Women’s satisfaction with breast reconstruction after mastectomy and a survey on the decision process for type of reconstructive surgery

Reconstruction of the amputated breast after breast cancer surgery has great importance for women’s body image. Among women undergoing mastectomy in the USA an estimated 25–50% undergo breast reconstruction (BR) [1‐4]. Up to 90% of women with breast cancer reported improvement of emotional, psychological and social well-being after BR and may even contribute to an improved prognosis because it can enhance the woman’s hopes and willingness to survive [5‐11].

The BR can be performed using silicone shells or autologous tissue. It can be done immediately after mastectomy (primary reconstruction) or a few weeks or months later (secondary reconstruction). The surgical mode and timing of reconstruction should be discussed with the patient and decided individually [7, 12‐17].

Nowadays, silicone implants yield good cosmetic results with low complication rates. Silicone implants are the alternative choice especially for women who are too unstable in health to endure sophisticated tissue transplantation and those who do not possess adequate tissue for reconstruction due to low body mass index (BMI) [18‐22].

The use of BR with autologous tissue, the so-called flap surgery, can be performed either as primary or secondary reconstruction and is recommended especially in cases where subsequent radiotherapy is planned. Although silicone implants do not prevent radiotherapy, they can lead to overdosing or underdosing in the target volume of irradiation. Nowadays, three different surgical styles are used: transplanting tissue from the back (latissimus dorsi muscle flap, LD), tissue from the abdomen (transverse rectus abdominis myocutaneous flap, TRAM) or the deep inferior epigastric perforator (DIEP) flap technique, where skin and fatty tissue from the abdomen are used.

According to a comprehensive review [23] comparing satisfaction after implant vs. autologous tissue-based BR in over 8400 patients answering the BREAST‑Q satisfaction with breast scale, measuring a woman’s body image in terms of satisfaction with the breasts (score 0–100 lowest to highest satisfaction) in 14 studies, autologous tissue-based BR provided a benefit for women in terms of satisfaction with the breasts of 8.51 points. This is a substantial difference that speaks in favor of autologous tissue-based BR; however, large heterogeneity was observed and the reasons for the differences between studies are at present not well understood and may derive from differences in surgical techniques, perioperative care or financing of BR treatment. Complication rates were not different between implant vs. autologous tissue-based BR but also this meta-analytical finding was associated with a large heterogeneity. In the Supplementary Table 1, we provide an overview of studies from our scoping review that addressed women’s satisfaction after different types of breast oncoplastic surgery that is in line with the meta-analysis mentioned above.

There are few studies to date dealing with the reasons women with breast cancer have for or against BR. A common denominator of these studies is that women seek restoration of the familiar body image and good esthetic outcome [7, 17, 24‐30]. Obstacles are fear of additional surgery, concerns about possible complications, interference with detection of recurrence, time restraints because of family duties but also, although to a lesser degree, systemic factors, such as lack of knowledge about the options and no insurance coverage [3].

Very little is known yet about the conflicting and contrasting thoughts of women in the difficult decision-making process. Patients have to deal with incomplete, insufficient and sometimes dubious information. Too pressing advice can intensify fear and conflicts. Thus, healthcare providers must not only know about the personal conditions, such as life style, social and family conditions but also about the history of illness, complications or comorbidities to give helpful information to the patient [7, 13, 31‐33].

A retrospective study demonstrated that patients undergoing mastectomy and BR mainly reported having made their own decision after being informed about BR (66%) rather than reporting having participated in shared decision making (30%) and only 4% of the patients reported the decision was made by the doctor. General and esthetic satisfaction as well as quality of life were highest in informed and shared decision-making patients vs. patients seeking paternalistic providers [34]. Patients who underwent BR were more often informed about it at an early stage, discussed BR with their healthcare providers and were more often involved in the decision process [35]. The frequency and quality of discussing reconstruction influence the choice, regret and satisfaction of the patients [36, 37]. Information about the possibility of BR also helped the patients in decisions about mastectomy. Therefore, the informed decision-making model ensures the best quality of breast cancer treatment decisions [36]. In a Swedish study, lack of patient information and shared decision making negatively influenced immediate BR [38].

