Decisions regarding reconstructive surgery after mastectomy often do not align with personal goals

Most women undergoing mastectomy lacked the necessary knowledge to make a high-quality decision regarding breast reconstruction, according to a single-center, prospective cross-sectional study.

“Breast reconstruction after mastectomy has the potential to improve a person’s body image and quality of life but has important risks,” Clara Lee, MD, breast reconstructive surgeon at The Ohio State University Comprehensive Cancer Center, and colleagues wrote. “The decision about whether to undergo breast reconstruction is a preference-sensitive one, in that the optimal choice depends in part on personal goals.”

Lee and colleagues evaluated the quality of decisions made by 126 women (mean age, 53.2 years) with breast cancer undergoing mastectomy for stage I to stage III invasive ductal or lobular breast cancer, ductal carcinoma in situ or prophylaxis. Fifty-one patients underwent immediate reconstruction, 40 patients had adjuvant radiotherapy and 32 patients had adjuvant chemotherapy.

Patients completed a survey about their demographics; knowledge of recovery, number of surgeries, flaps vs. implants, complication risk, radiotherapy effects, surveillance, satisfaction after reconstruction and risk for recurrence; and preferences about breast shape, complication risk, number of surgeries and recover time.

The extent to which the decision regarding reconstructive surgery is informed and consistent with patients’ preferences constituted a “high-quality” decision.

“We were specifically interested in how often patients comprehended the major pros and cons of treatment alternatives and received treatment concordant with personal preferences,” Lee and colleagues wrote.

Women reported a mean knowledge score of 58.5%, which did not differ by receipt of mastectomy alone or with reconstruction.

Eighty-eight women (69.8%) reported a knowledge score of 50% or greater and were considered “informed.”

Eighteen participants correctly answered the question regarding risk for major complications in the first 2 years following reconstructive surgery.

Participants showed a high concern about risk for complications — with a 4.9 out of 5 mean importance rating — which did not differ by treatment preference. In total, 65.5% of patients ranked complication risk as their most important attribute regarding breast reconstruction.

“Many women were quite concerned about complication risks, but they didn't actually know how high the risk was,” Lee said in a press release. “This may explain some of the overtreatment that we saw.”

Of 82 participants with a calculated treatment preference of mastectomy only, 39 women underwent mastectomy only. Of 41 participants had a calculated treatment preference of mastectomy with reconstruction, 36 underwent both procedures. Researchers reported overall preference concordance of 61% ( = 0.29; 95% CI, 0.15-0.42).

Overall, researchers found less than half of women (43.3%; n = 52) made a high-quality decision.

“We found that less than half of the women had adequate medical knowledge about breast reconstruction and made a choice that aligned with their personal preferences,” Lee said. “This is very concerning to us, because it means that some women did not get the treatment they truly preferred, and quite a few had more treatment than they preferred.”

Multivariate analysis identified several factors independently associated with making a high-quality decision, including white race/ethnicity (OR = 2.72; 95% CI, 1-7.38), having private insurance (OR = 1.61; 95% CI, 1.35-1.93), having a high school education or less compared with some college (OR = 4.84; 95% CI, 1.22-19.21), having a college degree compared with some college (OR = 1.95; 95% CI, 1.53-2.49), and not having a malignant neoplasm (OR = 3.13; 95% CI, 1.25-7.85).

The researchers noted physicians must share the risks for complications associated with breast reconstruction, as well as assess how strongly patients feel toward having a normal breast shape in and out of clothing.

“As breast cancer providers, we need to talk about the pros and cons of surgery to help women make treatment choices,” Lee said. “Shared decision-making between the surgeon and patient would be particularly useful for this decision. We need to connect patients with decision aids to help them really think through what is most important to them.” – by Kristie L. Kahl

Disclosure: The researchers report no relevant financial disclosures.