Factors influencing the decision to pursue immediate breast reconstruction after mastectomy for breast cancer

Abstract

Background: Immediate breast reconstruction (IBR) after mastectomy has shown to be oncologically safe and to improve quality of life in breast cancer patients. However, most women undergoing mastectomy do not undergo IBR. In this study, we aim to identify breast surgeon-related factors in considering IBR and factors affecting patients' decision to choose for IBR.Methods: Retrospective analysis of the records of breast cancer patients who underwent mastectomy with or without IBR between 2010 and 2013. We documented all information whether or not a patient underwent IBR after mastectomy.Results: Of 437 patients, 97 (22.2%) underwent IBR, 89.8% of which received tissue expanders. Patient who did not undergo IBR had a higher age (62.2 versus 51.9 years, P<0.001) and higher body mass index (BMI) (27.0 versus 24.3, P<0.001). Hundred three patients declined IBR, mainly because considering reconstruction as too much trouble. In 128 cases the breast surgeon did not offer IBR, mostly because of the predicted need for post mastectomy radiation. Approximately 11% of the patients were not informed about IBR.Conclusions: Anticipated radiation therapy, higher age and higher BMI were important breast surgeonrelated factors in refraining from IBR. Almost one third of all patients declined IBR. In almost 10% of all patients, IBR was not discussed.Keywords: Breast neoplasms; breast reconstruction; decision making; mammaplasty; mastectomy Submitted Aug 11, 2016. Accepted for publication Oct 27, 2016Oct 27, . doi: 10.21037/gs.2016 View this article at: http://dx.doi.org/10.21037/gs.2016.11.11 44 Weenk et al. Decision-making process in IBR © Gland Surgery. All rights reserved.Gland Surg 2017;6(1):43-48 gs.amegroups.com States. In 2000, 12.9% of all mastectomies performed in the United States were combined IBR, increasing to 36.3% in 2009 (15). The United Kingdom Association of Breast Surgery recommends that any patient in which IBR is oncologically safe should have the possibility to choose for IBR (16). Dutch guidelines state IBR has a slight preference instead of delayed reconstruction and that every patient considered for mastectomy has to be informed about reconstructive options (17). However, despite the evidence and recommendations, almost two thirds of the mastectomies are still performed without IBR. We asked ourselves if there are elements in the pre-operative process that could facilitate or impede the choice for IBR. The major objective of this study was to investigate the decision-making process on whether or not a patient undergoes immediate reconstruction after mastectomy. In this study we focused on the role of patient as well as the role of the breast surgeon. MethodsWe investigated all electronic patient files of women diagnosed with DCIS or invasive carcinoma between 2010 and 2013, and underwent a mastectomy at the Canisius Wilhelmina Breast Center in Nijmegen, the Netherlands. Patients who underwent prophylactic mastectomy were excluded. IBR is defined as mastectomy and reconstruction performed on the same day. ...

What are the appropriate thresholds for High Quality Performance Indicators for breast surgery in Australia and New Zealand?

“…The Scottish guidelines suggest a target of 10% [ 18 ] and Singapore 20% [ 19 ] despite the well documented safety and psychological and emotional well-being related benefits [ 14 , 15 ]. A Dutch retrospective analysis found key factors inhibiting the decision making of IBR post mastectomy [ 22 ] included higher age (62.2 vs 51.9) and BMI (27 vs 24.3) and failure of surgeon to offer IBR due to predicted need for post mastectomy radiation (29.3%) or just failure of informing the patient (10%). In Australia reports of around 40% IBR rate have been achieved by some groups [ 20 ] with the main reasons not to have reconstruction being patient choice (45%) and surgeon’s perception of high-risk tumours (32%) [ 20 ].…”

Women and Partners’ Information Need, Emotional Adjustment, and Breast Reconstruction Decision-Making Before Mastectomy

“…BR decision-making is a difficult choice often made by physicians alone 8 and, for IBR, made essentially considering medical factors. 4,5 Women's opinion is more important in delayed BR (ie, a BR performed after adjuvant treatments) decisionmaking. 41 Yet, as pointed out by Fasse et al 9 and Harcourt and Rumsey, 42 women and partners indicate that physicians have a central role in BR decision-making, for choosing between IBR and delayed BR, as well as the technique used to reconstruct the breast (ie, implant or autologous).…”

“…It is proposed to nearly 30% of women, 4 as this choice is essentially influenced by medical factors (eg, tumor localization or severity of the disease). 4,5 This treatment is supposed to be decided upon in a shared decision-making process between the patient and the physician, involving the family. The interprofessional shared decision-making model 6 highlights the interactions between the patient, health professionals, and family members to make a treatment choice.…”

“…The interprofessional shared decision-making model 6 highlights the interactions between the patient, health professionals, and family members to make a treatment choice. However, Weenk et al 5 reported that MA is decided by the surgeon, without questioning the woman, in 50% of cases. To date, little is known about how IBR or MA is chosen in a shared decision-making.…”

Are There Disparities in Surgical Treatment for Breast Cancer Patients with Prior Physical Disability A Path Analysis

“…A qualitative study identified, among others, concerns regarding body image and the reduced burden of only a single operation as the reasons expressed by patients for favoring DR. Nevertheless, many women do not undergo DR after mastectomy for various reasons, including not having been offered or informed about DR [24]. Thus, the decisions for or against BCS and DR are preference-sensitive decisions for breast cancer patients, who should be able to make informed decisions together with their doctor by weighing the advantages and disadvantages of treatment options [25].…”