The paternalistic model of the patient-health-care provider relationship, with the patient delegating treatment decisions to the health-care provider, is becoming less prevalent in recent decades. It has been considered justified due to the asymmetry of knowledge. In contrast, the informed decision-making model intends to reduce this asymmetry by providing information about the risks and benefits of different treatment options in as clear and unbiased a fashion as possible. This should be done by taking care to invoke not additional fears, thereby enabling the informed patient to voice a treatment preference ultimately leading to shared-decision making [39]. Therefore, inquiring about the decision process needs to address the way information was received by the patient and about its sufficiency to make a decision.

In order to scrutinize the evidence base concerning BR satisfaction (study aim i), we performed a scoping review. To further investigate the decision process before BR (study aim ii), an own survey was conducted.

Hence the study aims were:

While the latter aim may be best assessed in prospective studies, a thorough consideration led to the decision to not interfere with the process while BR was still pending as this could lead to a change of the opinion of the women, and to perform a retrospective study in women that have already undergone BR.

Overall, 100 patients were extracted from the files of the department of Plastic, Aesthetic and Reconstructive Surgery of the Wilhelminenspital, Vienna, Austria. Of these patients, 5 were deceased and 95 eligible patients received the postal questionnaire. Of these women, 72 completed the questionnaire and sent it back (response rate 76%). The median age of respondents at the time of surgery was 50.3 years (interquartile range 44–57 years), with a range between 30 and 65 years. Nonresponders did not differ by age (median 50.2 years, range 36–65 years, p = 0.881) or method of BR (silicone 39% vs. 36%, p = 0.822). Reasons for nonparticipation were moved to unknown address (n = 11) and too busy (n = 12). Of the women three (4%) had severe complications and needed a second surgery (two with silicone implants and one with autologous tissue). All women were Austrian citizens, 70 women (97%) were married or in a fixed partnership and 65 women (95%) were in an active employment at the time of surgery. The time of the BR was between 1.5 and 10 years before the survey (mean ± SD, 5.6 ± 2.7 years). Contrasting patients with time since surgery in the first quartile (below 3 years) with those above the third quartile (7.7 years) revealed no indication of a relevant influence on the study variables (all p > 0.20).

Of the participants 61% chose autologous tissue, with 46% choosing autologous tissue without and 15% with silicone and 39% decided for silicone implants. Among women who chose autologous tissue, 61% voted for surgery with tissue from the abdomen by TRAM or DIEP and 39% chose LD flaps. Primary reconstruction was chosen by 43 women (60%), while 29 women (40%) preferred secondary reconstruction.

The vast majority (86%) mentioned visual appearance as the reason for choosing reconstruction. Medical (24%) and other reasons (19%) were present as the sole or as additional reasons in smaller numbers of women (women could select more than one reason). Concerning the choice of method of reconstruction, nearly a half (47%) gave medical reasons, with 10% mentioning a planned irradiation before reconstruction. Other reasons were length of hospital stay or stress of surgery (21%) and expected visual appearance (26%). The remaining women (6%) gave no specific reason for the choice of method.

Women choosing autologous tissue reconstruction did not differ in age from women choosing silicone (50.6 ± 8.1 years vs. 50.0 ± 9.8 years). There was no significant difference according to the type of surgery in reasons for choice of reconstruction (Table 1).

About one fifth (21%) of women decided for reconstruction immediately after diagnosis and 79% decided after some time of consideration, after consultation with healthcare providers or the partner. Hopes about outcome of reconstruction were realistic (with 76% overall hoping for an acceptable appearance). Little difference to the healthy breast and appearances as before surgery were hoped for in 17% and 7%, respectively.

