Breast Reconstruction Post Mastectomy: Patient Satisfaction and Decision Making

Abstract

Background:
Although breast reconstruction has been shown to improve psychological, physical, and sexual well-being, Australia still has one of the lowest reconstruction rates among well-developed countries. This study explores both the quality-of-life benefits of reconstruction and the factors that influence patients' decisions of whether or not to undergo reconstruction.

Methods:
This retrospective cohort study (296 consecutive mastectomy patients from 2000 to 2010) uses an internationally validated questionnaire (BREAST-Q) to evaluate patients' satisfaction with or without breast reconstruction. In addition, we analyzed factors that influence patients' decisions of whether to undergo reconstruction.

Results:
Two hundred nineteen patients responded (74%) and of the 143 patients who elected to participate, 79 were in the "reconstruction group" and 64 in the "no-reconstruction group" post mastectomy. Patient demographics and cancer variables of the 2 groups were matched with the exception of age (reconstruction group 9.7 years younger: P < 0.01). The reconstruction group showed statistically significantly higher BREAST-Q scores with regard to satisfaction with the breast (P < 0.0001), psychological well-being (P = 0.0068), and sexual well-being (P = 0.0001). For the reconstruction group, the main reasons for undergoing reconstruction included improved self-image, more clothing choices, and the feeling of overcoming the cancer. One third of non-reconstructed patients still feared that reconstruction would mask cancer recurrence.

Conclusion:
Our study confirms the positive effects of breast reconstruction post mastectomy and identifies reasons that influence patients' decisions of whether to undergo reconstruction. Breast reconstruction should be seen as an integral part in the comprehensive care of women with breast cancer and an important health care priority in Australia.

