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Making decisions about breast reconstruction: A systematic review of patient-reported factors influencing choice

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Abstract

Purpose

Many studies have explored women’s reasons for choosing or declining a particular type of breast reconstruction (BR) following mastectomy for breast cancer. This systematic review synthesises women’s reasons for choosing a range of BR options, including no BR, in different settings and across time.

Methods

Thirteen databases were systematically searched, with 30 studies (4269 participants), meeting the selection criteria. Information on study aim and time frame, participation rate, design/methods, limitations/bias, reasons and conclusions, as well as participant clinical and demographic information, was reported. An overall quality score was generated for each study. Reasons were grouped into eight domains.

Results

While study methodology and results were heterogeneous, all reported reasons were covered by the eight domains: Feeling/looking normal; Feeling/looking good; Being practical; Influence of others; Relationship expectations; Fear; Timing; and Unnecessary. We found a strong consistency in reasons across studies, ranging from 52% of relevant publications citing relationship expectations as a reason for choosing BR, up to 91% citing fear as a reason for delaying or declining BR. Major thematic findings were a lack of adequate information about BR, lack of genuine choice for women and additional access limitations due to health system barriers.

Conclusions

Understanding women’s reasons for wanting or not wanting BR can assist clinicians to help women make choices most aligned with their individual values and needs. Our thematic findings have equity implications and illustrate the need for surgeons to discuss all clinically appropriate BR options with mastectomy patients, even if some options are not available locally.

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References

  1. Australian Institute of Health and Welfare & Cancer Australia (2012). Breast cancer in Australia: An overview. Cancer series no. 71. Cat. no. CAN 67. Canberra: AIHW.

    Google Scholar 

  2. National Clinical Audit Support Programme (2009). National Mastectomy and Breast Reconstruction Audit (Report 2). London: The Information Centre (NHS).

    Google Scholar 

  3. Musgrave, K. J., Bochner, M., & Kollias, J. (2010). Surgical decision-making in immediate breast reconstruction. World Journal of Surgery, 34, 3029–3035.

    PubMed  Google Scholar 

  4. Cordeiro, P. G. (2008). Breast reconstruction after surgery for breast cancer. New England Journal of Medicine, 359, 1590–1601.

    CAS  PubMed  Google Scholar 

  5. Fang, S. Y., Shu, B. C., & Chang, Y. J. (2013). The effect of breast reconstruction surgery on body image among women after mastectomy: A meta-analysis. Breast Cancer Research and Treatment, 137, 13–21.

    PubMed  Google Scholar 

  6. Al-Ghazal, S. K., Fallowfield, L., & Blamey, R. W. (2000). Comparison of psychological aspects and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstruction. European Journal of Cancer, 36(15), 1938–1943.

    CAS  PubMed  Google Scholar 

  7. Atisha, D., Alderman, A. K., Lowery, J. C., Kuhn, L. E., Davis, J., & Wilkins, E. G. (2008). Prospective analysis of long-term psychosocial outcomes in breast reconstruction: Two-year postoperative results from the Michigan Breast Reconstruction Outcomes Study. Annals of Surgery, 247(6), 1019–1028. doi:10.1097/SLA.0b013e3181728a5c.

    Article  PubMed  Google Scholar 

  8. Manganiello, A., Hoga, L. A., Reberte, L. M., Miranda, C. M., & Rocha, C. A. (2011). Sexuality and quality of life of breast cancer patients post mastectomy. European Journal of Oncology Nursing, 15(2), 167–172.

    PubMed  Google Scholar 

  9. Neto, M. S., de Aguiar Menezes MV, Moreira, J. R., Garcia, E. B., Abla, L. E., & Ferreira, L. M. (2013). Sexuality after breast reconstruction post mastectomy. Aesthetic and Plastic Surgery, 37(3), 643–647.

