BREAST SURGERY
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),Þ Katrina M. Smith, BAppSci, GradDipHealthAdmin,Þ Belinda J. Brown, MBBS, FRACS,Þ and 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 explores 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 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 inf luence 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 G 0.01). The reconstruction group showed statistically significantly higher BREAST-Q scores with regard to satisfaction with the breast (P G 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 inf luence 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)
D
espite 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
Received January 26, 2014, and accepted for publication, after revision, March 27, 2014. From the *Departments of Plastic and Reconstructive Surgery and †Surgery, Peninsular Health, Victoria; and ‡Peninsula and Gippsland Clinical Schools, Monash University, Victoria, Australia. The results have been presented at the RACS Victoria Annual Scientific 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: [email protected]. Copyright * 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7606-0640 DOI: 10.1097/SAP.0000000000000242
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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 Excellence recommended that ‘‘reconstruction should be available to all women with breast cancer at the initial surgical operation’’.1 Reconstruction can be achieved using implants and/or autologous tissue and can be performed immediately with the initial mastectomy or as a delayed 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 reconstruction, 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 satisfaction. The general relevance of the published research from different 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 reconstructions 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 reconstruction 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 surgeons, 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. Annals of Plastic Surgery
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Annals of Plastic Surgery
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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 independent 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 dataanalyzing 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 BREASTQ 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 reliable, 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) somewhat 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 software package (Hinze J, 2009, NCSS; NCSS LLC, Kaysville, UT, USA) with 2-tailed tests of significance and the significance level set at P less than 0.05.
Study Population Two hundred ninety-six female patients who underwent therapeutic or prophylactic mastectomies between January 2000 and December 2010 were identified from both the Peninsula Health database (125) and a senior author’s private practice database (171). Males were excluded.
RESULTS Two hundred nineteen responses were received, giving a response 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 diagnosis was recorded. The 143 patients were divided into 2 groups: the first comprising 79 women (55%) who had a mastectomy with no reconstruction and the second comprising 64 women (45%) who had immediate or delayed reconstruction post mastectomy. * 2014 Wolters Kluwer Health, Inc. All rights reserved.
Breast 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, insurance status, and household income, with the exception of age, the reconstruction group being 9.7 years younger than the nonreconstructed group (P G 0.01) (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. Thirtysix women had immediate reconstruction (56%) and 28 women (44%) had delayed reconstruction. The overall scores for each BREAST-Q domain for the nonreconstructed group and reconstruction group are listed in Table 2. The reconstruction group reported a statistically significantly higher Q score in the satisfaction with breast (P G 0.0001), 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 reconstruction 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. combination of both). There was no statistically significant difference in all the domains within each subgroup. For women who had reconstruction post mastectomy, a significant 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)
Mean age at diagnosis 49.1 T 9.8 (23Y75) mean T SD (range) Marital status n (%) Single 5 (7.8) De facto 7 (10.9) Married 40 (62.5) Divorced 9 (14.1) Widowed 3 (4.7) Highest level of education n (%) Primary 1 (1.6) Some secondary 11 (17.2) Completed secondary 13 (20.3) Some additional 19 (26.7) Undergraduate 7 (10.9) Post graduate 13 (20.3) Annual household income $ n (%) G35,000 17 (26.6) 35Y55,000 10 (15.6) 55Y80,000 4 (6.2) 80Y110,000 10 (15.6) 110Y150,000 8 (12.5) 150Y200,000 6 (9.4) Not answered 8 (12.5)
Non-Reconstructed (n = 79) 58.8 T 13.6 (32Y93)