Full text

Breast Reconstruction Post Mastectomy
Patient Satisfaction and Decision Making
Sally K. Ng, MBBS(Hons), DipSurgAnat,* Rowena M. Hare, BA, BSc, MBBS,Þ
Ronny J. Kuang, MBBS(Hons),ÞKatrina M. Smith, BAppSci, GradDipHealthAdmin,Þ
Belinda J. Brown, MBBS, FRACS,Þand David J. Hunter-Smith, MBBS(Hons), FRACS*þ
Background: Although breast reconstruction has been shown to improve
psychological, physical, and sexual well-being, Australia still has one of the
lowest reconstruction rates among well-developed countries. This study ex-
plores both the quality-of-life benefits of reconstruction and the factors that
inf luence patients’ decisions of whether or not to undergo reconstruction.
Methods: This retrospective cohort study (296 consecutive mastectomy pa-
tients from 2000 to 2010) uses an internationally validated questionnaire
(BREAST-Q) to evaluate patients’ satisfaction with or without breast recon-
struction. In addition, we analyzed factors that influence patients’decisions of
whether to undergo reconstruction.
Results: Two hundred nineteen patients responded (74%) and of the 143 pa-
tients who elected to participate, 79 were in the ‘‘reconstruction group’’ and 64
in the ‘‘no-reconstruction group’’ post mastectomy. Patient demographics and
cancer variables of the 2 groups were matched with the exception of age (re-
construction group 9.7 years younger: PG0.01). The reconstruction group
showed statistically significantly higher BREAST-Q scores with regard to
satisfaction with the breast (PG0.0001), psychological well-being (P=
0.0068), and sexual well-being (P= 0.0001). For the reconstruction group, the
main reasons for undergoing reconstruction included improved self-image,
more clothing choices, and the feeling of overcoming the cancer. One third of
non-reconstructed patients still feared that reconstruction would mask cancer
recurrence.
Conclusion: Our study confirms the positive effects of breast reconstruction
post mastectomy and identif ies reasons that influence patients’ decisions of
whether to undergo reconstruction. Breast reconstruction should be seen as an
integral part in the comprehensive care of women with breast cancer and an
important health care priority in Australia.
Key Words: breast neoplasm, mastectomy, patient satisfaction, reconstructive
surgical procedures
(Ann Plast Surg 2016;76: 640Y644)
Despite the widespread use of breast conservation therapy, many
patients with breast cancer still require mastectomy as their
surgical treatment option. Mastectomy is often used when breast
conservation surgery would significantly distort the breast shape and
contour, when the tumor is multifocal, or when most of the breast is
involved. Prophylactic mastectomies for patients with hereditary breast
cancer genes BRCA1 and BRACA2 are also becoming more mainstream
in Western societies because of the availability of genetic testing.
Breast reconstruction aims to recreate the breast mound after
mastectomy and is now an integral component in the management of
breast cancer patients. In 2002, the National Institute for Health Ex-
cellence recommended that ‘‘reconstruction should be available to all
women with breast cancer at the initial surgical operation’’.
1
Recon-
struction can be achieved using implants and/or autologous tissue and
can be performed immediately with the initial mastectomy or as a de-
layed procedure. As far back as 1995, the National Health and Medical
Research Council made similar recommendations regarding the need to
discuss breast reconstruction with eligible women before mastectomy.
2
There is a growing acceptance of the value of breast recon-
struction, with many studies attesting to the physical, psychological,
and sexuality benefits of reconstruction for women with breast
cancer.
3Y6
A systematic review of studies of patient satisfaction with
breast reconstruction concluded that patients were generally satisfied
with breast reconstruction.
7
In addition, the benefits in psychosocial
well-being and body image continue to manifest at least 2 years after
reconstruction.
8
However, many of the earlier studies were based on
simple survey instruments and interviews to ascertain patient satis-
faction. The general relevance of the published research from dif-
ferent countries, with variable experiences and expectations, may not
be extrapolated and applicable to the Australian population.
Currently, the Royal Australian College of Surgeons Breast
Audit does not collect data about the total number of breast re-
constructions performed in Australia. In addition, it does not contain
information about satisfaction or quality-of-life outcomes.
Australian reconstruction rates are lower than in other Western
countries. In 1999, Hill et al reported that 6% of women underwent
breast reconstruction.
2
The National Breast Cancer Centre statistics
in 2003 indicated reconstruction rates of 8%.
9
The latest study by
Wang et al, based on the National Breast Cancer Audit between 1999
and 2006, found that the proportion of women having reconstruction
post mastectomy was highly age dependent, with 27% of women
aged 40 or less, 20% of women between 41 and 50 years, 9.4% of
women between 51 and 70 years, and less than 1% in women above
70 years having reconstructions.
10
On the contrary, reconstruction
rates in the UK have been reported as high as 32% (21% immediate
and 11% delayed)
11
and recent U.S. data show immediate recon-
struction rates of 38%.
12
Reasons for the relatively low uptake rate of reconstruction in
Australia are unclear. Potential barriers have been identified by
Sandelin et al, which include limited services in rural regions, long
waiting times in the public system, high out-of-pocket cost in the
private sector, inadequate involvement of breast reconstructive sur-
geons, and lack of information for women about reconstruction.
13
This study’s primary aim is to use a validated assessment tool
to evaluate patients’ satisfaction and quality of life with or without
reconstruction post mastectomy based on an Australian cohort. The
secondary aim is to identify factors that inf luence patient’s decision
of whether or not to undertake reconstruction.
BREAST SURGERY
640 www.annalsplasticsurgery.com Annals of Plastic Surgery &Volume 76, Number 6, June 2016
Received January 26, 2014, and accepted for publication, after revision, March 27,
2014.
From the *Departments of Plastic and Reconstructive Surgery and †Surgery, Penin-
sular Health, Victoria; and ‡Peninsula and Gippsland Clinical Schools, Monash
University, Victoria, Australia.
The results have been presented at the RACS Victoria AnnualScientific Meeting 2012
and Australia Society of Plastic Surgeon Annual Registrar Conference 2013 and
Royal Australasian College of Surgeons Annual Scientific Congress 2014.
Conflicts of interest and sources of funding: none declared.
Reprints: David Hunter-Smith, MBBS(Hons), FRACS, Department of Surgery, PO
Box 52, Frankston, Victoria 3199, Australia. E-mail: dhuntersmith@mac.com.
Copyright *2014 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0148-7043/16/7606-0640
DOI: 10.1097/SAP.0000000000000242
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