    Google Scholar 

  10. Harcourt, D. M., Rumsey, N. J., Ambler, N. R., Cawthorn, S. J., Reid, C. D., Maddox, P. R., et al. (2003). The psychological effect of mastectomy with or without breast reconstruction: A prospective, multicenter study. Plastic and Reconstructive Surgery, 111, 1060–1068.

    PubMed  Google Scholar 

  11. Metcalfe, K. A., Semple, J., Quan, M.-L., Vadaparampil, S. T., Holloway, C., Brown, M., et al. (2012). Changes in psychosocial functioning one year after mastectomy alone, delayed breast reconstruction, or immediate breast reconstruction. Annals of Surgical Oncology, 19(1), 233–241.

    PubMed  Google Scholar 

  12. Colakoglu, S., Khansa, I., Curtis, M. S., Yueh, J. H., Ogunleye, A., Haewyon, C., et al. (2011). Impact of complications on patient satisfaction in breast reconstruction. Plastic and Reconstructive Surgery, 127(4), 1428–1436.

    CAS  PubMed  Google Scholar 

  13. Brennan ME & Spillane AJ. (2013) Uptake and predictors of post-mastectomy reconstruction in women with breast malignancy—a systematic review. European Journal of Surgical Oncology, 39(6), 527–541.

    CAS  PubMed  Google Scholar 

  14. Azzopardi, J., Walsh, D., Chong, C., & Taylor, C. (2014). Impact of geographic location on surgical outcomes of women with breast cancer. Australia and New Zealand Journal of Surgery, 84, 735–739.

    Google Scholar 

  15. Azzopardi, J., Walsh, D., Chong, C., & Taylor, C. (2014). Surgical treatment for women with breast cancer in relation to socioeconomic and insurance status. The Breast, 20(1), 3–8.

    Google Scholar 

  16. Hall, S. E., & Holman CDJ. (2003). Inequalities in breast cancer reconstructive surgery according to social and locational status in Western Australia. European Journal of Surgical Oncology, 29, S19–S25.

    Google Scholar 

  17. Bell, R. J., Robinson, P. J., Fradkin, P., Schwarz, M., & Davis, S. R. (2012). Breast reconstruction following mastectomy for invasive breast cancer is strongly influenced by demographic factors in women in Victoria, Australia. The Breast, 21, 394–400.

    CAS  PubMed  Google Scholar 

  18. Flitcroft, K., Brennan, M., Costa, D., & Spillane, A. (2016). Documenting patterns of access to breast reconstruction in Australia: The national picture. The Breast, 30, 47–53.

    PubMed  Google Scholar 

  19. Ananian, P., Houvenaeghel, G., Protière, C., Rouanet, P., Arnaud, S., Moatti, J. P., et al. (2004). Determinants of patients’ choice of reconstruction with mastectomy for primary breast cancer. Annals of Surgical Oncology, 11(8), 762–771.

    CAS  PubMed  Google Scholar 

  20. Lardi, A. M., Myrick, M. E., Haug, M., Schaefer, D. J., Bitzer, J., Simmen, U., et al. (2013). The option of delayed reconstructive surgery following mastectomy for invasive breast cancer: Why do so few patients embrace this offer? European Journal of Surgical Oncology, 39, 36–43.

    CAS  PubMed  Google Scholar 

  21. Lam WWT, Fielding, R., Ho EYY, Chan, M., & Or, A. (2005). Surgeon’s recommendation, perceived operative efficacy and age dictate treatment choice by Chinese women facing breast cancer surgery. Psycho-Oncology, 14, 585–593.

    PubMed  Google Scholar 

  22. Handel, N., Silverstein, M. J., Waisman, E., & Waisman, J. R. (1990). Reasons why mastectomy patients do not have breast reconstruction. Plastic and Reconstructive Surgery, 86(6), 1118–1122.

    CAS  PubMed  Google Scholar 

  23. Keith DJW, Walker, M. B., Walker, L. G., Heys, S. D., Sarkar, T. K., Hutcheon, A. W., et al. (2003). Women who wish breast reconstruction: Characteristics, fears, and hopes. Plastic and Reconstructive Surgery, 111, 1051–1056.