2 (2.5) 3 (3.8) 51 (64.6) 11 (13.9) 12 (15.2) 3 (3.8) 26 (32.9) 22 (27.9) 15 (18.9) 6 (7.6) 7 (8.9) 36 (45.6) 15 (18.9) 8 (10.1) 6 (7.6) 5 (6.3) 4 (5.1) 4 (5.1)
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TABLE 2. Breast Q Scoring Breast Q Score (Mean T SD) Domain Satisfaction with breast Psychological well-being Physical well-being Sexual well-being Satisfaction with information Satisfaction with surgeon Satisfaction with medical staff Satisfaction with office staff
Reconstructed Non-Reconstructed (n = 64) (n = 79) 68.3 T 19.9 73.7 T 19.2 73.0 T 15.4 55.2 T 21.9 70.7 T 20.9 89.7 T 17.8 89.7 T 18.8 91.7 T 18.6
48.9 T 21.9 64.2 T 21.2 71.2 T 19.4 37.7 T 26.8 Not assessed 87.4 T 18.3 93.0 T 15.2 93.6 T 13.4
P 0.0001 0.0068 0.5400 0.0001 V 0.4600 0.2500 0.4800
convenience of not wearing prosthesis or clothing limitations (78.7%), the association of overcoming cancer (76.7%), and improving their relationship with others (60.0%) as the most important reasons for their decision to undergo reconstruction (Fig. 1). Of interest, 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 important factor that inf luenced their decision. Over 30% of women in this group indicated that they are exploring or would like to reexplore 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
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age, the reconstruction group showed a more favorable outcome for the domains of general health and well-being.19 One of the limitations of this study was the use of generic assessment scales, which are insensitive to the unique issues of breast reconstruction patients.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 undergoing different breast surgeries. In our patient population, response to the BREAST-Q demonstrated a statistically significantly higher overall satisfaction with breast reconstruction, psychological wellbeing, and sexual well-being for the group of women who had reconstruction. 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 differences 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 immediate 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 reconstruction.23Y26 However, the rates of implant reconstruction have also increased significantly in the United States because of the significant rise in immediate reconstruction, and it is still a popular option for some patients.12 We have performed a subgroup analysis of Q scores comparing 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). 642
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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 evidence 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, nonindigenous background, and private insurance were more likely to opt for reconstruction. On the other hand, women in lower socioeconomic 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 undergo 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 reconstruction. Other factors such as inter-current medical or social problems are likely to affect the decision-making process and each patient is likely to have their unique reasons. Our role as surgeons is to understand 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 postmastectomy reconstruction does not interfere with the ability to detect local recurrence.30Y32 The quality and availability of preoperative information must therefore be improved to enable women to understand the risk and impact of surgery. Considering the positive effect of breast reconstruction highlighted in our study, it is important to ensure that breast reconstruction 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 reconstructive management for each patient should be discussed at a multidisciplinary 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 reconstruction outcomes using a well-validated assessment tool such as BREAST-Q. The Q score can be used to benchmark care across * 2014 Wolters Kluwer Health, Inc. All rights reserved.
Breast Reconstruction Post Mastectomy
different institutes within the state and nationally. The information generated from the national audit can subsequently be used 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 wellvalidated instrument to determine if there is a satisfaction difference between patients who did or did not have reconstruction post mastectomy. The results confirm that women who have reconstruction 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 comprehensive 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 of service and outcome of care applicable to the Australian population. REFERENCES 1. National Institute for Clinical Excellence (NICE). Guidance on cancer services: improving outcomes in breast cancerVmanual update. London: NICE, 2002. Available from: http://www.nice.org.uk/nicemedia/pdf/Improving_outcomes_ breastcancer_manual.pdf 2. Hill D, Jamrozik K, White V, et al. Surgical Management of Breast Cancer in Australian Women in 1995. Sydney: NHMRC National Breast Cancer Centre; 1999. 