and EUC groups (mean = 29.7 vs. 30.0 minutes; P > 0.05). BREASTChoice had high usability (mean score = 6.3/7). Participants completed BREASTChoice in about 27 minutes.

CONCLUSIONS

BREASTChoice can improve breast reconstruction decision quality by improving patients' knowledge and providing them with personalized risk estimates. More research is needed to facilitate point-of-care decision support and examine BREASTChoice's impact on patients' decisions over time.

The impact of an online patient decision aid for women with breast cancer considering immediate breast reconstruction: study protocol of a multicenter randomized controlled trial

Background

Most breast cancer patients undergoing mastectomy are candidates for breast reconstruction. Deciding about breast reconstruction is complex and the preference-sensitive nature of this decision requires an approach of shared decision making between patient and doctor. Women considering breast reconstruction have expressed a need for decision support. We developed an online patient decision aid (pDA) to support decision making in women considering immediate breast reconstruction. The primary aim of this study is to assess the impact of the pDA in reducing decisional conflict, and more generally, on the decision-making process and the decision quality. Additionally, we will investigate the pDA’s impact on health outcomes, explore predictors, and assess its cost-effectiveness.

Methods

A multicenter, two-armed randomized controlled trial (1:1) will be conducted. Women with breast cancer or ductal carcinoma in situ who will undergo a mastectomy and are eligible for immediate breast reconstruction will be invited to participate. The intervention group will receive access to the online pDA, whereas the control group will receive a widely available free information leaflet on breast reconstruction. Participants will complete online questionnaires at: baseline (T0), 1 week after consultation with a plastic surgeon (T1), and 3 (T2) and 12 months (T3) after surgery. The primary outcome is decisional conflict. Secondary outcomes include other measures reflecting the decision-making process and decision quality (e.g., decision regret), patient-reported health outcomes (e.g., satisfaction with the breasts) and costs.

Discussion

This study will provide evidence about the impact of an online pDA for women who will undergo mastectomy and are deciding about breast reconstruction. It will contribute to the knowledge on how to optimally support women in making this difficult decision.

Trial registration

This study is retrospectively registered at ClinicalTrials.gov (NCT03791138).

Satisfaction, disappointment and regret surrounding fertility preservation decisions in the paediatric and adolescent cancer population

PURPOSE

With over 80% of paediatric and adolescent cancer patients surviving into adulthood, quality-of-life issues such as future fertility are increasingly important. However, little is known about regret around decisions to pursue or forgo fertility preservation (FP). We investigated the risk of decision regret in families involved in making a FP decision and explored contributive factors.

METHODS

Parents and patients ≥ 15 years were invited to participate. Participants completed a 10-item survey, including a validated Decision Regret Scale. Scores ≥ 30 indicated high regret. Free-text response items allowed participants to provide reasons for satisfaction or regret.

RESULTS

A total of 108 parents and 30 patients participated. Most (81.4%) reported low regret (mean score 13.7). On multivariate analysis, predictors of low regret included having a FP procedure and a fertility discussion pre-treatment. Most participants believed that FP offers hope for future fertility. Some reported dissatisfaction with the process of decision-making.

CONCLUSION

Overall levels of regret in the study population were low, with factors associated with quality, timely discussion and belief in the success of FP technology being predictors of low regret. However, dissatisfaction with the decision-making process itself revealed that refinements to the programme are required to meet families' needs.

Patient factors affecting decision regret in the medical treatment process of gynecological diseases

BACKGROUND

To ensure that patients continue treatment, it is essential that the patient is satisfied with the decision-making process of the treatment. One way to address this is to assess the healthcare quality using the concept of regret, which can measure "Being convinced in decision-making." This study aimed to elucidate patient factors affecting regret using the Japanese version of the Decision Regret Scale (DRS).

METHODS

A questionnaire survey was conducted with 197 patients with uterine myoma, ovarian tumors, and endometriosis. We then examined the relationship between the Japanese DRS, the Japanese SF-8 as a health-related quality of life (QOL), and patient factors using latent class analysis and path analysis through a multi-group comparison.