    PubMed  Google Scholar 

  24. Adachi, K., Ueno, T., Fujioka, T., Fujitomi, Y., & Ueo, H. (2007). Psychosocial factors affecting the therapeutic decision-making and postoperative mood states in Japanese breast cancer patients who underwent various types of surgery: Body image and sexuality. Japanese Journal of Clinical Oncology, 37(6), 412–418.

    PubMed  Google Scholar 

  25. Begum, S., Grunfeld, E. A., Ho-Asjoe, M., & Farhadi, J. (2011). An exploration of patient decision-making for autologous breast reconstructive surgery following a mastectomy. Patient Education and Counseling, 84, 105–110.

    PubMed  Google Scholar 

  26. Morrow, M., Li, Y., Alderman, A. K., Jagsi, R., Hamilton, A. S., Graff, J. J., et al. (2014). Access to breast reconstruction after mastectomy and patient perspectives on reconstruction decision making. JAMA Surgery, 149(10), 1015–1021.

    PubMed  PubMed Central  Google Scholar 

  27. Alderman, A. K., Hawley, S. T., Janz, N. K., Majahid, M. S., Morrow, M., Hamilton, A. S., et al. (2009). Racial and ethnic disparities in the use of postmastectomy breast reconstruction: Results from a population-based study. Journal of Clinical Oncology, 27, 5325–5330.

    PubMed  PubMed Central  Google Scholar 

  28. Tseng, J. F., Kronowitz, S. J., Sun, C. C., Perry, A. C., Hunt, K. K., Babiera, G. V., et al. (2004). The effect of ethnicity on immediate reconstruction rates after mastectomy for breast cancer. Cancer, 101, 1514–1523.

    PubMed  Google Scholar 

  29. Shameem, H., Yip, C. H., & Fong, E. (2008). Immediate breast reconstruction after mastectomy—why do women choose this option? Asian Pacific Journal of Cancer Prevention, 9, 409–412.

    PubMed  Google Scholar 

  30. Sheehan, J., Sherman, K. A., Lam, T., & Boyages, J. (2008). Regret associated with the decision for breast reconstruction: The association of negative body image, distress and surgery characteristics with decision regret. Psychology & Health, 23(2), 207–219.

    Google Scholar 

  31. Neill, K. M., Armstrong, N., & Burnett, C. B. (1988). Choosing reconstruction after mastectomy: A qualitative analysis. Oncology Nursing Forum, 25(4), 743–750.

    Google Scholar 

  32. Lee, C. N., Hultman, C. S., & Sepucha, K. (2010). What are patients’ goals and concerns about breast reconstruction after mastectomy? Annals of Plastic Surgery, 64(5), 567–569.

    CAS  PubMed  Google Scholar 

  33. Nelson, J. A., Fischer, J. P., Radecki, M. A., Pasick, C., McGrath, J., Serletti, J. M., et al. (2013). Delayed autologous breast reconstruction: Factors which influence patient decision making. Journal of Plastic, Reconstructive & Aesthetic Surgery, 66, 1513–1520.

    Google Scholar 

  34. Reaby, L. L. (1998). Reasons why women who have mastectomy decide to have or not to have breast reconstruction. Plastic & Reconstructive Surgery, 101, 1810–1818.

    CAS  Google Scholar 

  35. Manne, S. L., Topham, N., Kirstein, L., Myers Virtue, S., Brill, K., Devine, K. A., et al. (2016). Attitudes and decisional conflict regarding breast reconstruction among breast cancer patients. Cancer Nursing. doi:10.1097/NCC.320.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Snell, L., McCarthy, C., Klassen, A., Cano, S., Rubin, L., Hurley, K., et al. (2010). Clarifying the expectations of patients undergoing implant breast reconstruction: A qualitative study. Plastic & Reconstructive Surgery, 126, 1825–1830.