3. Wilkins EG, Cederna PS, Lowery JC, et al. Prospective analysis of psychosocial outcomes in breast reconstruction: one year post-operative results from the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg. 2000;106:1014Y1025. 4. Nano MT, Gill PG, Kollias J, et al. Psychological impact and cosmetic outcome of surgical breast cancer strategies. ANZ J Surg. 2005;75:940Y947. 5. Al-Ghazal SK, Fallowfield L, Blamey RW. Comparison of psychological aspects and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstruction. Eur J Cancer. 2000;36:1938Y1943. 6. Neto MS, de Aguiar Menezes MV, Moreira JR, et al. Sexuality after breast reconstruction post mastectomy. Aesthetic Plast Surg. 2013;37:643Y647. 7. Guyomard V, Leinster S, Wilkinson M. Systematic review of studies of patients’ satisfaction with breast reconstruction after mastectomy. Breast. 2007;16:547Y567. 8. Atisha D, Alderman AK, Lowery JC, et al. Prospective analysis of long-term psychosocial outcomes in breast reconstruction: two-year postoperative results from the Michigan Breast Reconstruction Outcome Study. Ann Surg. 2008;247:1019Y1028. 9. Breast Cancer Network Australia (BCNA). Breast Reconstruction Project Report. Melbourne: BCNA; 2011. 10. Wang J, Kollias J, Boult M, et al. Patterns of surgical treatment for women with breast cancer in relation to age. Breast J. 2010;16:60Y65. 11. Jeevan R, Browne J, van der Meulen J et al. Fourth annual report of the National Mastectomy and Breast Reconstruction Audit 2011. Leeds: The NHS Information Centre 2011. Available form: http://www.hscic.gov.uk/catalogue/ PUB02731/clin-audi-supp-prog-mast-brea-reco-2011-rep1.pdf. 12. Albornoz CR, Bach PB, Mehrara BJ, et al. A paradigm shift in U.S. breast reconstruction: increasing implant rates. Plast Reconstr Surg. 2013;131:15Y23. 13. Sandelin KW, King E, Redman S. Breast reconstruction following mastectomy: current status in Australia. ANZ J Surg. 2003;73:701Y706. 14. Pusic AL, Klassen AF, Scott AM, et al. Development of a new patient reported outcome measure for breast surgery: the BREAST-Q. Plast Reconstr Surg. 2009;124:345Y353. 15. Memorial Sloan-Kettering Cancer Centre. Breast Q User Manual. New York: Memorial Sloan-Kettering Cancer Center; 2012. Available from: https:// webcore.mskcc.org/breastq/qscore/qscore-manual.pdf. 16. Cano SK, Klassen AF, Scott AM, et al. The BREAST-Q: further validation in independent clinical samples. Plast Reconstr Surg. 2012;129:293Y302. 17. Cano SJ, Klassen AF, Scot AM, et al. A closer look at the BREAST-Q. Clin Plast Surg. 2013;40:287Y296.
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18. Panjari M, Robin JB, Davis SR. Sexual function after breast cancer. J Sex Med. 2011;8:294Y302. 19. Bell RJ, Robinson PJ, Fradkin P, et al. Breast reconstruction following mastectomy for invasive breast cancer is strongly influenced by demographic factors in women in Victoria, Australia. Breast. 2012;21:394Y400. 20. Morrow M, Pusic A. Time for a new era in outcomes reporting for breast reconstruction. J Natl Cancer Inst. 2011;103:5Y7. 21. Norman GR, Sloan JA, Wyrwich KW. Interpretation of changes in healthrelated quality of life: the remarkable universality of half a standard deviation. Med Care. 2003;41:582Y592. 22. D’Souza N, Darmanin G, Fedorowicz Z. Immediate versus delayed reconstruction following surgery for breast cancer. Cochrane Database Syst Rev. 2011:1Y26. 23. Alderman AK, Wilkins EF, Lowery JC, et al. Determinants of patient satisfaction in post-mastectomy breast reconstruction. Plast Reconstr Surg. 2000;106:769Y776. 24. Clough KB, O’Donoghue JM, Fitoussi AD, et al. Prospective evaluation of late cosmetic results following breast reconstruction II TRAM flap reconstruction. Plast Reconstr Surg. 2001;107:1710Y1716.
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25. Damen TH, de Bekker-Grob EW, Mureau MA, et al. Patients’ preference for breast reconstruction: a discrete choice experiment. J Plast Reconstr Aesthet Surg. 2011;64:75Y83. 26. Damen THC, Timman R, Kunst HH, et al. High satisfaction rates in women after DIEP flap breast reconstruction. J Plast Reconstr Aesthet Surg. 2010;63:93Y100. 27. Hall SE, Holman CD. Inequalities in breast cancer reconstructive surgery according to social and locational status in Western Australia. Eur J Surg Oncol. 2003;29:519Y525. 28. Reaby LL. Reasons why women who have mastectomy decide to have or not to have breast reconstruction. Plast Reconstr Surg. 1998;101:1810Y1818. 29. Crompvoets S. Comfort, control or conformity: women who choose breast reconstruction following mastectomy. Health Care Women Int. 2006;27:75Y93. 30. Singletary SE. Skin sparing mastectomy with immediate breast reconstruction: the MD Anderson Cancer Center experience. Ann Surg Oncol. 1996;4:411Y416. 31. Noone RB, Frazier TG, Noone GC, et al. Recurrence of breast carcinoma following immediate reconstruction: a 13-year review. Plast Reconstr Surg. 1994;93:96Y106. 32. Johnson CH, van Heerden JA, Donohue JH, et al. Oncological aspects of immediate breast reconstruction following mastectomy for malignancy. Arch Surg. 1989;124:819Y823.
