Readability analysis and concept mapping of PROMs used for headache disorders

OBJECTIVE

To assess the readability and the comprehensiveness of patient-reported outcome measures (PROMs) utilized in primary headache disorders literature.

BACKGROUND

As the health-care landscape has evolved toward a patient-centric model, numerous PROMs have been developed to capture treatment outcomes in patients with headache disorders. For these PROMs to advance our understanding of headache disorders and their treatment impact, they must be easy to understand (i.e., reading grade level 6 or less) and comprehensively capture what matters to patients with headache. The aim of this study was to (a) assess the readability of PROMs utilized in headache disorders literature, and (b) assess the comprehensiveness of PROMs by mapping their content to a health-related quality of life framework.

METHODS

In this scoping review, recently published systematic reviews were used to identify PROMs used in primary headache disorders literature. Readability analysis was performed at the level of individual items and full PROM using established readability metrics. The content of the PROMs was mapped against a health-related quality-of-life framework by two independent reviewers.

RESULTS

In total, 22 PROMs (15 headache disorders related, 7 generic) were included. The median reading grade level varied between 7.1 (interquartile range [IQR] 6.3-7.8) and 12.7 (IQR 11.8-13.2). None of the PROMs were below the recommended reading grade level for patient-facing material (grade 6). Three PROMs, the Migraine-Treatment Assessment Questionnaire, the Eurolight, and the European Quality of Life 5 Dimensions 3 Level Version, were between reading grade levels 7 and 8; the remaining 19 PROMs were above reading grade level 8. In total, the PROMs included 425 items. Most items (n = 134, 32%) assessed physical function (e.g., work, activities of daily living). The remaining items assessed physical symptoms (n = 127, 30%; e.g., pain, nausea), treatment effects on symptoms (n = 65, 15%; e.g., accompanying symptoms relief, headache relief), treatment impact (n = 56, 13%; e.g., function, side effects), psychological well-being (n = 41, 10%; e.g., anger, frustration), social well-being (n = 29, 7%; e.g., missing out on social activities, relationships), psychological impact (n = 14, 3%; e.g., feeling [not] in control, feeling like a burden), and sexual well-being (n = 3, 1%; e.g., sexual activity, sexual interest). Some of the items pertained to treatment (n = 27, 6%), of which most were about treatment type and use (n = 12, 3%; e.g., medication, botulinum toxin), treatment access (n = 10, 2%; e.g., health-care utilization, cost of medication), and treatment experience (n = 9, 2%; e.g., treatment satisfaction, confidence in treatment).

CONCLUSION

The PROMs used in studies of headache disorders may be challenging for some patients to understand, leading to inaccurate or missing data. Furthermore, no available PROM comprehensively measures the health-related quality-of-life impact of headache disorders or their treatment, resulting in a limited understanding of patient-reported outcomes. The development of an easy-to-understand, comprehensive, and validated headache disorders-specific PROM is warranted.

Translation and psychometric assessment of the mastectomy module of the BREAST-Q questionnaire for use in Nigeria

BACKGROUND

The majority of non-metastatic breast cancer patients in sub-Saharan Africa are recommended to have mastectomy. The impact of mastectomy on a predominantly young African patient population requires evaluation. The BREAST-Q is a validated patient-reported outcome measure of quality-of-life following breast surgery that has been translated into 30 languages-none in Africa. This study aimed to translate and assess the psychometric properties of the mastectomy module of the BREAST-Q for use in Nigeria.

METHODS

The BREAST-Q mastectomy module was translated from English to Yoruba and its psychometric properties assessed using best practice guidelines. Translation was performed in 4 steps: forward translation (x2), back translation, back translation review, and cognitive interviews with post-mastectomy patients. The translated BREAST-Q instrument was administered to post-mastectomy patients (n = 21) alongside the EORTC-QLQ BR23 to evaluate construct validity. Test-retest reliability was evaluated using intraclass correlation coefficients (ICC); surveys were re-administered 4 weeks apart.

RESULTS

The translation process identified English phrases not amenable to direct translation, including "emotionally healthy" and descriptions of pain ("nagging," "throbbing," "sharp"). Translations were amended to reflect local context and question intent. During cognitive interviews, patients provided suggestions to simplify complex phrases, e.g. "discomfort in your breast area.". Internal consistency within scales was over 0.70 for psychosocial wellbeing (α = 0.84-0.87), sexual wellbeing (α = 0.98-0.99), physical wellbeing in chest (α = 0.84-0.86), and satisfaction with care (α = 0.89-0.93). ICC for test-retest reliability was moderate (0.46-0.63).

CONCLUSIONS

The Yoruba version of the BREAST-Q mastectomy module presents a unique opportunity to adequately capture the experiences of Nigerian women post mastectomy. This instrument is being used in a pilot study of Nigerian patients to identify targets for intervention to improve the patient experience and compliance with breast cancer surgery.

Transforming Plastic and Reconstructive Surgical Care in Low- and Middle-Income Countries: A Paradigm Shift to the Diagonal Model

SUMMARY

The article highlights the global lack of access to basic surgical services, particularly in low- and middle-income countries (LMICs), where only 3.5% of surgical procedures serve 34.8% of the population. Plastic and reconstructive surgery, constituting 16% of treatable conditions, is a significant unmet need. Surgical outreach, popular for burns, trauma, and cleft lip, is addressed by organizations like ReSurge, Smile Train, and Operation Smile. The shift from the traditional "vertical model" to a "diagonal model" prioritizes long-term relationships, capacity-building, and sustainable healthcare. Efforts include education through programs like the ReSurge Global Training Program, a blended learning approach, and technology integration for ongoing support. The diagonal model aims to address not just immediate patient needs but also systemic challenges, emphasizing collaboration and empowerment for sustainable healthcare outcomes.

"I Want to Look Natural": Development and Validation of the FACE-Q Aesthetics Natural Module

BACKGROUND

The concept of natural after a facial aesthetic treatment represents an under-studied area. We added scales to FACE-Q Aesthetics to provide a means to measure this concept from the patient's perspective.

OBJECTIVES

To develop and validate FACE-Q natural scales.

METHODS

Concept elicitation interviews with people having minimally invasive treatments were conducted to explore the natural concept and develop scales. Patient and expert input was used to refine scale content. An online sample (i.e., Prolific) of people who had a facial aesthetic treatment to examine psychometric properties using Rasch Measurement Theory analysis. A test-retest reliability study was performed, and construct validity examined.

RESULTS

Interviews with 26 people were conducted. Three scales were developed and refined with input from 12 experts, 11 patients, and 184 online survey participants. Data from 1358 online participants provided evidence of scale reliability and validity. Reliability was high with Person Separation Index, Cronbach alpha and intraclass correlation coefficients values without extremes >0.82. Tests of construct validity confirmed that the scales functioned as hypothesized. Higher scores on the Expectations scale were associated with wanting a more natural look and movement after treatment. In addition, higher scores on the Natural Appearance and Natural Outcome scales correlated with better scores on other FACE-Q Aesthetics scales, and were associated with the face looking and feeling natural.

CONCLUSIONS

Many people seeking facial aesthetic treatments want to look natural. These new FACE-Q Aesthetics scales provide a means to measure the concept of 'natural' from the patient's perspective.

Identifying health-related quality of life concepts to inform the development of the WOUND-Q

OBJECTIVE

The impact of hard-to-heal wounds extends beyond traditional clinical metrics, negatively affecting a patient's health-related quality of life (HRQoL). Yet treatment outcomes are seldom measured from the patient's perspective. The purpose of the present study was to perform in-depth qualitative interviews with patients diagnosed with varying types of hard-to-heal wounds to identify outcomes important to them.

METHOD

Participants were recruited from wound care clinics in Canada, Denmark, the Netherlands and the US, and were included if they had a hard-to-heal wound (i.e., lasting ≥3 months), were aged ≥18 years, and fluent in English, Dutch or Danish. Qualitative interviews took place between January 2016 and March 2017. An interpretive description qualitative approach guided the data analysis. Interviews were audio-recorded, transcribed and coded line-by-line. Codes were categorised into top-level domains and themes that formed the final conceptual framework.

RESULTS

We performed 60 in-depth interviews with patients with a range of wound types in different anatomic locations that had lasted from three months to 25 years. Participants described outcomes that related to three top-level domains and 13 major themes: wound (characteristics, healing); HRQoL (physical, psychological, social); and treatment (cleaning, compression stocking, debridement, dressing, hyperbaric oxygen, medication, suction device, surgery).

CONCLUSION

The conceptual framework developed as part of this study represents the outcome domains that mattered the most to the patients with hard-to-heal wounds. Interview quotes were used to generate items that formed the WOUND-Q scales, a patient-reported outcome measure for patients with hard-to-heal wounds.

Feasibility of implementing patient-reported outcome measures into routine breast cancer care delivery using a novel collection and reporting platform

Objectives

imPROVE is a new Health Information Technology platform that enables systematic patient-reported outcome measure (PROM) collection through a mobile phone application. The purpose of this study is to describe our initial experience and approach to implementing imPROVE among breast cancer patients treated in breast and plastic surgery clinics.

Materials and Methods

We describe our initial implementation in 4 phases between June 2021 and February 2022: preimplementation, followed by 3 consecutive implementation periods (P1, P2, P3). The Standards for Reporting Implementation Studies statement guided this study. Iterative Plan-Do-Study-Act (PDSA) cycles supported implementation, and success was evaluated using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework.

Results

Qualitative interviews conducted during the preimplementation phase elicited 4 perceived implementation barriers. Further feedback collected during each phase of implementation resulted in the development of brochures, posters in clinic spaces, and scripts for clinic staff to streamline discussions with patients, and the resolution of technical issues concerning patient login capabilities, such as compatibility with cell phone software and barriers to downloading imPROVE. Feedback also generated ideas for facilitating provider interpretation of PROM results. By the end of P3, 2961 patients were eligible, 1375 (46.4%) downloaded imPROVE, and 1070 (36.1% of those eligible, 78% of those who downloaded) completed at least 1 PROM.