    CAS  Google Scholar 

  37. Flitcroft, K., Brennan, M., Costa, D., Wong, A., Snook, K., & Spillane, A. (2016). An evaluation of factors affecting preference for immediate, delayed or no breast reconstruction in women with high-risk breast cancer. Psycho-Oncology. doi:10.1002/pon.4087.

    Article  PubMed  Google Scholar 

  38. Kmet, L. M., Lee, R. C., & Cook, L. S. (2004). Standard quality assessment criteria for evaluating primary research papers from a variety of fields. Health Technology Assessment Initiative No. 13. February 2004. Alberta: Alberta Heritage Foundation for Medical Research.

  39. Daly, J., Willis, K., Small, R., Green, J., Welch, N., Kealy, M., et al. (2007). A hierarchy of evidence for assessing qualitative health research. Journal of Clinical Epidemiology, 60, 43–49.

    PubMed  Google Scholar 

  40. Alderman, A. K., Hawley, S. T., Morrow, M., Salem, B., Hamilton, A., Graff, J. J., et al. (2011). Receipt of delayed breast reconstruction after mastectomy: Do women revisit the decision? Annals of Surgical Oncology, 18(6), 1748–1756.

    PubMed  PubMed Central  Google Scholar 

  41. Breast Cancer Network Australia (BCNA) (2013). Issue of concern. Breast reconstruction. The Beacon, 63, 3.

    Google Scholar 

  42. Breast Cancer Network Australia (BCNA) (2011). Breast reconstruction project report November 2011, Melbourne: BCNA. [2010 survey available from: http://www.bcna.org.au/sites/default/files/breast-reconstruction-report.pdf.].

  43. Clifford E. (1979). The reconstruction experience: The search for restitution. In NG Georgiade (Ed.), Breast reconstruction following mastectomy (pp. 22–34). St Louis,MO: CV Mosby.

    Google Scholar 

  44. Contant CME, van Wersch AMEA, Wiggers, T., Wai RTJ, & van Geel, A. N. (2000). Motivations, satisfaction and information of immediate breast reconstruction following mastectomy. Patient Education and Counseling, 40, 201–208.

    CAS  PubMed  Google Scholar 

  45. Duggal, C. S., Metcalfe, D., Sackeyfio, R., Carlson, G. W., & Losken, A. (2013). Patient motivations for choosing postmastectomy breast reconstruction. Annals of Plastic Surgery, 70(5), 574–580.

    CAS  PubMed  Google Scholar 

  46. Elder, E. E., Brandberg, Y., Björklund, T., Rylander, R., Lagergren, J., & Jurell, G. (2005). Quality of life and patient satisfaction in breast cancer patients after immediate breast reconstruction: A prospective study. The Breast, 14, 201–208.

    PubMed  Google Scholar 

  47. Gopie, J. P., Hilhorst, M. T., Kleijne, A., Timman, R., Menke-Pluymers MBE, Hofer SOP, et al. (2011). Women’s motives to opt for either implant or DIEP-flap breast reconstruction. Journal of Plastic, Reconstructive & Aesthetic Surgery, 64, 1062–1067.

    Google Scholar 

  48. Héquet D, Zarca K, Dolbeault S, Couturaud B, Ngô C, Fourchotte V, et al. (2013). Reasons of not having breast reconstruction: A historical cohort of 1937 breast cancer patients undergoing mastectomy. Springer 2, 325–334.

    Google Scholar 

  49. Meretoja, T., & Suominen, E. (2005). Demand for plastic surgical operations after primary breast cancer surgery. Scandinavian Journal of Surgery, 94, 211–215.

    CAS  PubMed  Google Scholar 

  50. Nozawa, K., Ichimura, M., Oshima, A., Tokunaga, E., Masuda, N., Kitano, A., et al. (2015). The present state and perception of young women with breast cancer towards breast reconstructive surgery. International Journal of Clinical Oncology, 20, 324–331.