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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),Þ Katrina M. Smith, BAppSci, GradDipHealthAdmin,Þ Belinda J. Brown, MBBS, FRACS,Þ and 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 explores 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 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 inf luence 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 G 0.01). The reconstruction group showed statistically significantly higher BREAST-Q scores with regard to satisfaction with the breast (P G 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 inf luence 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)
D
espite 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
Received January 26, 2014, and accepted for publication, after revision, March 27, 2014. From the *Departments of Plastic and Reconstructive Surgery and †Surgery, Peninsular Health, Victoria; and ‡Peninsula and Gippsland Clinical Schools, Monash University, Victoria, Australia. The results have been presented at the RACS Victoria Annual Scientific 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: [email protected]. Copyright * 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7606-0640 DOI: 10.1097/SAP.0000000000000242
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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 Excellence recommended that ‘‘reconstruction should be available to all women with breast cancer at the initial surgical operation’’.1 Reconstruction can be achieved using implants and/or autologous tissue and can be performed immediately with the initial mastectomy or as a delayed 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 reconstruction, 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 satisfaction. The general relevance of the published research from different 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 reconstructions 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 reconstruction 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 surgeons, 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. Annals of Plastic Surgery
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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 independent 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 dataanalyzing 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 BREASTQ 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 reliable, 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) somewhat 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 software package (Hinze J, 2009, NCSS; NCSS LLC, Kaysville, UT, USA) with 2-tailed tests of significance and the significance level set at P less than 0.05.
Study Population Two hundred ninety-six female patients who underwent therapeutic or prophylactic mastectomies between January 2000 and December 2010 were identified from both the Peninsula Health database (125) and a senior author’s private practice database (171). Males were excluded.
RESULTS Two hundred nineteen responses were received, giving a response 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 diagnosis was recorded. The 143 patients were divided into 2 groups: the first comprising 79 women (55%) who had a mastectomy with no reconstruction and the second comprising 64 women (45%) who had immediate or delayed reconstruction post mastectomy. * 2014 Wolters Kluwer Health, Inc. All rights reserved.
Breast 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, insurance status, and household income, with the exception of age, the reconstruction group being 9.7 years younger than the nonreconstructed group (P G 0.01) (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. Thirtysix women had immediate reconstruction (56%) and 28 women (44%) had delayed reconstruction. The overall scores for each BREAST-Q domain for the nonreconstructed group and reconstruction group are listed in Table 2. The reconstruction group reported a statistically significantly higher Q score in the satisfaction with breast (P G 0.0001), 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 reconstruction 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. combination of both). There was no statistically significant difference in all the domains within each subgroup. For women who had reconstruction post mastectomy, a significant 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)
Mean age at diagnosis 49.1 T 9.8 (23Y75) mean T SD (range) Marital status n (%) Single 5 (7.8) De facto 7 (10.9) Married 40 (62.5) Divorced 9 (14.1) Widowed 3 (4.7) Highest level of education n (%) Primary 1 (1.6) Some secondary 11 (17.2) Completed secondary 13 (20.3) Some additional 19 (26.7) Undergraduate 7 (10.9) Post graduate 13 (20.3) Annual household income $ n (%) G35,000 17 (26.6) 35Y55,000 10 (15.6) 55Y80,000 4 (6.2) 80Y110,000 10 (15.6) 110Y150,000 8 (12.5) 150Y200,000 6 (9.4) Not answered 8 (12.5)
Non-Reconstructed (n = 79) 58.8 T 13.6 (32Y93)