RESULTS

The final sample comprised 102 patients. Patients were classified into the following two groups based on the latent class analysis of patient characteristics: many patients who were married and had children and a few patients who were unmarried and had no children (class 1), and many patients who were unmarried and had no children and a few patients who were married and had children (class 2). The path analysis through the group comparison of the two classes revealed that subjective symptoms, preferences, and surgical procedure (laparotomy or laparoscopic surgery) had a direct impact on regret. The magnitude of the influence factors for Class 1 and Class 2 Regret was different. The indirect effect on regret was through mental component summary.

CONCLUSION

Our results suggest that it is necessary to present treatment methods with consideration to patients' backgrounds and to obtain informed consent from patients.

Synergistic Interaction Increases Complication Rates following Microvascular Breast Reconstruction

BACKGROUND

Microvascular breast reconstruction is a complex procedure that can be associated with high complication rates. Although a number of individual predictors of perioperative complications have been identified, few studies have explored interaction between risk factors. Understanding the synergistic effects of multiple risk factors is central to accurate and personalized preoperative risk prediction.

METHODS

The authors conducted a retrospective cohort study of patients who underwent microvascular breast reconstruction at their institution between 2009 and 2017. All intraoperative and postoperative complications were recorded. A multivariable logistic regression exploratory model identified independent predictors of complications. Interactions between individual variables were then assessed using the relative excess risk index (RERI) and the synergy index (SI).

RESULTS

Nine hundred twelve patients were included in the study and 26.1 percent experienced at least one perioperative complication. Obesity (OR, 1.54; p = 0.009), immediate reconstruction (OR, 1.49; p = 0.028), and comorbidities (OR, 1.43; p = 0.033) were identified as independent predictors of complications. Obesity and comorbidities had significant synergistic interactions with immediate reconstruction (RERI, 0.86; SI, 2.35; p = 0.0002; and RERI, 0.54; SI, 1.78; p = 0.001), bilateral reconstruction (RERI, 0.12; SI, 1.15; p = 0.002; and RERI, 0.59; SI, 3.16; p = 0.005), and previous radiotherapy (RERI, 0.62; SI, 4.43; p = 0.01; and RERI, 0.11; SI, 1.23; p = 0.040). Patients undergoing immediate breast reconstruction who were both obese and smokers had a 12-fold increase in complication rates (OR, 12.68; 95 percent CI, 1.36 to 118.46; p = 0.026) with a very strong synergistic interaction between variables (RERI, 10.55; SI, 10.33).

CONCLUSION

Patient- and treatment-related variables interact in a synergistic manner to increase the risk of complications following microvascular breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Local Therapy Decisional Regret in Older Women With Breast Cancer: A Population-Based Study

PURPOSE

Older women with nonmetastatic breast cancer can often choose from several surgery and radiation treatment options. Little is known regarding how these choices contribute to decisional regret, which is a negative emotion reflecting the idea that another surgery or radiation decision might have been preferable. We sought to characterize the burden of and examine potential risk factors for local therapy decisional regret among a population-based cohort of older breast cancer survivors.

METHODS AND MATERIALS

National Medicare claims for age ≥67 female breast cancer incident in 2009 identified patients treated with lumpectomy plus whole-breast irradiation, brachytherapy, or endocrine therapy or mastectomy with or without radiation. We sampled 330 patients per treatment group (N = 1650), of whom 1253 agreed to receive a paper survey including the Decisional Regret Scale and EQ-5D-3L Health-Utility Scale. Local therapy regret was defined as neutral or worse response to questions regarding surgery- or radiation-related decisional regret. Local therapy regret risk factors were evaluated using a multivariable generalized linear model. Association of local therapy regret with health utility was modeled using multivariable linear regression.