    PubMed  Google Scholar 

  51. Panieri, E., Lazarus, D., Dent, D. M., Hudson, D. A., Murray, E., & Werner, D. (2003). A study of patient factors affecting reconstruction after mastectomy for breast carcinoma. American Surgeon, 69(2), 95–97.

    PubMed  Google Scholar 

  52. Rowland, J. H., Holland, J. C., Chaglassian, T., & Kinne, D. (1993). Psychological response to breast reconstruction: Expectations for and impact on postmastectomy functioning. Psychosomatics, 34(3), 241–250.

    CAS  PubMed  Google Scholar 

  53. Schain, W. S., Wellisch, D. K., Pasnau, R. O., & Landsverk, J. (1985). The sooner the better: A study of psychological factors in women undergoing immediate versus delayed breast reconstruction. American Journal of Psychiatry, 142(1), 40–46.

    CAS  PubMed  Google Scholar 

  54. Somogyi, R. B., Webb, A., Baghdikian, N., Stephenson, J., Edward, K., & Morrison, W. (2015). Understanding the factors that influence breast reconstruction decision making in Australian women. The Breast, 24, 124–130.

    PubMed  Google Scholar 

  55. Zieliński T, Lorenc-Podgórska K, Antoszewski B. (2014). Why women who have mastectomy decide not to have breast reconstruction? Polski Przegląd Chirurgiczny, 86 (10), 451–455.

    Google Scholar 

  56. Mátrai, Z., Kenessey, I., Sávolt Á, Újhelyi, M., Bartal, A., & Kásler, M. (2014). Evaluation of patient knowledge, desire, and psychosocial background regarding postmastectomy breast reconstruction in Hungary: A questionnaire study of 500 cases. Medical Science Monitor, 20, 2633–2642.

    PubMed  PubMed Central  Google Scholar 

  57. Cancer Australia. (2001) Clinical practice guidelines for the management of early breast cancer (2nd edn). Retrieved July, 5 2016, from http://canceraustralia.gov.au/publications-resources/cancer-australia-publications/clinical-practice-guidelines-management-early.

  58. National Comprehensive Cancer Network.(2013) NCCN guidelines Version 3. Breast cancer. Retrieved July 5, 2016, from http://www.nccn.org/professionals/physician_gls/pdf/breast.pdf.

  59. National Institute for Health and Care Excellence (NICE) (2009) Guidelines. Breast cancer (Early & Locally Advanced). Breast cancer. Retrieved July 5, 2016, from http://www.nice.org.uk/guidance/CG80.

  60. Cancer Australia. (2016) Influencing best practice in breast cancer Retrieved July 5, 2016, from https://thestatement.canceraustralia.gov.au/.

  61. Wong, A., Snook, K., Brennan, M., Flitcroft, K., Tucker, M., Hiercz, D., et al. (2014). Increasing breast reconstruction rates by offering more women a choice. Australia and New Zealand Journal of Surgery, 84, 31–36.

    Google Scholar 

  62. Roder, D., Zorbas, H., Kollias, J., Pyke, C., Walters, D., Campbell, I., et al. (2013). Factors predictive of immediate breast reconstruction following mastectomy for invasive breast cancer in Australia. The Breast. doi:10.1016/j.breast.2013.09.011.

    Article  PubMed  Google Scholar 

  63. National Breast and Ovarian Cancer Centre (NBOCC) and the Royal Australasian College of Surgeons (RACS) (2009). National Breast Cancer Audit—Public Health Monitoring Report on 2007 Data. Sydney: NBOCC and RACS.

    Google Scholar 

  64. Rococo, E., Mazouni, C., Or, Z., Mobillion, V., Koon Sun Pat, M., & Bonastre, J. (2016). Variation in rates of breast cancer surgery: A national analysis based on French Hospital Episode Statistics. European Journal of Surgical Oncology, 42(1), 51–58.