2 (2.5) 3 (3.8) 51 (64.6) 11 (13.9) 12 (15.2) 3 (3.8) 26 (32.9) 22 (27.9) 15 (18.9) 6 (7.6) 7 (8.9) 36 (45.6) 15 (18.9) 8 (10.1) 6 (7.6) 5 (6.3) 4 (5.1) 4 (5.1)
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TABLE 2. Breast Q Scoring Breast Q Score (Mean T SD) Domain Satisfaction with breast Psychological well-being Physical well-being Sexual well-being Satisfaction with information Satisfaction with surgeon Satisfaction with medical staff Satisfaction with office staff
Reconstructed Non-Reconstructed (n = 64) (n = 79) 68.3 T 19.9 73.7 T 19.2 73.0 T 15.4 55.2 T 21.9 70.7 T 20.9 89.7 T 17.8 89.7 T 18.8 91.7 T 18.6
48.9 T 21.9 64.2 T 21.2 71.2 T 19.4 37.7 T 26.8 Not assessed 87.4 T 18.3 93.0 T 15.2 93.6 T 13.4
P 0.0001 0.0068 0.5400 0.0001 V 0.4600 0.2500 0.4800
convenience of not wearing prosthesis or clothing limitations (78.7%), the association of overcoming cancer (76.7%), and improving their relationship with others (60.0%) as the most important reasons for their decision to undergo reconstruction (Fig. 1). Of interest, 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 important factor that inf luenced their decision. Over 30% of women in this group indicated that they are exploring or would like to reexplore 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
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age, the reconstruction group showed a more favorable outcome for the domains of general health and well-being.19 One of the limitations of this study was the use of generic assessment scales, which are insensitive to the unique issues of breast reconstruction patients.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 undergoing different breast surgeries. In our patient population, response to the BREAST-Q demonstrated a statistically significantly higher overall satisfaction with breast reconstruction, psychological wellbeing, and sexual well-being for the group of women who had reconstruction. 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 differences 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 immediate 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 reconstruction.23Y26 However, the rates of implant reconstruction have also increased significantly in the United States because of the significant rise in immediate reconstruction, and it is still a popular option for some patients.12 We have performed a subgroup analysis of Q scores comparing 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). 642
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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 evidence 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, nonindigenous background, and private insurance were more likely to opt for reconstruction. On the other hand, women in lower socioeconomic 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 undergo 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 reconstruction. Other factors such as inter-current medical or social problems are likely to affect the decision-making process and each patient is likely to have their unique reasons. Our role as surgeons is to understand 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 postmastectomy reconstruction does not interfere with the ability to detect local recurrence.30Y32 The quality and availability of preoperative information must therefore be improved to enable women to understand the risk and impact of surgery. Considering the positive effect of breast reconstruction highlighted in our study, it is important to ensure that breast reconstruction 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 reconstructive management for each patient should be discussed at a multidisciplinary 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 reconstruction outcomes using a well-validated assessment tool such as BREAST-Q. The Q score can be used to benchmark care across * 2014 Wolters Kluwer Health, Inc. All rights reserved.
Breast Reconstruction Post Mastectomy
different institutes within the state and nationally. The information generated from the national audit can subsequently be used 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 wellvalidated instrument to determine if there is a satisfaction difference between patients who did or did not have reconstruction post mastectomy. The results confirm that women who have reconstruction 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 comprehensive 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 of service and outcome of care applicable to the Australian population. REFERENCES 1. National Institute for Clinical Excellence (NICE). Guidance on cancer services: improving outcomes in breast cancerVmanual update. London: NICE, 2002. Available from: http://www.nice.org.uk/nicemedia/pdf/Improving_outcomes_ breastcancer_manual.pdf 2. Hill D, Jamrozik K, White V, et al. Surgical Management of Breast Cancer in Australian Women in 1995. Sydney: NHMRC National Breast Cancer Centre; 1999. 