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Original Investigation
May 3, 2017

Quality of Patient Decisions About Breast Reconstruction After Mastectomy

Author Affiliations
  • 1Department of Plastic Surgery, College of Medicine, The Ohio State University, Columbus
  • 2Richard J. Solove Research Institute, Comprehensive Cancer Center–Arthur G. James Cancer Hospital, The Ohio State University, Columbus
  • 3Division of Health Services Management and Policy, College of Public Health, The Ohio State University, Columbus
  • 4Lineberger Comprehensive Cancer Center Biostatistics Core Facility, University of North Carolina–Chapel Hill
  • 5Duke-Margolis Center for Health Policy, Fuqua School of Business, Duke University, Durham, North Carolina
  • 6Duke-Margolis Center for Health Policy, Sanford School of Public Policy, Duke University, Durham, North Carolina
  • 7Duke-Margolis Center for Health Policy, Duke University School of Medicine, Durham, North Carolina
  • 8Department of Surgery, University of North Carolina Hospitals, University of North Carolina–Chapel Hill
  • 9Gastrointestinal Unit, Massachusetts General Hospital, Boston
  • 10Department of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina–Chapel Hill
  • 11Department of Internal Medicine, Dell Medical School, University of Texas at Austin
  • 12Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
JAMA Surg. Published online May 3, 2017. doi:10.1001/jamasurg.2017.0977
Key Points

Question  What is the quality of patient decisions about breast reconstruction after mastectomy?

Findings  In this cross-sectional survey study of 126 women, a minority of participants (43.3%) made a high-quality decision, defined as having knowledge of at least half of the important facts and undergoing treatment concordant with one’s personal preferences.

Meaning  Decisions about breast reconstruction after mastectomy could be improved.

Abstract

Importance  Breast reconstruction has the potential to improve a person’s body image and quality of life but has important risks. Variations in who undergoes breast reconstruction have led to questions about the quality of patient decisions.

Objective  To assess the quality of patient decisions about breast reconstruction.

Design, Setting, and Participants  A prospective, cross-sectional survey study was conducted from June 27, 2012, to February 28, 2014, at a single, academic, multidisciplinary oncology clinic among women planning to undergo mastectomy for stage I to III invasive ductal or lobular breast cancer, ductal carcinoma in situ, or prophylaxis.

Exposures  Mastectomy only and mastectomy with reconstruction.

Main Outcome and Measures  Knowledge, as ascertained using the Decision Quality Instrument; preference concordance, based on rating and ranking of key attributes; and decision quality, defined as having knowledge of 50% or more and preference concordance.

Results  During the 20-month period, 214 patients were eligible, 182 were approached, and 32 missed. We enrolled 145 patients (79.7% enrollment rate), and received surveys from 131 patients (72.0% participation rate). Five participants became ineligible. The final study population was 126 patients. Among the 126 women in the study (mean [SD] age, 53.2 [12.1] years), the mean (SD) knowledge score was 58.5% (16.2%) and did not differ by treatment group (mastectomy only, 55.2% [15.0%]; mastectomy with reconstruction, 60.5% [16.5%]). A total of 82 of 123 participants (66.7%) had a calculated treatment preference of mastectomy only; 39 of these women (47.6%) underwent mastectomy only. A total of 41 participants (32.5%) had a calculated treatment preference of mastectomy with reconstruction; 36 of these women (87.8%) underwent mastectomy with reconstruction. Overall, 52 of 120 participants (43.3%) made a high-quality decision. In multivariable analysis, white race/ethnicity (odds ratio [OR], 2.72; 95% CI, 1.00-7.38; P = .05), having private insurance (OR, 1.61; 95% CI, 1.35-1.93; P < .001), having a high school education or less (vs some college) (OR, 4.84; 95% CI, 1.22-19.21; P = .02), having a college degree (vs some college) (OR, 1.95; 95% CI, 1.53-2.49; P < .001), and not having a malignant neoplasm (eg, BRCA carriers) (OR, 3.13; 95% CI, 1.25-7.85; P = .01) were independently associated with making a high-quality decision.

Conclusions and Relevance  A minority of patients undergoing mastectomy in a single academic center made a high-quality decision about reconstruction. Shared decision making is needed to support decisions about breast reconstruction.

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