PATIENTS AND METHODS
This is a retrospective cohort study approved by the Peninsula
Health Human Research and Ethics Committee.
Assessment Tools
A validated patient-reported outcome instrument known as the
BREAST-Q was used to assess patients’ satisfaction and quality of
life (QOL) after mastectomy.
14
Two cohorts were analyzed: those
who had reconstruction and those who did not have reconstruction.
Each module of the BREAST-Q consists of a core of indepen-
dent scales assessing 3 quality-of-life domains (physical, psychosocial,
and sexual well-being) and 3 satisfaction domains (satisfaction with
breasts, outcome, and care).
Questionnaire responses are entered into Q score, a data-
analyzing program that converts raw scores into a summary score
between 0 and 100. A higher score means higher satisfaction or better
health-related quality of life.
It is acknowledged that the clinical meaning of the BREAST-
Q score is not yet defined; however, the interpretation of the clinical
significance of the Q score suggests that a mean change of 5 to 10 is
perceived as ‘‘little’’ change, 10 to 20 as ‘‘moderate’’ change, and
greater than 20 as ‘‘significant’’ change.
15
To date, the BREAST-Q
has been validated in multiple studies and proven to be highly reli-
able, valid, and responsive to differences in patient outcomes.
16,17
The second section of the questionnaire aimed to explore the
reasons why patients made the decision whether or not to have breast
reconstruction after mastectomy. Responses in this section were a
categorical ranking of (1) important, (2) not important, or (3) some-
what important.
Data Collection
Each patient completed a study-specific questionnaire that
included demographic details and components of BREAST-Q as
described. Two reminders were sent to those who did not respond to
the initial mail-out.
Data Analysis
Descriptive data was calculated for continuous variables (mean
and standard deviation) and categorical values (frequency).
All analyses were performed using the NCSS statistical soft-
ware package (Hinze J, 2009, NCSS; NCSS LLC, Kaysville, UT,
USA) with 2-tailed tests of significance and the significance level
set at Pless than 0.05.
Study Population
Two hundred ninety-six female patients who underwent ther-
apeutic or prophylactic mastectomies between January 2000 and
December 2010 were identified from both the Peninsula Health da-
tabase (125) and a senior author’s private practice database (171).
Males were excluded.
RESULTS
Two hundred nineteen responses were received, giving a re-
sponse rate of 74.0%. Of those, 69 patients declined participation and
7 were notified as deceased. The remaining 143 patients formed the
study population, all of whom signed informed consent and the study
questionnaire.
The mean age at diagnosis of the study population was 54.5 T
12.9 years. When a patient had 2 diagnoses, the earliest age of di-
agnosis was recorded.
The 143 patients were divided into 2 groups: the first com-
prising 79 women (55%) who had a mastectomy with no recon-
struction and the second comprising 64 women (45%) who had
immediate or delayed reconstruction post mastectomy.
In the non-reconstructed group, there were 47 public and 32
private patients (59% and 41%, respectively). In the mastectomy with
reconstruction group, there were 24 public and 40 private patients
(38% and 62% respectively).
Demographic variables of the 2 groups were matched for
marital status, number of children, education, country of birth, in-
surance status, and household income, with the exception of age, the
reconstruction group being 9.7 years younger than the non-
reconstructed group (PG0.01) (Table 1). The cancer type and
treatment received by patients in each group were also matched.
In the reconstruction group, 41 women (64%) had autologous
reconstruction, 16 women (25%) had implant/tissue expander, and
7 women (11%) had autologous with implant reconstruction. Thirty-
six women had immediate reconstruction (56%) and 28 women
(44%) had delayed reconstruction.
The overall scores for each BREAST-Q domain for the non-
reconstructed group and reconstruction group are listed in Table 2.
The reconstruction group reported a statistically significantly higher
Q score in the satisfaction with breast (PG0.0001), psychological
well-being (P= 0.0068), and sexual well-being (P= 0.0001) domain
by 19.4, 9.5, and 17.5 points, respectively. The Q score for other
domains (physical well-being and satisfaction with surgeon, medical
staff, and office staff ) did not differ by statistically significant
amounts between the 2 groups.
Further analysis of the Q score was performed within the re-
construction group to determine if there were any differences with
regard to the timing of the reconstruction (immediate vs. delayed)
and the type of reconstruction (implant vs. autologous vs. combina-
tion of both). There was no statistically signif icant difference in all
the domains within each subgroup.
For women who had reconstruction post mastectomy, a sig-
nificant portion of patients rated improved self-image (80.6%),
TABLE 1. Baseline Patient Variables for the Reconstructed and
Non-Reconstructed Group
Variable
Reconstructed
(n = 64)
Non-Reconstructed
(n = 79)
Mean age at diagnosis
mean TSD (range)
49.1 T9.8 (23Y75) 58.8 T13.6 (32Y93)
Marital status n (%)
Single 5 (7.8) 2 (2.5)
De facto 7 (10.9) 3 (3.8)
Married 40 (62.5) 51 (64.6)
Divorced 9 (14.1) 11 (13.9)