Discussion and Conclusion

Implementation efforts across 2 surgical departments at 2 academic teaching hospitals enabled collaboration across clinical specialties and longitudinal PROM reporting for patients receiving breast cancer care; the implementation effort also highlighted patient difficulties with mobile app-based PROM collection, particularly around initial engagement.

Determining Construct Validity of a Patient-Reported Outcome Measure for Birthmarks on the Face and Body

Background: The FACE-Q Craniofacial module includes a scale that measures how bothered an individual is by the appearance of a birthmark on the face or body. Objective: To determine if the Birthmark scale measuring appearance of the birthmark has evidence of construct validity among children and young adults, aged 8-29 years old, with a birthmark on the face or body. Methods: Participants were recruited as part of the field test of the FACE-Q Craniofacial module. Construct validity of the Birthmark scale was examined using a priori hypotheses testing. Results: Two hundred seventy participants were included, who were predominantly female (60.4%) and had a facial birthmark (71.5%). The Birthmark scale correlated (p ≤ 0.01) with scale scores for Face, Appearance Distress, Psychological, School, and Social. Scores for participants with more "noticeable" birthmarks were (p ≤ 0.01) associated with worse Birthmark scale scores. Conclusion: The findings support that the Birthmark scale can be used to measure the patient's perspective of the appearance of their birthmark, providing a means for clinicians to incorporate the patient's view in shared decision-making and research.

A Remote Symptom Monitoring Tool As Part of Ambulatory Cancer Surgery Recovery: A Qualitative Analysis of Patient Experience

PURPOSE

Patients recovering from ambulatory cancer surgery at home may find it difficult to determine whether their postoperative symptoms are normal or potentially serious. We developed the Recovery Tracker to help patients navigate such issues. The Recovery Tracker is a 10-day, web-based electronic survey that monitors symptoms daily and provides feedback as to whether reported symptoms are expected or require follow-up. We sought to examine patient perceptions using this tool.

METHODS

Semistructured interviews were conducted from August 2017 to September 2019 with a convenience sample of patients from a larger randomized controlled trial of the Recovery Tracker. Patients undergoing surgery at an ambulatory cancer center dedicated to the surgical treatment of breast, gynecologic, urologic, head, and neck cancers and benign tumors were included. Thematic analysis was applied to derive key themes and codes via NVivo qualitative analysis software. Recruitment was conducted iteratively until thematic saturation.

RESULTS

Forty-three patients were interviewed. Interview responses were organized into five main themes: (1) The Recovery Tracker led to more seamless communication with the care team; (2) symptoms not expected or not listed on the Recovery Tracker caused stress; (3) the Recovery Tracker was perceived as an extension of care, prompting reflection about symptoms and recovery; (4) Enhanced Feedback provided reassurance and helped set expectations; and (5) the Recovery Tracker was easy to use.

CONCLUSION

The patient experience of electronic symptom monitoring and feedback is congruent with the aims of such monitoring and feedback. Further qualitative research is required in more diverse populations.

The Impact of Psychiatric Diagnoses on Patient-reported Satisfaction and Quality of Life in Postmastectomy Breast Reconstruction

OBJECTIVE

The purpose of this study was to determine the prevalence of psychiatric diagnoses among a sample of breast reconstruction patients and measure the association between these diagnoses and reconstruction-related, patient-reported outcomes.

BACKGROUND

The impact of psychiatric disorders in conjunction with breast cancer diagnosis, treatment, and reconstruction have the potential to cause significant patient distress but remains not well understood.

METHODS

A retrospective review of postmastectomy breast reconstruction patients from 2007 to 2018 at Memorial Sloan Kettering Cancer Center was conducted. Patient demographics, comorbidities, cancer characteristics, psychiatric diagnoses, and BREAST-Q Reconstruction Module scores (measuring satisfaction with breast, well-being of the chest, psychosocial, and sexual well-being) at postoperative years 1 to 3 were examined. Mixed-effects models and cross-sectional linear regressions were conducted to measure the effect of psychiatric diagnostic class type and number on scores.

RESULTS

Of 7414 total patients, 50.1% had at least 1 psychiatric diagnosis. Patients with any psychiatric diagnoses before reconstruction had significantly lower BREAST-Q scores for all domains at all time points. Anxiety (50%) and depression (27.6%) disorders were the most prevalent and had the greatest impact on BREAST-Q scores. Patients with a greater number of psychiatric diagnostic classes had significantly worse patient-reported outcomes compared with patients with no psychiatric diagnosis. Psychosocial (β: -7.29; 95% confidence interval: -8.67, -5.91), and sexual well-being (β: -7.99; 95% confidence interval: -9.57, -6.40) were most sensitive to the impact of psychiatric diagnoses.

CONCLUSIONS

Mental health status is associated with psychosocial and sexual well-being after breast reconstruction surgery as measured with the BREAST-Q. Future research will need to determine what interventions (eg, screening, early referral) can help improve outcomes for breast cancer patients with psychiatric disorders undergoing breast reconstruction.

Patient-Reported Outcome Measures in Gender-Affirming Surgery

Patient-reported outcome measures (PROMs) are questionnaires that assess how patients feel and function. PROMs should be developed and validated using a mixed methods, multistep approach with extensive patient input to ensure that they are easy to understand, comprehensive, and relevant. PROMs that are specific to gender-affirming care (including surgery), such as the GENDER-Q, can be used to educate patients, align patients' goals and preferences with realistic expectations about the surgical procedures' purposes and outcomes, and conduct comparative effectiveness research. PROM data can contribute to evidence-based, shared decision making and just access to gender-affirming surgical care.

Outcomes of Different Quality of Life Assessment Modalities After Breast Cancer Therapy: A Network Meta-analysis

Importance

Improvement in clinical understanding of the priorities of patients with breast cancer (BC) regarding postoperative aesthetic outcomes (AOs) is needed.

Objective

To assess expert panel and computerized evaluation modalities against patient-reported outcome measures (PROMs), the gold standard of AO assessment, in patients after surgical management of BC.

Data Sources

Embase, MEDLINE, PsycINFO, PubMed, the Cochrane Central Register of Controlled Trials, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov were interrogated from inception through August 5, 2022. Search terms included breast conserving AND aesthetic outcome AND breast cancer. Ten observational studies were eligible for inclusion, with the earliest date of database collection on December 15, 2022.

Study Selection

Studies with at least 1 pairwise comparison (PROM vs expert panel or PROM vs computerized evaluation with Breast Cancer Conservation Treatment cosmetic results [BCCT.core] software) were considered eligible if they included patients who received BC treatment with curative intent. Studies reporting solely on risk reduction or benign surgical procedures were excluded to ensure transitivity.

Data Extraction and Synthesis

Two independent reviewers extracted study data with an independent cross-check from a third reviewer. The quality of included observational studies was assessed using the Newcastle-Ottawa Scale, and the level of evidence quality was assessed using the Grading of Recommendations Assessment, Development and Evaluation tool. Confidence in network meta-analysis results was analyzed with the Confidence in Network Meta-analysis semiautomated tool. Effect size was reported using random-effects odds ratios (ORs) and cumulative ratios of ORs with 95% credibility intervals (CrIs).

Main Outcomes and Measures

The primary outcome of this network meta-analysis was modality (expert panel or computer software) discordance from PROMs. Four-point Likert responses across PROMs, expert panel assessment, and BCCT.core evaluation of AOs were assessed.

Results

A total of 10 observational studies including 3083 patients (median [IQR] age, 59 [50-60] years; median [range] follow-up, 39.0 [22.5-80.5] months) with reported AOs were assessed and homogenized in 4 distinct Likert response groups (excellent, very good, satisfactory, and bad). Overall network incoherence was low (χ22 = 0.35; P = .83). Overall, panel and software modalities graded AO outcomes worse than PROMs. Specifically, for excellent vs all other responses, the panel to PROM ratio of ORs was 0.30 (95% CrI, 0.17-0.53; I2 = 86%) and the BCCT.core to PROM ratio of ORs was 0.28 (95% CrI, 0.13-0.59; I2 = 95%), while the BCCT.core to panel ratio of ORs was 0.93 (95% CrI, 0.46-1.88; I2 = 88%).

Conclusions and Relevance

In this study, patients scored AOs higher than both expert panels and computer software. Standardization and supplementation of expert panel and software AO tools with racially, ethnically, and culturally inclusive PROMs is needed to improve clinical evaluation of the journey of patients with BC and to prioritize components of therapeutic outcomes.

The Development, Deployment, and Evaluation of the CLEFT-Q Computerized Adaptive Test: A Multimethods Approach Contributing to Personalized, Person-Centered Health Assessments in Plastic Surgery

BACKGROUND

Routine use of patient-reported outcome measures (PROMs) and computerized adaptive tests (CATs) may improve care in a range of surgical conditions. However, most available CATs are neither condition-specific nor coproduced with patients and lack clinically relevant score interpretation. Recently, a PROM called the CLEFT-Q has been developed for use in the treatment of cleft lip or palate (CL/P), but the assessment burden may be limiting its uptake into clinical practice.

OBJECTIVE

We aimed to develop a CAT for the CLEFT-Q, which could facilitate the uptake of the CLEFT-Q PROM internationally. We aimed to conduct this work with a novel patient-centered approach and make source code available as an open-source framework for CAT development in other surgical conditions.