3. Wilkins EG, Cederna PS, Lowery JC, et al. Prospective analysis of psychosocial outcomes in breast reconstruction: one year post-operative results from the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg. 2000;106:1014Y1025. 4. Nano MT, Gill PG, Kollias J, et al. Psychological impact and cosmetic outcome of surgical breast cancer strategies. ANZ J Surg. 2005;75:940Y947. 5. Al-Ghazal SK, Fallowfield L, Blamey RW. Comparison of psychological aspects and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstruction. Eur J Cancer. 2000;36:1938Y1943. 6. Neto MS, de Aguiar Menezes MV, Moreira JR, et al. Sexuality after breast reconstruction post mastectomy. Aesthetic Plast Surg. 2013;37:643Y647. 7. Guyomard V, Leinster S, Wilkinson M. Systematic review of studies of patients’ satisfaction with breast reconstruction after mastectomy. Breast. 2007;16:547Y567. 8. Atisha D, Alderman AK, Lowery JC, et al. Prospective analysis of long-term psychosocial outcomes in breast reconstruction: two-year postoperative results from the Michigan Breast Reconstruction Outcome Study. Ann Surg. 2008;247:1019Y1028. 9. Breast Cancer Network Australia (BCNA). Breast Reconstruction Project Report. Melbourne: BCNA; 2011. 10. Wang J, Kollias J, Boult M, et al. Patterns of surgical treatment for women with breast cancer in relation to age. Breast J. 2010;16:60Y65. 11. Jeevan R, Browne J, van der Meulen J et al. Fourth annual report of the National Mastectomy and Breast Reconstruction Audit 2011. Leeds: The NHS Information Centre 2011. Available form: http://www.hscic.gov.uk/catalogue/ PUB02731/clin-audi-supp-prog-mast-brea-reco-2011-rep1.pdf. 12. Albornoz CR, Bach PB, Mehrara BJ, et al. A paradigm shift in U.S. breast reconstruction: increasing implant rates. Plast Reconstr Surg. 2013;131:15Y23. 13. Sandelin KW, King E, Redman S. Breast reconstruction following mastectomy: current status in Australia. ANZ J Surg. 2003;73:701Y706. 14. Pusic AL, Klassen AF, Scott AM, et al. Development of a new patient reported outcome measure for breast surgery: the BREAST-Q. Plast Reconstr Surg. 2009;124:345Y353. 15. Memorial Sloan-Kettering Cancer Centre. Breast Q User Manual. New York: Memorial Sloan-Kettering Cancer Center; 2012. Available from: https:// webcore.mskcc.org/breastq/qscore/qscore-manual.pdf. 16. Cano SK, Klassen AF, Scott AM, et al. The BREAST-Q: further validation in independent clinical samples. Plast Reconstr Surg. 2012;129:293Y302. 17. Cano SJ, Klassen AF, Scot AM, et al. A closer look at the BREAST-Q. Clin Plast Surg. 2013;40:287Y296.
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18. Panjari M, Robin JB, Davis SR. Sexual function after breast cancer. J Sex Med. 2011;8:294Y302. 19. Bell RJ, Robinson PJ, Fradkin P, et al. Breast reconstruction following mastectomy for invasive breast cancer is strongly influenced by demographic factors in women in Victoria, Australia. Breast. 2012;21:394Y400. 20. Morrow M, Pusic A. Time for a new era in outcomes reporting for breast reconstruction. J Natl Cancer Inst. 2011;103:5Y7. 21. Norman GR, Sloan JA, Wyrwich KW. Interpretation of changes in healthrelated quality of life: the remarkable universality of half a standard deviation. Med Care. 2003;41:582Y592. 22. D’Souza N, Darmanin G, Fedorowicz Z. Immediate versus delayed reconstruction following surgery for breast cancer. Cochrane Database Syst Rev. 2011:1Y26. 23. Alderman AK, Wilkins EF, Lowery JC, et al. Determinants of patient satisfaction in post-mastectomy breast reconstruction. Plast Reconstr Surg. 2000;106:769Y776. 24. Clough KB, O’Donoghue JM, Fitoussi AD, et al. Prospective evaluation of late cosmetic results following breast reconstruction II TRAM flap reconstruction. Plast Reconstr Surg. 2001;107:1710Y1716.
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25. Damen TH, de Bekker-Grob EW, Mureau MA, et al. Patients’ preference for breast reconstruction: a discrete choice experiment. J Plast Reconstr Aesthet Surg. 2011;64:75Y83. 26. Damen THC, Timman R, Kunst HH, et al. High satisfaction rates in women after DIEP flap breast reconstruction. J Plast Reconstr Aesthet Surg. 2010;63:93Y100. 27. Hall SE, Holman CD. Inequalities in breast cancer reconstructive surgery according to social and locational status in Western Australia. Eur J Surg Oncol. 2003;29:519Y525. 28. Reaby LL. Reasons why women who have mastectomy decide to have or not to have breast reconstruction. Plast Reconstr Surg. 1998;101:1810Y1818. 29. Crompvoets S. Comfort, control or conformity: women who choose breast reconstruction following mastectomy. Health Care Women Int. 2006;27:75Y93. 30. Singletary SE. Skin sparing mastectomy with immediate breast reconstruction: the MD Anderson Cancer Center experience. Ann Surg Oncol. 1996;4:411Y416. 31. Noone RB, Frazier TG, Noone GC, et al. Recurrence of breast carcinoma following immediate reconstruction: a 13-year review. Plast Reconstr Surg. 1994;93:96Y106. 32. Johnson CH, van Heerden JA, Donohue JH, et al. Oncological aspects of immediate breast reconstruction following mastectomy for malignancy. Arch Surg. 1989;124:819Y823.
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