    CAS  PubMed  Google Scholar 

  65. Takahashi, M., Kai, I., Hisata, M., & Higashi, Y. (2006). The association between breast surgeons’ attitudes toward breast reconstruction and their reconstruction-related information-giving behaviors: A nationwide survey in Japan. Plastic & Reconstructive Surgery, 118(7), 1507–1514.

    CAS  Google Scholar 

  66. Alderman, A. K., Hawley, S. T., Waljee, J., Mujahid, M., Morrow, M., & Katz, S. J. (2008). Understanding the impact of breast reconstruction on the surgical decision-making process for breast cancer. Cancer, 112, 489–494.

    PubMed  Google Scholar 

  67. Lee, C. N., Belkora, J., Change, Y., Moy, B., Partridge, A., & Sepucha, K. (2011). Are patients making high-quality decisions about breast reconstruction after mastectomy? Plastic & Reconstructive Surgery, 127(1), 18–26.

    CAS  Google Scholar 

  68. Weenk, M., Wunschel, P., Heine, E., & Strobbe, L. (2016). Factors influencing the decision to pursue immediate breast reconstruction after mastectomy for breast cancer. European Journal of Cancer, 57, S23

    Google Scholar 

  69. Lam, T. C., Hsieh, F., & Boyages, J. (2013). The effects of postmastectomy adjuvant radiotherapy on immediate two-stage prosthetic breast reconstruction: A systematic review. Plastic & Reconstructive Surgery, 132, 511–518.

    CAS  Google Scholar 

  70. Barry M, Kell MR. (2011). Radiotherapy and breast reconstruction: A meta-analysis. Breast Cancer Research & Treatment, 127, 15–22.

    CAS  Google Scholar 

  71. Lee, C. N., Hultman, C. S., & Sepucha, K. (2010). Do patients and providers agree about the most important facts and goals for breast reconstruction decisions? Annals of Plastic Surgery, 64(5), 563–566.

    CAS  PubMed  Google Scholar 

  72. Brennan, M. E., Flitcroft, K., Warrier, S., Snook, K., & Spillane, A. (2016). Immediate expander/implant breast reconstruction followed by post-mastectomy radiotherapy for breast cancer: Aesthetic, surgical, satisfaction and quality of life outcomes in women with high-risk breast cancer. The Breast, 30, 59–65.

    PubMed  Google Scholar 

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Acknowledgements

The I-BREAST study is generously funded by The Friends of the Mater Foundation, North Sydney, Australia. The study sponsors did not influence the study design, collection, analysis or interpretation of data, or the writing of the manuscript. We also acknowledge the assistance of Ngaire Pettit-Young (Information Specialist, Information First) in conducting the literature search.

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Authors and Affiliations

  1. Breast & Surgical Oncology at The Poche Centre, 40 Rocklands Rd, North Sydney, NSW, 2060, Australia

    Kathy Flitcroft, Meagan Brennan & Andrew Spillane

  2. Northern Clinical School, University of Sydney, Sydney, NSW, 2006, Australia

    Kathy Flitcroft, Meagan Brennan & Andrew Spillane

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  1. Kathy Flitcroft
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  2. Meagan Brennan
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Correspondence to Kathy Flitcroft.

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All authors declare there are no conflicts of interest.

Ethics approval

This systematic review was conducted under the auspices of the Improving Breast Reconstruction Equity of Access through Stakeholder consultation and Translation into Policy and Practice (I-BREAST) study. Ethics approval for I-BREAST was obtained from StVincent’s Hospital, Sydney, Human Research Ethics Committee (14/181). I-BREAST is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR number 12616000188437). Separate ethics approval was not required for this systematic review.

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Flitcroft, K., Brennan, M. & Spillane, A. Making decisions about breast reconstruction: A systematic review of patient-reported factors influencing choice. Qual Life Res 26, 2287–2319 (2017). https://doi.org/10.1007/s11136-017-1555-z

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