METHODS

CATs were developed with the Rasch measurement theory, using full-length CLEFT-Q responses collected during the CLEFT-Q field test (this included 2434 patients across 12 countries). These algorithms were validated in Monte Carlo simulations involving full-length CLEFT-Q responses collected from 536 patients. In these simulations, the CAT algorithms approximated full-length CLEFT-Q scores iteratively, using progressively fewer items from the full-length PROM. Agreement between full-length CLEFT-Q score and CAT score at different assessment lengths was measured using the Pearson correlation coefficient, root-mean-square error (RMSE), and 95% limits of agreement. CAT settings, including the number of items to be included in the final assessments, were determined in a multistakeholder workshop that included patients and health care professionals. A user interface was developed for the platform, and it was prospectively piloted in the United Kingdom and the Netherlands. Interviews were conducted with 6 patients and 4 clinicians to explore end-user experience.

RESULTS

The length of all 8 CLEFT-Q scales in the International Consortium for Health Outcomes Measurement (ICHOM) Standard Set combined was reduced from 76 to 59 items, and at this length, CAT assessments reproduced full-length CLEFT-Q scores accurately (with correlations between full-length CLEFT-Q score and CAT score exceeding 0.97, and the RMSE ranging from 2 to 5 out of 100). Workshop stakeholders considered this the optimal balance between accuracy and assessment burden. The platform was perceived to improve clinical communication and facilitate shared decision-making.

CONCLUSIONS

Our platform is likely to facilitate routine CLEFT-Q uptake, and this may have a positive impact on clinical care. Our free source code enables other researchers to rapidly and economically reproduce this work for other PROMs.

Financial Toxicity Among Patients With Breast Cancer Worldwide: A Systematic Review and Meta-analysis

IMPORTANCE

Financial toxicity (FT) is the negative impact of cost of care on financial well-being. Patients with breast cancer are at risk for incurring high out-of-pocket costs given the long-term need for multidisciplinary care and expensive treatments.

OBJECTIVE

To quantify the FT rate of patients with breast cancer and identify particularly vulnerable patient populations nationally and internationally.

DATA SOURCES

A systematic review and meta-analysis were conducted. Four databases-Embase, PubMed, Global Index Medicus, and Global Health (EBSCO)-were queried from inception to February 2021. Data analysis was performed from March to December 2022.

STUDY SELECTION

A comprehensive database search was performed for full-text, English-language articles reporting FT among patients with breast cancer. Two independent reviewers conducted study screening and selection; 462 articles underwent full-text review.

DATA EXTRACTION AND SYNTHESIS

A standardized data extraction tool was developed and validated by 2 independent authors; study quality was also assessed. Variables assessed included race, income, insurance status, education status, employment, urban or rural status, and cancer stage and treatment. Pooled estimates of FT rates and their 95% CIs were obtained using the random-effects model.

MAIN OUTCOMES AND MEASURES

FT was the primary outcome and was evaluated using quantitative FT measures, including rate of patients experiencing FT, and qualitative FT measures, including patient-reported outcome measures or patient-reported severity and interviews. The rates of patients in high-income, middle-income, and low-income countries who incurred FT according to out-of-pocket cost, income, or patient-reported impact of expenditures during breast cancer diagnosis and treatment were reported as a meta-analysis.

RESULTS

Of the 11 086 articles retrieved, 34 were included in the study. Most studies were from high-income countries (24 studies), and the rest were from low- and middle-income countries (10 studies). The sample size of included studies ranged from 5 to 2445 people. There was significant heterogeneity in the definition of FT. FT rate was pooled from 18 articles. The pooled FT rate was 35.3% (95% CI, 27.3%-44.4%) in high-income countries and 78.8% (95% CI, 60.4%-90.0%) in low- and middle-income countries.

CONCLUSIONS AND RELEVANCE

Substantial FT is associated with breast cancer treatment worldwide. Although the FT rate was higher in low- and middle-income countries, more than 30% of patients in high-income countries also incurred FT. Policies designed to offset the burden of direct medical and nonmedical costs are required to improve the financial health of vulnerable patients with breast cancer.

Nipple-Sparing Mastectomy and Immediate Reconstruction: A Propensity Score-Matched Analysis of Satisfaction and Quality of Life

BACKGROUND

Although it is intuitive that nipple-sparing mastectomy in selected patients would result in excellent cosmetic outcomes and high patient satisfaction, studies of clinical outcomes and health-related quality of life are limited and show mixed results. This study aimed to use a propensity score-matching analysis to compare satisfaction and health-related quality-of-life outcomes in patients who underwent implant-based reconstruction following bilateral nipple-sparing mastectomy or skin-sparing mastectomy.

METHODS

A propensity score-matching analysis (1:1 matching, no replacement) was performed comparing patients undergoing nipple-sparing or skin-sparing mastectomy with immediate bilateral implant-based breast reconstruction. Patients with a history of any radiation therapy were excluded. Matched covariates included age, body mass index, race, smoking history, neoadjuvant chemotherapy, bra size, and history of psychiatric diagnosis. Outcomes of interest included BREAST-Q scores and complications.

RESULTS

The authors examined 1371 patients for matching and included 460 patients (nipple-sparing mastectomy, n = 230; skin-sparing mastectomy, n = 230) in the final analyses. The authors found no significant differences in baseline, cancer, and surgical characteristics between matched nipple-sparing and skin-sparing mastectomy patients, who also had similar profiles for surgical complications. Interestingly, the authors found that postoperative Satisfaction with Breasts scores and all other health-related quality-of-life domains were stable over a 3-year period and did not differ significantly between the two groups.

CONCLUSIONS

Compared with skin-sparing mastectomy, bilateral nipple-sparing mastectomy did not improve patient-reported or clinical outcomes when combined with immediate implant-based reconstruction. The impact that nipple-sparing mastectomy may have on breast aesthetics and the ability of the BREAST-Q to gauge an aesthetic result following nipple-sparing mastectomy warrant further investigation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

A qualitative analysis of caregiver burden during the recovery process in ambulatory cancer surgery

PURPOSE

Cancer impacts caregivers as well as patients. Ambulatory oncology surgeries requiring a short hospital stay place additional responsibility on informal caregivers as they help patients navigate their post-operative recovery at home, and determine if symptoms are expected or emergent. Our objective was to explore the experience of informal caregivers during patients' ambulatory cancer surgery and then recovery at home with remote monitoring of symptoms via web-based patient-reported outcomes questionnaire ("Recovery Tracker").

METHODS

Semi-structured interviews were conducted with caregivers from a larger sample participating in a randomized trial of the Recovery Tracker. Thematic analysis was applied to derive key themes and codes via NVivo qualitative analysis software (QSR International Inc.). Recruitment was conducted iteratively to ensure a heterogenous sample and thematic saturation.

RESULTS

Twenty-three semi-structured interviews were conducted. Four main themes emerged: (1) Predictability reduced stress among caregivers; (2) Unexpected events caused stress for caregivers; (3) The importance of a caregiver being present during the recovery process; and (4) Caregiver involvement in remote monitoring of symptoms was minimal.

CONCLUSION

Caregivers report not being overly burdened by the ambulatory surgery process, but they are very sensitive to any deviations from what they expected to happen. Further research and clinical practice on caregivers in the ambulatory setting should focus on how to set expectations and avoid unexpected events.

Oncoplastic breast consortium recommendations for mastectomy and whole breast reconstruction in the setting of post-mastectomy radiation therapy

Aim

Demand for nipple- and skin- sparing mastectomy (NSM/SSM) with immediate breast reconstruction (BR) has increased at the same time as indications for post-mastectomy radiation therapy (PMRT) have broadened. The aim of the Oncoplastic Breast Consortium initiative was to address relevant questions arising with this clinically challenging scenario.

Methods

A large global panel of oncologic, oncoplastic and reconstructive breast surgeons, patient advocates and radiation oncologists developed recommendations for clinical practice in an iterative process based on the principles of Delphi methodology.

Results

The panel agreed that surgical technique for NSM/SSM should not be formally modified when PMRT is planned with preference for autologous over implant-based BR due to lower risk of long-term complications and support for immediate and delayed-immediate reconstructive approaches. Nevertheless, it was strongly believed that PMRT is not an absolute contraindication for implant-based or other types of BR, but no specific recommendations regarding implant positioning, use of mesh or timing were made due to absence of high-quality evidence. The panel endorsed use of patient-reported outcomes in clinical practice. It was acknowledged that the shape and size of reconstructed breasts can hinder radiotherapy planning and attention to details of PMRT techniques is important in determining aesthetic outcomes after immediate BR.

Conclusions

The panel endorsed the need for prospective, ideally randomised phase III studies and for surgical and radiation oncology teams to work together for determination of optimal sequencing and techniques for PMRT for each patient in the context of BR

•

Autologous breast reconstruction is increasingly preferred over implants in the setting of radiation therapy.

•

Use of patient-reported outcomes is endorsed.

•

Shape and size of reconstructed breasts can hinder radiotherapy planning.

•

There is a need for randomised phase III trials.

User-centered design and agile development of a novel mobile health application and clinician dashboard to support the collection and reporting of patient-reported outcomes for breast cancer care

Objectives

There is a need for advancements in health information technology that will transform how patient-reported outcomes (PRO) data are collected, reported, and used in breast cancer care. The objective of this study was to develop an innovative and customizable platform, called imPROVE to support PRO uptake in breast cancer care.

Design

User-centered design and agile development were employed. Recurrent stakeholder meetings with experts in the field of breast cancer care, in-depth one-on-one qualitative interviews with a clinical sample of patients with breast cancer, and focus groups with Dana-Farber/Harvard Cancer Center (DF/HCC) Breast Cancer Advisory Group members, were used to elicit feedback for the design features and functions of a patient mobile application and clinician dashboard.

Setting

This study was conducted at two academic hospitals in the USA.

Participants

Participants included experts in the field of breast cancer care, value-based healthcare, and health information technology, a clinical sample of patients with breast cancer, and members of the DF/HCC Breast Cancer Advisory Group.

Main outcome measures

imPROVE incorporates the International Consortium for Health Outcomes Measurement (ICHOM) breast cancer standard outcome set as well as the complete BREAST-Q Breast Cancer Module.