RESULTS

The response rate was 30.2% (n = 498 of 1650); 421 surveys were included in this analysis. Median diagnosis age was 72 years, and surveys were completed 6 years after diagnosis. Overall, 23.8% of respondents (n = 100) reported experiencing local therapy decisional regret. Type of local therapy was not associated with local therapy regret. Predictors of increased regret included black race (risk ratio [RR], 2.09; 95% confidence interval [CI], 1.33-3.29), high school education or less (RR, 1.87; 95% CI, 1.27-2.75), and axillary nodal dissection (RR, 2.13; 95% CI, 1.33-3.41). Local therapy regret was not associated with health utility (P = .37).

CONCLUSIONS

Local therapy regret afflicts nearly one quarter of our cohort of older breast cancer survivors, and it is associated with black race, less education, and more extensive nodal dissection, but not breast surgery. Regret is distinct from health utility, suggesting that it is a unique psychosocial construct that merits further study and mitigation strategies.

Quality of life in breast cancer patients and surgical results of immediate tissue expander/implant-based breast reconstruction after mastectomy

OBJECTIVES

The purpose of this study was to analyze the effects of prior radiotherapy (RT) as well as postmastectomy radiotherapy (PMRT) on patient-reported quality of life (QoL) and on surgical/aesthetic outcomes in patients with expander-/implant-based delayed immediate reconstruction (EIBR) compared to patients that underwent EIBR without any RT.

MATERIAL AND METHODS

QoL was assessed by BREAST-Q, the surgical/aesthetic outcome by a structured examination and a picture analysis (BCCT.CORE software) and subsequently compared between the three cohorts.

RESULTS

Of 161 eligible patients, 97 followed the invitation (no RT n = 54, 9 of them with bilateral EIBR; PMRT n = 26; history of RT n = 15). The surgical/aesthetic results were better in the RT-naive cohort than in the PMRT cohort, but satisfaction with outcome and psychosocial well-being were better in the PMRT cohort. The RT-naive cohort showed (significantly) higher scores in satisfaction with breast, satisfaction with implant and sexual well-being compared to the history of RT cohort, although satisfaction with outcome was comparable. The PMRT cohort reached significantly more points in almost all categories and better BCCT.CORE and examination results than the history of RT cohort. Of all patients, 92.7%, 84.6% and 78.6% (RT naive, PMRT, history of RT) would agree to undergo EIBR again.

CONCLUSION

EIBR results in acceptable QoL and surgical results. In patients with a prior RT, QoL is significantly lower and surgical results are significantly worse. However, high acceptance rates suggest EIBR being a justifiable option even for this group. Prospective studies and long-term follow-up are required for definitive conclusions.

Determinants of regret in elderly dialysis patients

AIMS

In Singapore, most elderly end-stage renal disease (ESRD) patients choose dialysis over palliative management. However, dialysis may not be the optimal treatment option given only moderate survival benefits and high costs and treatment burden compared to non-dialysis management. Elderly patients may therefore come to regret this decision. This study investigated: (i) extent of patients' decision regret after starting dialysis, and (ii) potentially modifiable predictors of regret: satisfaction with chronic kidney disease education, decisional conflict, and decision-making involvement.

METHODS

The present study was a cross-sectional study of 103 dialysis patients above 70 years of age, surveyed at Singapore General Hospital's renal medicine clinics between March and June 2017. Participants reported their levels of decision regret on the Decision Regret Scale (DRS), retrospective decisional conflict on the Decisional Conflict Scale, information satisfaction, and decision-making involvement.

RESULTS

In total, 81% of participants reported no decision regret (DRS score < 50), 11% ambivalence (DRS = 50), and 8% regret (DRS >50). In individual DRS items, 19% felt dialysis had done them harm and 16% would not make the same decision again. In multivariable analyses, lower information satisfaction [b = -0.07 (95% CI: -0.13, -0.01)] and decisional conflict [b = 0.004 (95% CI: 0.002, 0.006)] were significantly associated with decision regret.

CONCLUSION

Although the majority of elderly dialysis patients were comfortable with their decision to start dialysis, a proportion was ambivalent or regretted this choice. Regret was more likely among those who experienced decisional conflict and/or expressed poorer information satisfaction. Healthcare professionals should recognize these risk factors and take steps to minimize chances of regret among this population subset.