Widowed 3 (4.7) 12 (15.2)
Highest level of education n (%)
Primary 1 (1.6) 3 (3.8)
Some secondary 11 (17.2) 26 (32.9)
Completed secondary 13 (20.3) 22 (27.9)
Some additional 19 (26.7) 15 (18.9)
Undergraduate 7 (10.9) 6 (7.6)
Post graduate 13 (20.3) 7 (8.9)
Annual household income $ n (%)
G35,000 17 (26.6) 36 (45.6)
35Y55,000 10 (15.6) 15 (18.9)
55Y80,000 4 (6.2) 8 (10.1)
80Y110,000 10 (15.6) 6 (7.6)
110Y150,000 8 (12.5) 5 (6.3)
150Y200,000 6 (9.4) 4 (5.1)
Not answered 8 (12.5) 4 (5.1)
Annals of Plastic Surgery &Volume 76, Number 6, June 2016 Breast Reconstruction Post Mastectomy
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convenience of not wearing prosthesis or clothing limitations
(78.7%), the association of overcoming cancer (76.7%), and im-
proving their relationship with others (60.0%) as the most important
reasons for their decision to undergo reconstruction (Fig. 1). Of in-
terest, 77.4% of these women indicated that they paid $8,000 to
$10,000 total out-of-pocket cost for their reconstructive surgery.
For women who did not have reconstruction, approximately
one third of the women indicated that the reasons why they did not
wish to undertake reconstruction was that they feared the possibility
of reconstruction masking cancer recurrence (29.1%) and risks with
additional surgery (36.7%). However, cost did not appear to be a
hindering factor, with 40.5% of women indicating it was not an im-
portant factor that inf luenced their decision. Over 30% of women in
this group indicated that they are exploring or would like to re-
explore the option of reconstruction after participating in our study.
DISCUSSION
There is limited literature that investigates patients’satisfaction
and outcomes of breast reconstruction in Australia. One of the first
outcome studies by Panjari et al reported no difference in body image
between women who had or had not undergone reconstruction.
18
However, a recent publication by Bell et al, which focused on the
assessment of psychological well-being, found that, by adjusting for
age, the reconstruction group showed a more favorable outcome for
the domains of general health and well-being.
19
One of the limita-
tions of this study was the use of generic assessment scales, which
are insensitive to the unique issues of breast reconstruction pa-
tients.
20
Our present study is one of the few to examine whether there
is a difference in quality of life and satisfaction outcome for women
who had undergone mastectomy with or without reconstruction,
using a psychometrically robust patient-reported outcome instrument
specifically designed to evaluate outcomes among women undergo-
ing different breast surgeries. In our patient population, response to
the BREAST-Q demonstrated a statistically significantly higher
overall satisfaction with breast reconstruction, psychological well-
being, and sexual well-being for the group of women who had re-
construction. The score differences between the groups (satisfaction
with breast 19.4, psychological well-being 9.5, and sexual well-being
17.5) are referred to as ‘‘moderate’’ change. The clinical meaning of
the BREAST-Q scores requires further definition.
17
However, it has
been suggested that the interpretation of the clinical significance
between the 2 groups for scores on a health-related quality of life
instrument could be based on whether the difference exceeds 0.5 of a
standard deviation.
21
In our study, the BREAST-Q domains that
showed statistically significantly higher scores had mean score dif-
ferences that were at least 0.5 of a standard deviation. Therefore, it is
appropriate to consider the changes in these domains to be clinically
significant.
Controversy remains over the ideal timing of reconstruction,
and the effect of adjuvant therapy needs to be considered. The
Cochrane review in 2011 on immediate versus delayed reconstruction
concluded that there was some, albeit unreliable, evidence that im-
mediate reconstruction, compared with delayed or no reconstruction,
reduced psychiatric morbidity 3 months postoperatively.
22
In terms
of the types of reconstruction, a number of authors have reported
that patients generally expressed preference for autologous recons-
truction.
23Y26
However, the rates of implant reconstruction have also
increased significantly in the United States because of the signif icant
rise in immediate reconstruction, and it is still a popular option for
some patients.
12
We have performed a subgroup analysis of Q scores com-
paring immediate versus delay reconstruction, as well as implant
versus autologous reconstruction. In our study sample, there was no
FIGURE 1.Reasons for undergoing reconstruction (% respondent).
TABLE 2. Breast Q Scoring
Breast Q Score (Mean TSD)
Domain
Reconstructed
(n = 64)
Non-Reconstructed
(n = 79) P
Satisfaction with breast 68.3 T19.9 48.9 T21.9 0.0001
Psychological well-being 73.7 T19.2 64.2 T21.2 0.0068
Physical well-being 73.0 T15.4 71.2 T19.4 0.5400
Sexual well-being 55.2 T21.9 37.7 T26.8 0.0001
Satisfaction with information 70.7 T20.9 Not assessed V
Satisfaction with surgeon 89.7 T17.8 87.4 T18.3 0.4600
Satisfaction with medical staff 89.7 T18.8 93.0 T15.2 0.2500
Satisfaction with office staff 91.7 T18.6 93.6 T13.4 0.4800
Ng et al Annals of Plastic Surgery &Volume 76, Number 6, June 2016
642 www.annalsplasticsurgery.com *2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