Results

Feedback was elicited from eight stakeholder meetings (n=28 members), interviews with a clinical sample of patients (n=28), and two focus groups with members of the DF/HCC Breast Cancer Advisory Group (n=17 members in each focus group). Participant feedback led to the development of a patient mobile application consisting of five components (myCare, myStory, myResources, myCommunity, and myNotes) and a clinician dashboard that includes an overview table and individual patient profiles with data displays.

Conclusions

imPROVE has the potential to transform the way we deliver care to patients. Developed from best practices in user-centered design, agile development, and qualitative methods; imPROVE addresses the needs of multiple stakeholders, including patients, clinicians, healthcare administrators, and researchers.

Lessons Learned in Implementing Patient-Reported Outcome Measures (PROMs) in the Australian Breast Device Registry (ABDR)

BACKGROUND

The Australian Breast Device Registry (ABDR) is a clinical quality registry which utilizes both surgical data and patient-reported outcome measures (PROMs) to understand device performance. The ABDR is the first national breast device registry utilizing the BREAST-Q Implant Surveillance module to conduct PROMs via text messaging as the primary method of contact for most patients. ABDR PROMs are structured upon a successful acceptability and feasibility study and a pilot study.

OBJECTIVES

This aim of this paper was to examine the challenges we faced and consider how lessons learned in implementing PROMs might inform future registry studies and interventions.

METHODS

We tracked the number of completed follow-ups and documented feedback between October 2017 and December 2018 from various stakeholders, including sites, surgeons, and patients.

RESULTS

In total, 10,617 patients were contacted: 59% of breast augmentation and 77% breast reconstruction patients responded to our PROMs survey. We encountered challenges and developed solutions to overcome several key issues, including database setup; follow-up contact methods; ethics; education of surgeons and patients; associated costs; and ongoing evaluation and modification. The strategies we devised to address these challenges included drawing on experiences from previous studies, greater communication with sites and surgeons, and having the flexibility to improve and modify our PROMs.

CONCLUSIONS

The ABDR PROMs experience and lessons learned can inform a growing number of registries seeking to conduct PROMs. We describe our approach, obstacles encountered, and strategies to increase patient participation. As more breast device registries worldwide adopt PROMs, data harmonization is crucial to better understand patient outcomes and device performance.

A Review of PROM Implementation in Surgical Practice

OBJECTIVE

To synthesize the current state of PROM implementation and collection in routine surgical practice through a review of the literature.

SUMMARY OF BACKGROUND DATA

Patient-reported outcomes (PROs) are increasingly relevant in the delivery of high quality, individualized patient care. For surgeons, PROMs can provide valuable insight into changes in patient quality of life before and after surgical interventions. Despite consensus within the surgical community regarding the promise of PROMs, little is known about their real-world implementation.

METHODS

The literature search was conducted in MEDLINE and Embase for studies published after 2012. We conducted a scoping review to synthesize the current state of implementation of PROs across all sizes and types of surgical practices. Studies were included if they met the following inclusion criteria: (1) patients ≥18 years 2) routine surgical practice, (3) use of a validated PRO instrument in the peri-operative period to report on general or disease-specific health-related quality of life, (4) primary or secondary outcome was implementation. Two independent reviewers screened 1524 titles and abstracts.

FINDINGS

16 studies were identified that reported on the implementation of PROMs for surgical patients. Sample size ranged from 41 patients in a single-center pilot study to 1324 patients in a study across 17 institutions. PROs were collected pre-operatively in 3 studies, post-operatively in 10, and at unspecified times in 4. The most commonly reported implementation outcomes were fidelity (12) and feasibility (11). Less than half of studies analyzed nonrespondents. All studies concluded that collection of PROMs was successful based on outcomes measured.

CONCLUSIONS

The identified studies suggest that implementation metrics including minimum standards of collection pre- and postintervention, reporting for response rates in the context of patient eligibility and analysis of respondents and nonrespondents, in addition to transparency regarding the resources utilized and cost, can facilitate adoption of PROMs in clinical care and accountability for surgical outcomes.

Understanding Preoperative Breast Satisfaction among Patients Undergoing Mastectomy and Immediate Reconstruction: BREAST-Q Insights

BACKGROUND

This study aims to present normative values for satisfaction with breasts among preoperative breast reconstruction patients as assessed using the BREAST-Q instrument and to delineate factors associated with preoperative breast satisfaction.

METHODS

A retrospective analysis of prospectively collected data was performed examining women undergoing postmastectomy breast reconstruction at a tertiary care center who preoperatively completed the BREAST-Q from 2010 to 2017. Because breast satisfaction scores were nonnormally distributed, scores were categorized into quartiles for analysis. Patient- and treatment-level variables were tested in a multivariable ordinal logistic regression model as predictors of breast satisfaction. Preoperative satisfaction was also tested for association with choice of reconstructive modality.

RESULTS

Among 1306 postmastectomy reconstruction patients included in the study, mean preoperative Satisfaction with Breasts score was 61.8 ± 21.5 and the median score was 58.0 (interquartile range, 48 to 70). Factors associated with significantly lower preoperative satisfaction included history of psychiatric diagnosis, preoperative radiotherapy, marital status (married), and higher body mass index. Factors associated with significantly higher scores were malignancy (localized tumor), medium bra size (B to C cup), and self-identification as black. Preoperative breast satisfaction was lower among patients who elected autologous reconstruction than among those with implant reconstruction (p < 0.001).

CONCLUSIONS

Preoperative breast satisfaction is influenced by multiple factors. Understanding these factors may improve preoperative counseling and expectation management for patients who undergo postmastectomy breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Outcomes in breast cancer from the patient perspective: Development of an innovative, user-centered platform for collection and reporting of patient-reported data

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Background: Transition towards a patient-centered healthcare model has been recognized as an important step towards improving the quality and coordination of breast cancer care. Although evidence suggests that patient self-reporting of quality of life improves clinical care, there are significant barriers to successful collection and use of patient-reported data (PRD) including a lack of a technology designed to fully engage patients and providers, limited electronic health record (EHR) integration, and suboptimal clinical implementation strategies. To address this, our team developed imPROVE, an innovative and customizable patient-reported data (PRD) collection platform consisting of a patient web-application and a clinician portal. Methods: This study was performed as a quality improvement initiative at Dana-Farber Cancer Institute (DFCI) and Brigham and Women’s Hospital (BWH). Multiple perspectives were sought from key stakeholders to ensure that the content and design of the platform target the needs of the end-users and garners the latest in technological advances. Development and testing were performed using best practices in user-centered design and agile development, and iterative programming sprints followed by stakeholder feedback and testing. Content was evaluated using probing questions about relevance, comprehensiveness, and clarity. Design was assessed through feedback about the look and feel of the platform and its usability. Results: A multidisciplinary team of 28 stakeholders in the field of breast cancer care, patient-reported outcomes research and value-based healthcare was assembled. Recurring group meetings (n = 8), individual patient interviews (n = 23), and two focus groups with the DF/HCC Breast Cancer Advocacy Group, were conducted. The resultant application is a hybrid mHealth application that is supported by iOS and Android and is comprised of five screens (myCare, myStory, myResources, myCommunity, myNotes). Patients are provided written and graphical displays of their PRD as well as tailored resources that are customized depending on their type and stage of treatment. The clinician portal is comprised of an overview table listing all patients enrolled for each individual clinician, as well as individual patient profiles demonstrating demographic, clinical, and outcomes data. Conclusions: imPROVE has the potential to create a paradigm shift in the delivery of care for breast cancer patients. Next steps will include implementation of imPROVE within the breast oncology and plastic surgery services at DFCI and BWH.

An international study to develop the EAR-Q patient-reported outcome measure for children and young adults with ear conditions

BACKGROUND

There is currently a lack of patient-reported outcome measures for ear reconstruction. We developed the EAR-Q to measure ear appearance and post-operative adverse effects from the patient perspective.

METHODS

Field-test data were collected from children and young adults in eight countries between 13 May 2016 and 12 December 2019. Rasch measurement theory (RMT) analysis was used to refine the scales and to examine their psychometric properties.

RESULTS

Participants had microtia (n = 607), prominent ears (n = 145) or another ear condition (n = 111), and provided 960 assessments for the Appearance scale (e.g., size, shape, photos), and 137 assessments for the Adverse Effects scale (e.g., itchy, painful, numb). RMT analysis led to the reduction of each scale to 10-items. Data fit the Rasch model for the Appearance (X2(80) = 90.9, p = 0.19) and Adverse Effects (X2(20) = 24.5, p = 0.22) scales. All items in each scale had ordered thresholds and good item fit. There was no evidence of differential item function for the Appearance scale by age, gender, language, or type of ear condition. Reliability was high for the Appearance scale, with person separation index (PSI) and Cronbach alpha values with and without extremes ≥0.92. Reliability for the Adverse Effects scale was adequate (i.e., PSI and Cronbach alpha values ≥0.71). Higher scores (liked appearance more) correlated with higher scores (better) on Psychological, Social and School scales.

INTERPRETATION

The EAR-Q can be used in those 8-29 years of age to understand the patient perspective in clinical practice and research, and in addition, can be used to benchmark outcomes for ear reconstruction internationally.

Health-related quality of life in the treatment and survivorship phases of breast cancer

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Background: Understanding the health-related quality of life (HRQOL) of breast cancer during treatment and survivorship is important; however, little data are available - particularly for long-term ( > 5 year) survivors. Health utility scores anchored between 0 (death) and 1 (perfect/best possible health) have been shown to be a good proxy index score of the overall HRQOL. The aim of this study was to estimate the utilities in the treatment and survivorship of breast cancer using validated preference-based measures(PBMs). Methods: Women (18 years or older) with history of breast cancer (on/off treatment) were recruited via Love Research Army (LRA), an online community of women engaged in breast cancer research. Members of the LRA were invited to participate via email and women who self-selected to be eligible were asked to complete clinical and demographics form and two generic PBMs - EQ-5D and Short Form-12 (SF-12), and one cancer-specific PBM-European Organization for Research and Treatment of Cancer-8D (EORTC-8D). Descriptive statistics and non-parametric analysis of variance tests were used to examine differences between the survivorship groups. Results: 1,636 women aged 46 ± 10 years were included in the analysis. Mean age at primary diagnosis was 35 ± 10 years and most patients were diagnosed with breast cancer stage 0-2 (n = 1362, 83.25%). For women currently on treatments, mean utility values were: chemotherapy (EQ-5D = 0.61, SF-6D = 0.67,EORTC-8D = 0.69), radiation(EQ-5D = 0.71, SF-6D = 0.67, EORTC-8D = 0.66), hormone replacement therapy (EQ-5D = 0.82,SF-6D = 0.76,EORTC-8D = 0.85), targeted therapy (EQ-5D = 0.77, SF-6D = 0.74, EORTC-8D = 0.82), and surgery (EQ-5D = 0.81,SF-6D = 0.69, EORTC-8D = 0.78). For women diagnosed with arm lymphedema (n = 182,11%), utility values were EQ-5D = 0.79,SF-6D = 0.74, EORTC-8D = 0.82. Women who were ≤ 5 years post-primary diagnosis reported slightly lower utility values (EQ-5D = 0.82,SF-6D = 0.76,EORTC-8D = 0.84) than women who were 6-10 years (EQ-5D = 0.83,SF-6D = 0.76,EORTC-8D = 0.85; p = 0.117) post-primary diagnosis. However, when utilities for women who were ≤ 5 years post-primary diagnosis were compared to women who were 11 to 15 years (EQ-5D = 0.86,SF-6D = 0.79,EORTC-8D = 0.88) and over 15 years (EQ-5D = 0.86,SF-6D = 0.81,EORTC-8D = 0.89) post-primary diagnosis, the difference was statistically significant (p = 0.000). Women who belonged to non-White ethnic groups, had lower levels of education (Bachelors or less) and reported less than USD 50,000 annual income in the previous year reported lower utility values across all time points, after adjusting for age and cancer stage. Conclusions: This study shows that the HRQOL decline in the first five years post-primary breast cancer diagnosis persists for several years into survivorship. Further, women from ethnic minority groups and lower socioeconomic background have lower HRQOL, irrespective of their age and cancer stage.

The BODY-Q Chest Module: Further Validation in a Canadian Chest Masculinization Surgery Sample

BACKGROUND

The BODY-Q Chest module is a patient-reported outcome (PRO) instrument that measures satisfaction with how the chest (10 items) and nipples (5 items) look. This PRO instrument was previously field tested in an international sample of people seeking treatment for gynecomastia (n = 174), weight loss (n = 224), and chest masculinization (n = 341).

OBJECTIVES

The aim of this study was to examine the psychometric performance of the BODY-Q Chest module in a new chest masculinization surgery sample.

METHODS

Data were collected from patients attending a private plastic surgery outpatient clinic in Canada between January 2018 and June 2019. Rasch measurement theory analysis was used to examine how the scales performed psychometrically.

RESULTS

The sample provided 266 assessments (115 preoperative, 151 postoperative). All items had ordered thresholds, providing evidence that the 4 response options for each scale worked as expected. Item fit was within ±2.5 for all items, with all Bonferroni adjusted chi-square values nonsignificant. The data for the chest (χ2(20) = 18.72, P = 0.54) and nipples (χ 2(10) = 12.28, P = 0.27) scales fit the requirements of the Rasch model. Reliability was high with person separation index and Cronbach's α values of ≥0.95 for the chest and ≥0.87 for the nipple scales, respectively. More depressive symptoms on the Patient Health Questionnaire-9 and lower health-related quality of life scales were weakly correlated with worse scores on the chest and nipple scales (P < 0.001).

CONCLUSIONS

The BODY-Q Chest module was shown to be scientifically sound in an independent sample of patients seeking chest masculinization surgery.

Test-Retest Reliability of the BREAST-Q IS in the Australian Breast Device Registry

BACKGROUND

Patient-reported outcome measures (PROMs) are increasingly employed in healthcare to assess outcomes. The BREAST-Q Implant Surveillance module (BREAST-Q IS) is a 5-question PROM utilized by the Australian Breast Device Registry to monitor the performance of breast devices. Validation of this tool is needed to assess its utility in this setting.

OBJECTIVES

The objective of this study was to assess the test-retest reliability of the BREAST-Q IS among breast implant recipients within a registry setting.

METHODS

A test-retest reliability study was undertaken. Patients who underwent breast augmentation or breast reconstruction and registered with the Australian Breast Device Registry were eligible to participate. A total of 250 surveys were distributed. The BREAST-Q IS was administered to the same group of participants on 2 separate occasions with a 2-week test interval. Participants were divided into 2 groups: breast augmentation and breast reconstruction. A weighted kappa coefficient was calculated to assess the degree of test-retest reliability of the BREAST-Q IS.

RESULTS

A total of 207 participants completed both tests. The response rate was 82% (n = 113) for the breast augmentation group and 94% (n = 94) for the breast reconstruction group. All 5 questions on the BREAST-Q IS obtained weighted kappa scores above 0.74 among both groups.

CONCLUSIONS

The BREAST-Q IS has good to excellent test-retest reliability for utilization among breast implant recipients in a registry setting. Further validation of the BREAST-Q IS will be required to establish the BREAST-Q IS as a valid and reliable PROM tool for breast implant recipients following breast device surgery.

Abstract OT-23-03: Pre- versus sub-pectoral implant-based breast reconstruction after skin-sparing mastectomy or nipple-sparing mastectomy (OPBC-02 PREPEC): A pragmatic, multicenter, randomized, superiority trial

Background The emphasis on aesthetic outcomes and quality of life (QoL) has motivated surgeons to develop skin- and nipple-sparing mastectomy (SSM/NSM) for breast cancer (BC) treatment or prevention. Immediate breast reconstruction is based on implants or autologous tissue. The optimal positioning of the implant is not clear: While pre-pectoral positioning respects the anatomic position of the mammary gland and avoids surgery-induced alterations of the pectoralis major muscle, the lack of muscle coverage may increase the risk of additional surgical interventions due to major complications. The Oncoplastic Breast Consortium (OPBC) identified this knowledge gap as research priority in 2019.

Trial design International, multicenter study with a superiority trial design and two parallel groups with 1:1 random allocation to pre- or sub-pectoral implant-based breast reconstruction (IBBR). Following a pragmatic approach, randomly assigned IBBR will be performed according to the surgeons’ usual care by use of a one- or two-stage approach with or without adjunctive mesh. Follow-up visits are performed within routine care (visits at 10 days and at 1, 6, 12, 18 and 24 months after surgery). Oncological follow-up will be conducted annually for 10 years. ClinicalTrials.gov identifier: NCT04293146.

Eligibility We include women ≥ 18 years, with an indication for NSM or SSM and IBBR in the therapeutic or risk-reducing setting, the ability to complete QoL questionnaires and the adequateness of skin flap(s) for pre-pectoral IBBR (intraoperative decision of the surgeon).

Specific aims The primary objective is to test whether pre-pectoral IBBR provides better QoL with respect to long-term (24 months) physical well-being of the chest (BREAST-Q) compared to sub-pectoral IBBR for patients undergoing SSM or NSM for prevention or treatment of BC. Secondary endpoints include loss of expander or implant, complications, other BREAST-Q QoL and patient satisfaction domains, aesthetic outcomes and recurrence free survival. Interference of different dose distributions of radiation therapy and its consequences on the distribution of local tumor recurrences will be assessed.

Statistical methods The primary analysis will be performed on the full analysis set following the intention-to-treat principle. To test the primary hypothesis, a linear mixed model will be fitted with the BREAST-Q score as response variable and treatment assignment as independent variable. The analysis will be adjusted for baseline BREAST-Q score, stratification factors (i.e. uni- vs bilateral surgery and NSM vs SSM) and other potential confounders. A random intercept to account for the center effect will be included. As a sensitivity analysis, an unadjusted t-test will be performed on the BREAST-Q score change from baseline to compare the two treatment arms. The sample size was determined for the primary endpoint, with an expected mean score of 76 points for sub-pectoral and 80 points for pre-pectoral implants. The clinically relevant difference to be detected in this superiority design is 4 points, with an expected common standard deviation of 13 points. A sample size of 334 patients provides an 80% power for a two-sided t-test at level α = 0.05. Compensating for a 10% dropout rate, the total sample size was calculated to include 372 patients.

Present accrual and target accrual By June 2020, one study site (Basel) has been initiated. During a 21-month recruitment period, we plan to include 372 patients at 21 sites in Switzerland, USA, China, Austria, Germany, Hungary and Sweden.

Contact information Prof. Dr. Walter Paul Weber, Chefarzt Brustchirurgie, Breast Surgeon SSO, Universitätsspital Basel, Spitalstrasse 21, CH-4031 Basel, Tel: +41 61 328 61 49, Walter.Weber@usb.ch

Citation Format: Walter Paul Weber, Elisabeth A Kappos, Meredith M Regan, Giusi Moffa, Yves Harder, Karin Ribi, Shelley Potter, Andrea Pusic, Mathias K Fehr, Lars G Hemkens, Thomas Holzbach, Jian Farhadi, Colin Simonson, Michael Knauer, Ralph Verstappen, Heiner Bucher, Daniel Zwahlen, Frank Zimmermann, Matthias Schwenkglenks, Rosine Mucklow, Vesna Bjelic-Radisic, Amelia Chiorescu, Yoon Chun, Subrina Farah, Xiasong Chen, Linda Nigard, Sherko Kümmel, Roland Reitsamer, Maik Hauschild, Ilario Fulco, Christoph Tausch, Thomas Fischer, Dimitri Sarlos, Mihai Constantinescu, Judith E Lupatsch, Florian Fitzal, Joerg Heil, Zoltán Mátrai, Jana de Boniface, Christian Kurzeder, Martin Haug, Alexandra Schulz. Pre- versus sub-pectoral implant-based breast reconstruction after skin-sparing mastectomy or nipple-sparing mastectomy (OPBC-02 PREPEC): A pragmatic, multicenter, randomized, superiority trial [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr OT-23-03.