statistically significant difference in Q scores in all domains between
the subgroups. However, it is difficult to interpret these findings as
our sample sizes in each subgroup were relatively small compared to
current published studies.
Methodologically rigorous multicenter prospective studies are
still required to compare the best and most appropriate timing and
method of breast reconstruction post mastectomy. Before such evi-
dence becomes available, all relevant reconstructive options should
be discussed with equal weighting to suitable patients.
Hall et al conducted one of the early studies looking at the
effects of socioeconomic factors on the likelihood of women
choosing to undertake reconstruction post mastectomy. They found
that women who were younger, with less co-morbidities, non-
indigenous background, and private insurance were more likely to
opt for reconstruction. On the other hand, women in lower socio-
economic groups or those from rural areas were less likely to receive
reconstruction.
27
Bell et el reported similar findings, where women
who had reconstruction were shown to be younger, educated beyond
school level, lived in metropolitan areas, had private insurance, and
had no dependent children.
19
In our study, there were no statistically
significant differences on any of the demographic variables, with the
exception of age, between the non-reconstruction and reconstruction
group. Although our cohort would be representative of women living
in metropolitan and regional areas of the state, we have not included
women in rural and remote areas. The establishment of a central
database of all the reconstruction cases is essential to analyze the
incidences and trends of reconstruction across the state and nation.
The decision-making process about reconstruction is complex.
Two Australian studies looking at the determinants for reconstruction
found that a major reason for reconstruction is ‘‘to feel whole again’’,
and the elimination of the prostheses helps to restore lost femininity
and sexuality.
28,29
In our study, the main reasons for women to un-
dergo reconstruction included improved self-image, convenience of
not having to use a prosthesis or clothing limitations, an improvement
to their relationship, and the sense of overcoming cancer. Of interest,
although some women in the reconstruction group reported a high
out-of-pocket cost for their surgery, it was not a major reason why
women in the non-reconstruction group decided not to have recon-
struction. Other factors such as inter-current medical or social prob-
lems are likely to affect the decision-making process and each patient
is likely to have their unique reasons. Our role as surgeons is to un-
derstand the factors involved and actively engaged patients in the
decision-making process.
There are still misconceptions about breast reconstruction,
with 29.1% of patients in the non-reconstruction group fearing that
reconstruction may mask the detection of cancer recurrence. Many
retrospective studies have demonstrated that the use of post-
mastectomy reconstruction does not interfere with the ability to de-
tect local recurrence.
30Y32
The quality and availability of preoperative
information must therefore be improved to enable women to under-
stand the risk and impact of surgery.
Considering the positive effect of breast reconstruction high-
lighted in our study, it is important to ensure that breast reconstruc-
tion can be offered on a routine basis in Australia, in both the private
and public sectors and irrespective of geographical distance. Patients
should receive accurate information in a format and level of detail
that meets their individual needs. The oncological and reconstruc-
tive management for each patient should be discussed at a multi-
disciplinary meeting and documented in the treatment plan. If
patients wish to defer reconstruction to a later stage, they should be
given an opportunity to re-explore reconstruction when they are
ready. To ensure a consistent standard of service, it is fundamental to
establish a national audit to assess the provision of service and re-
construction outcomes using a well-validated assessment tool such
as BREAST-Q. The Q score can be used to benchmark care across
different institutes within the state and nationally. The information
generated from the national audit can subsequently beused to develop a
set of best-practice guidelines for all the health care providers involved
with the management of breast cancer and breast reconstruction.
CONCLUSION
This is one of the few Australian studies that used a well-
validated instrument to determine if there is a satisfaction differ-
ence between patients who did or did not have reconstruction post
mastectomy. The results confirm that women who have reconstruc-
tion have overall higher satisfaction with appearance of the breast, as
well as their psychological and sexual well-being.
This highlights the importance of reconstruction in the compre-
hensive care of women with breast cancer. We as clinicians should ensure
that appropriate resources are available to enable equitable access to
breast reconstruction post mastectomy. To this end, it is also important to
establish a comprehensive national database to assess provision ofservice
and outcome of care applicable to the Australian population.
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