The BODY-Q Cellulite Scale: A Development and Validation Study

BACKGROUND

Cellulite is a localized metabolic disorder of the subcutaneous tissue. To measure the impact of cellulite and its treatment(s) on patients' health-related quality of life, a psychometrically sound patient-reported outcome measure is needed.

OBJECTIVES

The authors sought to develop and field test a new BODY-Q cellulite scale to measure the appearance of cellulite.

METHODS

Appearance-related codes from the original BODY-Q qualitative interviews were reexamined, and a set of cellulite-specific items was developed and refined through cognitive patient interviews (n = 10) and expert input (n = 17). This scale was field-tested in adults with cellulite through 2 crowdworking platforms. Rasch Measurement Theory analysis was employed to refine the scale and examine its psychometric properties.

RESULTS

The field-test sample included 2129 participants. The 15-item scale was reduced in length to 11 items. Data from the sample fit the Rasch model (X2 [99] = 21.32, P = 0.06). All items had ordered thresholds and mapped out a targeted clinical hierarchy. The reliability statistics for the person separation index was 0.94 and for Cronbach's alpha was 0.97. In terms of validity, worse scores on the cellulite scale were associated with being more bothered by how the cellulite looked overall, having more severe cellulite on the Patient-Reported Photo-numeric Cellulite Severity Scale, and having more self-reported cellulite and more areas of the body with cellulite.

CONCLUSIONS

The BODY-Q cellulite scale can be utilized to measure appearance of cellulite and provides a solid basis for future studies evaluating the impact of cellulite and its treatment.

Prediction of Persistent Pain Severity and Impact 12 Months After Breast Surgery Using Comprehensive Preoperative Assessment of Biopsychosocial Pain Modulators

BACKGROUND

Persistent post-mastectomy pain (PPMP) is a significant negative outcome occurring after breast surgery, and understanding which individual women are most at risk is essential to targeting of preventive efforts. The biopsychosocial model of pain suggests that factors from many domains may importantly modulate pain processing and predict the progression to pain persistence.

METHODS

This prospective longitudinal observational cohort study used detailed and comprehensive psychosocial and psychophysical assessment to characterize individual pain-processing phenotypes in 259 women preoperatively. Pain severity and functional impact then were longitudinally assessed using both validated surgery-specific and general pain questionnaires to survey patients who underwent lumpectomy, mastectomy, or mastectomy with reconstruction in the first postsurgical year. An agnostic, multivariable modeling strategy identified consistent predictors of several pain outcomes at 12 months.

RESULTS

The preoperative characteristics most consistently associated with PPMP outcomes were preexisting surgical area pain, less education, increased somatization, and baseline sleep disturbance, with axillary dissection emerging as the only consistent surgical variable to predict worse pain. Greater pain catastrophizing, negative affect, younger age, higher body mass index (BMI), and chemotherapy also were independently predictive of pain impact, but not severity. Sensory disturbance in the surgical area was predicted by a slightly different subset of factors, including higher preoperative temporal summation of pain.

CONCLUSIONS

This comprehensive approach assessing consistent predictors of pain severity, functional impact, and sensory disturbance may inform personalized prevention of PPMP and also may allow stratification and enrichment in future preventive studies of women at higher risk of this outcome, including pharmacologic and behavioral interventions and regional anesthesia.

Use of bilateral prophylactic nipple-sparing mastectomy in patients with high risk of breast cancer

BACKGROUND

Nipple-sparing mastectomy (NSM) is being performed increasingly for risk reduction in high-risk groups. There are limited data regarding complications and oncological outcomes in women undergoing bilateral prophylactic NSM. This study reviewed institutional experience with prophylactic NSM, and examined the indications, rates of postoperative complications, incidence of occult malignant disease and subsequent breast cancer diagnosis.

METHODS

Women who had bilateral prophylactic NSM between 2000 and 2016 were identified from a prospectively maintained database. Rates of postoperative complications, incidental breast cancer, recurrence and overall survival were evaluated.

RESULTS

A total of 192 women underwent 384 prophylactic NSMs. Indications included BRCA1 or BRCA2 mutations in 117 patients (60·9 per cent), family history of breast cancer in 35 (18·2 per cent), lobular carcinoma in situ in 29 (15·1 per cent) and other reasons in 11 (5·7 per cent). Immediate breast reconstruction was performed in 191 patients. Of 384 NSMs, 116 breasts (30·2 per cent) had some evidence of skin necrosis at follow-up, which resolved spontaneously in most; only 24 breasts (6·3 per cent) required debridement. Overall, there was at least one complication in 129 breasts (33·6 per cent); 3·6 and 1·6 per cent had incidental findings of ductal carcinoma in situ and invasive breast cancer respectively. The nipple-areola complex was preserved entirely in 378 mastectomies. After a median follow-up of 36·8 months, there had been no deaths and no new breast cancer diagnoses.

CONCLUSION

These findings support the use of prophylactic NSM in high-risk patients. The nipples could be preserved in the majority of patients, postoperative complication rates were low, and, with limited follow-up, there were no new breast cancers.

Towards data-driven decision-making for breast cancer patients undergoing mastectomy and reconstruction: Prediction of individual patient-reported outcomes at two-year follow-up using machine learning

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Background: Post-surgical satisfaction with breasts is a key outcome for women undergoing cancer-related mastectomy and reconstruction. Current decision making relies on group-level evidence, which may not offer optimal choice of treatment for individuals. We developed and validated machine learning algorithms to predict individual post-surgical breast-satisfaction. We aim to facilitate individualized data-driven decision making in breast cancer. Methods: We collected clinical, perioperative, and patient-reported data from 3058 women who underwent breast reconstruction due to breast cancer across 11 sites in North America. We trained and evaluated four algorithms (regularized regression, Support Vector Machine, Neural Network, Regression Tree) to predict significant changes in satisfaction with breasts at 2-year follow up using the validated BREAST-Q measure. Accuracy and area under the receiver operating characteristics curve (AUC) were used to determine algorithm performance in the test sample. Results: Machine learning algorithms were able to accurately predict changes in women’s satisfaction with breasts (see table). Baseline satisfaction with breasts was the most informative predictor of outcome, followed by radiation during or after reconstruction, nipple-sparing and mixed mastectomy, implant-based reconstruction, chemotherapy, unilateral mastectomy, lower psychological well-being, and obesity. Conclusions: We reveal the crucial role of patient-reported outcomes in determining post-operative outcomes and that Machine Learning algorithms are suitable to identify individuals who might benefit from alternative treatment decisions than suggested by group-level evidence. We provide a web-based tool for individuals considering mastectomy and reconstruction. importdemo.com . Clinical trial information: NCT01723423 . [Table: see text]

Machine learning with PROs in breast cancer surgery; caution: Collecting PROs at baseline is crucial

As high breast cancer survival rates are achieved nowadays, irrespective of type of surgery performed, prediction of long‐term physical, sexual, and psychosocial outcomes is very important in treatment decision‐making. Patient‐reported outcomes (PROs) can help facilitate this shared decision‐making. Given the significance of more personalized medicine and the growing trend on the application of machine learning techniques, we are striving to develop an algorithm using machine learning techniques to predict PROs in breast cancer patients treated with breast surgery. This short communication describes the bottlenecks in our attempt to predict PROs.

Systematic Review of Patient-Reported Outcomes following Surgical Treatment of Lymphedema

Introduction: Analysis of quality of life (QOL) outcomes is an important aspect of lymphedema treatment since this disease can substantially impact QOL in affected individuals. There are a growing number of studies reporting patient-reported outcomes (PROMs) for patients with lymphedema. The purpose of this study was to conduct a systematic review of outcomes and utilization of PROMs following surgical treatment of lymphedema. Methods: A literature search of four databases was performed up to and including March, 2019. Studies included reported on QOL outcomes after physiologic procedures, defined as either lymphovenous bypass (LVB) or vascularized lymph node transplant (VLNT), to treat upper and/or lower extremity primary or secondary lymphedema. Results: In total, 850 studies were screened—of which, 32 studies were included in this review. Lymphovenous bypass was the surgical intervention in 16 studies, VLNT in 11 studies, and both in 5 studies. Of the 32 total studies, 16 used validated survey tools. The most commonly used PROM was the lymph quality of life measure for limb lymphedema (LYMQOL) (12 studies). In the remaining four studies, the upper limb lymphedema 27 scale (ULL27), the short form 36 questionnaire (SF-36), the lymphedema functioning, disability and health questionnaire (Lymph-ICF), and lymphedema life impact scale (LLIS) were each used once. QOL improvement following surgical treatment was noted in all studies. Conclusions: Physiologic surgical treatment of lymphedema results in improved QOL outcomes in most patients. The use of validated PROM tools is increasing but there is no current consensus on use. Future research to evaluate the psychometric properties of PROMs in lymphedema is needed to guide the development and use of lymphedema-specific tools.

CanPROS Scientific Conference 2019 Oral Abstracts

Background: Generic preference-based measures (pbms), though commonly used, may not be optimal for use in the economic evaluations assessing the impact of breast cancer interventions. Concerns that are unique to women with breast cancer (for example, body image, appearance, treatment-specific adverse effects) are not adequately captured by the existing generic measures. No breast cancer–specific pbm exists. The objective of this study was to construct a health state classification system specific to breast cancer which is amenable to valuation. Methods: We conducted semi-structured interviews in a heterogeneous sample of women with breast cancer [stages 0–4, any stage of treatment(s)]. Interviews were audio recorded, transcribed verbatim, and coded using the constant comparison approach to develop the conceptual framework. Patients were also asked to describe their most and least important concerns during the interview and to rate items in the related breast-q module (that is, mastectomy, breast-conserving therapy, or reconstruction) on a modified 5-point Likert scale (ranging from Not important to Very important). A faceto- face meeting with an expert panel of health care professionals, health economists, and hrqol researchers was used to obtain feedback on the health state classification system, response levels, and wording of the items. Results: Interviews (n = 59) with patients aged 59.9 years were completed. The resultant conceptual framework included site-specif ic (that is, abdomen, arm, breast) and overall (that is, body image, appearance, cancer, psychological, sexual, and social) domains. Triangulation of the qualitative and quantitative evidence led to the selection of key constructs for inclusion in the new pbm. The field test version of the breast-q utility health state classification system consisted of 13 attributes with 4 response levels each. Conclusions: The health state classification system for the preference-based module of the breast-q (breast-q-u) was derived using patient and expert feedback. The next phase will involve establishing psychometric properties of the breast-q-u, followed by a valuation study to generate utility weights.

Incorporating Patient-Reported Outcome Measures into Breast Surgical Oncology: Advancing Toward Value-Based Care

Value in health care is defined as the health outcome achieved per unit of cost. For health care systems, improving value means achieving better outcomes at lower costs. Improving outcomes, including patient-reported outcomes (PROs), as well as more established metrics such as mortality and complication rates, ensures high-quality care. This is particularly true in breast cancer surgery, where survival and recurrence rates are comparable across different surgical approaches. Outcomes reflecting survivorship quality may therefore better inform decision making regarding surgical approaches. PROs can be assessed using validated instruments known as patient-reported outcome measures (PROMs). They are obtained directly from patients reflecting their health-related quality of life (HRQOL). Ongoing initiatives strive to define PROMs that accurately reflect HRQOL and demonstrate value, with the goal of establishing benchmarks for quality of care. Clinicians caring for patients with breast cancer are well positioned to be involved in defining meaningful measures of value-based breast cancer care. This article reviews value-based breast cancer care in the context of locoregional therapy, with attention paid to the work done by the International Consortium of Health Outcome Measures in which a "standard set" of value-based patient-centered outcomes for breast cancer for international use is defined. In addition, an overview is provided of relevant PROMs and previously reported scores. Recommendations and future challenges for implementation of routine collection of PROs are also discussed. IMPLICATIONS FOR PRACTICE: Opportunity exists to act as early adopters of the routine collection of longitudinal patient-reported outcome data for breast cancer, allowing transition of current care to value-based cancer care.

Increase in Utilization of Nipple-Sparing Mastectomy for Breast Cancer: Indications, Complications, and Oncologic Outcomes

BACKGROUND

Nipple-sparing mastectomy (NSM) is increasingly performed for invasive breast cancer. Growing evidence supporting the oncologic safety of NSM has led to its widespread use and broadened indications. In this study, we examine the indications, complications, and long-term outcomes of therapeutic NSM.

METHODS

From 2003 to 2016, women undergoing NSM for invasive cancer or ductal carcinoma in situ (DCIS) were identified from a prospectively maintained database. Patient and disease characteristics were compared by procedure year, while complications were compared by procedure year using generalized mixed-effects models accounting for a random surgeon effect. Overall survival and time to recurrence were examined.

RESULTS

Of the 467 therapeutic NSMs, 337 (72%) were invasive cancer, 126 (27%) were DCIS, and 4 (1%) were phyllodes tumors. Median age was 45 years (range 24-75) and median follow-up among survivors was 39.4 months. Three hundred and fifty-seven (76.4%) cases were performed in 2011 or after. When comparing NSMs performed before and after 2011, there was a significant increase in NSMs performed for invasive tumors (58% vs. 77%; p < 0.001). There was no difference in family history, genetic mutations, smoking status, neoadjuvant chemotherapy, prior radiation, nodal involvement, or tumor subtype. Twenty-one (4.5%) nipple excisions were performed, of which 14 were performed for cancer at the nipple margin. Forty-four breasts (9.4%) had complications that required re-operation. Fifteen patients had locoregional recurrence or distant metastasis.

CONCLUSIONS

NSM use for invasive carcinoma has doubled at our institution since 2011, while postoperative complications and recurrence rates remain low. Our experience supports the selective use of NSM in the malignant setting with careful patient selection.

Inclusion of older patients with cancer in randomised controlled trials with patient-reported outcomes: a systematic review

OBJECTIVES

Inclusion of patient-reported outcomes (PROs) in cancer randomised controlled trials (RCTs) may be particularly important for older patients. The objectives of this systematic review were to quantify the frequency with which older patients are included in RCTs with PROs and to evaluate the quality of PRO reporting in those trials.

METHODS

All RCTs with PRO endpoints, published between January 2004 and February 2019, which included a patient sample with a mean/median age ≥70 years, were considered for this systematic review. The following cancer malignancies were considered: breast, colorectal, lung, prostate, gynaecological and bladder cancer.Quality of PRO reporting was evaluated using the International Society for Quality of Life Research-PRO standards. Studies meeting at least two-thirds of these criteria were considered to have high-quality PRO reporting.

RESULTS

Of 649 RCTs identified with a PRO endpoint, only 72 (11.1%) included older patients. Of these, 35 trials (48.6%) were conducted in patients with metastatic/advanced disease. PROs were primary endpoints in 20 RCTs (27.8%). Overall survival was the most frequently reported clinical outcome in studies of patients with metastatic/advanced cancer (n=28, 80%). One-third of the RCTs (n=24, 33.3%) were considered to have high-quality PRO reporting. Overall, the largest prevalence of RCTs with high-quality PRO reporting was observed in prostate and colorectal cancers.

CONCLUSIONS

Our review indicates not only that PRO-RCT-based studies in oncology rarely include older patients but also that completeness of PRO reporting of many of them is often suboptimal.

Establishing the acceptability of a brief patient reported outcome measure and feasibility of implementing it in a breast device registry - a qualitative study

Background

To examine the acceptability of a Patient Reported Outcome Measure (PROM) that assesses perceptions and experiences of implants for breast reconstruction or augmentation, and the feasibility of implementing it in the Australian Breast Device Registry (ABDR).

Methods

The BREAST-Q Implant Surveillance (BREAST-Q IS) is a 5-question PROM derived from the BREAST-Q questionnaire. It assesses perceptions of breast appearance and sensation, and experiences of pain. Breast implant recipients (recruited via community networks, social media and notices in surgeons’ rooms) and surgeons contributing to the ABDR were invited to review the BREAST-Q-IS. Participation was by individual semi-structured interviews by telephone or email, or by completion of a paper questionnaire. Transcripts of audio recordings and emailed text were analysed thematically.

Results

Twenty one breast implant recipients (10 after reconstruction and 11 augmentation), 8 surgeons (five plastic, three breast) and 2 medical professionals performing cosmetic surgeries were interviewed. Six themes were identified: Overall impression, Emotional response to the BREAST-Q IS, Method of follow-up, Suggested improvements, Group variation, and Potential Clinical utility. Overall, breast implant recipients and surgeons found the BREAST-Q IS to be acceptable and unlikely to provoke strong emotional reactions. Email was the preferred mode of contact. Most suggested improvements were to add questions. Surgeons expressed concern that subjective responses to the PROM might not accurately reflect experiences and that the PROM would predict need for revision rather than device failure.

Conclusion

This study supports the acceptability and feasibility of BREAST-Q IS as a PROM for recipients of breast implants. Further validation of the Breast-Q IS is required.

Patient-Reported Outcome Measures for Breast Implant Surgery: A Pilot Study

BACKGROUND

The Breast-Q Implant Surveillance module (BREAST-Q IS) is a patient-reported outcome measure (PROM) that asks 5 questions on satisfaction (shape, feel, and rippling) and symptoms (pain and tightness) derived from the BREAST-Q.

OBJECTIVES

We aimed to pilot BREAST-Q IS on patients within the Australian Breast Device Registry (ABDR), an opt-out clinical quality device registry, and explored Short Message Service (SMS) communication as a follow-up method.

METHODS

Patients with a breast device surgery in the previous 10 to 15 months, age ≥18 years, with a mobile phone number, were invited to complete the 5-question PROM via SMS initially, followed by 3 phone call attempts if no response, an e-mail, and then a letter by post as a final engagement strategy.

RESULTS

The study included 197 participants [breast augmentation (BA) = 118; breast reconstruction (BR) = 79]. Mean ± SD age was 40 ± 12 years (BA) and 44 ± 11 years (BR). Mean ± SD time since surgery was 414 ± 36 days (BA) and 413 ± 51 days (BR). The total response rate, including opt-outs, was 76%. Responses indicated that >90% of BA and >79% of BR were very or somewhat satisfied with shape, feel, and wrinkling; >70% of BA and >46% of BR reported no pain or tightness. Completion of survey via SMS was 51% (BA) and 55% (BR). Further responses were received by phone (25%, 26%), post (21%, 16%), and e-mail (3%, 3%).

CONCLUSIONS

This pilot demonstrated high levels of satisfaction and low levels of pain and tightness in patients with breast augmentation and breast reconstruction 1 year postoperatively. It also showed the effectiveness of our engagement strategy, which achieved a 76% response rate. Over 50% of respondents used SMS to reply to a 5-question PROM assessing long-term surgical outcomes. This engagement strategy will be used as BREAST-Q IS is rolled out nationally.

Computerized Quality of Life Assessment: A Randomized Experiment to Determine the Impact of Individualized Feedback on Assessment Experience

Background

Quality of life (QoL) assessments, or patient-reported outcome measures (PROMs), are becoming increasingly important in health care and have been associated with improved decision making, higher satisfaction, and better outcomes of care. Some physicians and patients may find questionnaires too burdensome; however, this issue could be addressed by making use of computerized adaptive testing (CAT). In addition, making the questionnaire more interesting, for example by providing graphical and contextualized feedback, may further improve the experience of the users. However, little is known about how shorter assessments and feedback impact user experience.

Objective

We conducted a controlled experiment to assess the impact of tailored multimodal feedback and CAT on user experience in QoL assessment using validated PROMs.

Methods

We recruited a representative sample from the general population in the United Kingdom using the Oxford Prolific academic Web panel. Participants completed either a CAT version of the World Health Organization Quality of Life assessment (WHOQOL-CAT) or the fixed-length WHOQOL-BREF, an abbreviated version of the WHOQOL-100. We randomly assigned participants to conditions in which they would receive no feedback, graphical feedback only, or graphical and adaptive text-based feedback. Participants rated the assessment in terms of perceived acceptability, engagement, clarity, and accuracy.

Results

We included 1386 participants in our analysis. Assessment experience was improved when graphical and tailored text-based feedback was provided along with PROMs (Δ=0.22, P<.001). Providing graphical feedback alone was weakly associated with improvement in overall experience (Δ=0.10, P=.006). Graphical and text-based feedback made the questionnaire more interesting, and users were more likely to report they would share the results with a physician or family member (Δ=0.17, P<.001, and Δ=0.17, P<.001, respectively). No difference was found in perceived accuracy of the graphical feedback scores of the WHOQOL-CAT and WHOQOL-BREF (Δ=0.06, P=.05). CAT (stopping rule [SE<0.45]) resulted in the administration of 25% fewer items than the fixed-length assessment, but it did not result in an improved user experience (P=.21).

Conclusions

Using tailored text-based feedback to contextualize numeric scores maximized the acceptability of electronic QoL assessment. Improving user experience may increase response rates and reduce attrition in research and clinical use of PROMs. In this study, CAT administration was associated with a modest decrease in assessment length but did not improve user experience. Patient-perceived accuracy of feedback was equivalent when comparing CAT with fixed-length assessment. Fixed-length forms are already generally acceptable to respondents; however, CAT might have an advantage over longer questionnaires that would be considered burdensome. Further research is warranted to explore the relationship between assessment length, feedback, and response burden in diverse populations.

Does the quality of patient-reported outcomes (PROs) assessment in randomized controlled trials (RCTs) differ across cancer types and over time? A pooled analysis of 610 RCTs published between 2004 and 2018

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Background: PRO endpoints are increasingly being used in cancer RCTs. However, the PRO assessment in such trials often suffers from serious methodological shortcomings, and the results seldom impact on clinical policy or practice. Methods: We performed a systematic review to identify RCTs with a PRO endpoint in breast, colorectal, lung, prostate, gynaecological and bladder cancer. A checklist score for quality of PRO reporting (ranging between 0-100), based on that of the International Society for Quality of Life Research (ISOQOL) and the CONSORT PRO extension, was computed for each RCT. Analyses were also conducted by type of PRO endpoint (primary versus secondary) and year of publication (i.e. before and after the publication of the CONSORT PRO extension). Results: We identified 610 RCTs with a total of 323,482 patients. PROs were most frequently used in RCTs of breast (N = 176), followed by lung (N = 123), prostate (N = 108), colorectal (N = 103), gynaecological (N = 83) and bladder (N = 17) cancer. Quality of PRO reporting (mean score: 56.4) was highest in RCTs conducted in prostate cancer (PCa) (Table). Regardless of cancer type, quality of reporting was typically higher in RCTs where PROs were primary endpoints. Quality of reporting was higher for RCTs published after the CONSORT PRO Extension (2013), with the exception of RCTs conducted in PCa, where quality was stable over time. Conclusions: PRO reporting of RCTs conducted in PCa has better quality than in the other cancer sites that were reviewed. Regardless of cancer site, quality of PRO reporting has improved after the publication of the CONSORT PRO Extension. [Table: see text]

Inclusion of patient-reported outcomes (PROs) in randomized controlled trials (RCTs) with elderly cancer patients: A systematic review

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Background: Inclusion of PROs in RCTs involving elderly cancer patients may be particularly important, as the elderly are often frail and vulnerable, and treatment decisions need to carefully balance potential burden against benefit. We aimed to determine how many RCTs involving elderly patients have included a PRO endpoint, and identified the most relevant PRO information available in this area. Methods: A systematic review in PubMed/Medline and Cochrane Library identified RCTs with PRO endpoint that enrolled a cancer sample (breast, colorectal, lung, prostate, gynaecological and bladder cancer) with a mean/ median age ≥70 years, published from January 2004 to June 2018. The quality of PRO reporting was evaluated using the ISOQOL-PRO recommended criteria. Two reviewers independently performed data extraction. RCTs meeting at least two-thirds of the recommended criteria were considered as “probably-robust” and therefore most likely to be able to inform patient care. Results: Out of the 610 RCTs with PRO endpoint identified, only 67 RCTs (11%) enrolled a sample that met the above criteria. In 19 RCTs (28.4%) PROs were the primary endpoint and 35 RCTs (52.2%) were conducted in a metastatic population. Less than one-third of these trials (n = 21) were considered as probably-robust. In 10 (47.6%) out of the 21 probably-robust RCTs, PROs favored the experimental arm and in 8 (38.1%) the arms did not differ. Overall survival (OS) was an endpoint in 13 of the probably-robust RCTs. In only 3 of these RCTs (23.1%) did OS improve in the experimental arm and in 10 (76.9%) there was no difference in OS between arms. In about half of the probably-robust trials evaluating OS (n = 7, 53.8%), PROs provided information that contrasted with survival findings. In two RCTs, OS improved in the experimental arm, while PROs either did not change between arms (n = 1) or favoured the control arm (n = 1). Conversely, in 5 RCTs (38.5%), OS did not differ between arms whereas PROs favoured the experimental arm. Conclusions: Among cancer RCTs including PROs, the proportion of those conducted in the elderly is low. However, PRO data may provide useful information for these type of patients and their clinicians.

Implementing Electronic Patient-Reported Outcome Measures in Outpatient Cosmetic Surgery Clinics: An Exploratory Qualitative Study

BACKGROUND

Patient-reported outcome measure (PROM) data are increasingly being collected over the internet or on a smart device by means of electronic versions (e-PROMs). Limited evidence exists about factors influencing e-PROM implementation in outpatient clinics.

OBJECTIVES

The authors sought to identify barriers to collection of PRO data from different locations (home or cosmetic surgery office) by means of different modes (paper vs e-PROM) from the perspective of patients, plastic surgeons, and clinic administrative staff; and to explore patient preferences for the design of e-PROM platforms.

METHODS

Semistructured interviews were conducted with 11 patients, 3 cosmetic surgeons, and administrative staff. Patients were shown 1 of the 3 PROMs (ie, the BODY-Q Satisfaction with Body scale, BREAST-Q Augmentation Module Satisfaction with Breast scale, or FACE-Q Satisfaction with Facial Appearance scale). The formats included paper and electronic (REDCap and TickiT) on a tablet and laptop computer. The interviews were audio-recorded and transcribed verbatim. Qualitative descriptive analysis was conducted.

RESULTS

Patients and providers preferred electronic over paper format. The flexibility of the hardware, data entry point (remote location vs point-of-care), and the privacy of the data were the most recurring themes from the patient's perspective. The objective of collecting PROM data, role in peer-benchmarking, and return on investment were key to surgeons and administrative staff.

CONCLUSIONS

The e-PROMs were well accepted in the community setting by the patients and plastic surgeons alike. The design and interface features of e-PROMs were explored in this study, which may be useful for future, mixed method studies evaluating the implementation of e-PROMs.

Understanding the Breast Cancer Experience of Women in East Africa: A Qualitative Study

Background: Breast cancer is one of the leading causes of premature death in women in East Africa. The majority of patients are diagnosed with advanced cancers (stage III and IV) which results in more cancer deaths. Even after a diagnosis of breast cancer, many patients do not complete their treatment. The reasons why delays in diagnosis and treatment occur are multilevel, involving a combination of both patient related factors, such as sociocultural reasons like stigma or fatalism, or the use of alternative medicine. Financial factors play a big role as many patients have to pay out of pocket for their health expenditure. System related factors such as a lack of resources for the diagnosis or treatment, lack of health worker knowledge leading to misdiagnosis with inappropriate treatment and poor referral pathways, also contribute to delays in care. Aim: To understand the experience of breast cancer patients in East Africa, to determine the facilitators and barriers to diagnosis, treatment and follow-up of breast cancer. Methods: 28 patients in Kenya and Tanzania who had completed at least a year of initial treatment were invited to participate in the study. A qualitative exploratory study was done using semistructured, in-depth interviews. Grounded theory was then used to analyze and develop themes that emerged from these narratives. Results: For these patients who had completed at least a year of treatment, the cost of treatment and expenses incurred was a major concern. Family disintegration emerged as a significant theme following cancer diagnosis. There was a prevalence of stigma around breast cancer and patients would not disclose their status to others in the community for fear of being ridiculed, pitied or isolated. A number of patients used alternative medicine resulting in delays in treatment. Family support, support groups and spirituality played a major role in facilitating the completion of initial care and in reducing psychological morbidity. System factors such as poor referral pathways, and inappropriate treatment emerged as minor themes. Conclusion: The sociocultural aspects of breast cancer need to be addressed to ensure comprehensive management of breast cancer patients and completion of treatment. As programs in the region, mainly run by governments, aim to improve the financial access to treatment, it would be critical to include efforts aimed at stigma reduction and interventions focusing on the sociocultural reintegration of these patients.