While the information received by healthcare providers (and especially by plastic surgeons) was important for almost all women, the personal opinion of these healthcare providers about reconstruction had little impact on the decision.

For some 90% the physical appearance was of importance in considerations about choice of reconstructive surgery. Likewise, body image (important in 94%) and feeling attractive (important in 78%) played a role in decision making and more than half of the women (56%) had intensive thoughts about how they will appear to others (Table 1).

There were only small differences in essential aspects of decision making in women who chose autologous tissue as compared to those who chose silicone; however, the structural aspects of decision making cannot be extracted from comparison of each component alone. Therefore, structural equation modelling was applied to elucidate the essential pathways that led to the decision for or against autologous tissue. Figure 1 shows the path diagram. It is apparent that there is only one main path of decision making that starts with thoughts about the procedure in the hospital and is concerned with length of stay and possible complications. If these concerns are strong then counselling by healthcare providers is particularly important and tends to lead to favoring silicone reconstruction. On the other hand, if there are no or little concerns about the hospital stay and complications women tended to decide on their own and favor autologous tissue reconstruction. Analysis revealed only two other but weakly influential paths: one starts from the body image and leads to favoring silicone if the women were greatly concerned about attractiveness and the other starts from the social role and its importance and from the perceived difficulty in fulfilling the social demands that, if deemed substantial by the women, also tended to lead to choosing silicone reconstruction.

In our study, 69% of the patients decided to have reconstruction with autologous tissue, either solely or in combination with silicone and 60% of the patients chose primary reconstruction.

Some studies found a tendency of women favoring silicone implants if they intend to very soon go back to normal life and retain their former body image [13, 43]. On the other hand, autologous reconstruction is considered by others to yield a more satisfying body image. Using one’s own tissue may lead to a natural shape of the breast, the reason why many women choose this method in spite of additional surgery and additional scars [44‐48]. Choosing the DIEP method, patients expected the best natural appearance and a more natural body feeling than with a silicone implant [47].

In 186 patients with either LD, LD + implant, TRAM or expander/implant, the autologous reconstruction was the preferred method and yielded the highest satisfaction despite more complications and additional scars. For autologous reconstruction, given a thorough selection of patients, a high postoperative satisfaction can be achieved [46].

Few authors distinguish between the modes of reconstruction. In one study patients reconstructed with LD methods showed the lowest rates of complications, compared with free TRAM flaps [49]. Comparing the results after TRAM and DIEP reconstruction, the DIEP group suffered less from complications [50].

For 86% of the patients in our study, restoration of the body image was the most important aspect, irrespective of the type of reconstruction. For 90%, natural appearance was important and 76% wanted at least a satisfactory result. These results are consistent with other studies concerning expectations of women with breast cancer facing BR. Feeling normal is the most important wish that women express before BR [13, 24, 25, 28, 51].

According to our own survey, discussion with health-care providers was important for 94% of all patients and 65% of women in a partnership sought the partner’s opinion. Personal expectations and personal feelings, however, had the greatest influence on decision making for BR. On the other hand, comprehensive information and support by healthcare providers could play a mediating role in choosing the method of reconstruction. As has been emphasized, the decision for immediate reconstruction is correlated with younger age and with the surgeon’s recommendation [52].

After a diagnosis of breast cancer and facing the necessity for mastectomy, a woman has to decide upon whether a BR should be done and which method should be applied. In such a stressful situation clear and balanced information by healthcare providers about the pros and cons are of great help. Surgery at a sexually attributed organ can raise special problems for the patient. As our study showed, for most of the women their individual expectations and hopes are decisive and they circle around maintaining an attractive appearance. Women’s own thoughts have priority; partner’s opinion is often asked for but plays no important role in the end. The opinion of friends and other members of family are relatively unimportant.

Concerns about treatment (length of stay in hospital and potential complications) play an important role for some women during the decision process. Although not statistically significant, women choosing autologous tissue BR had less fear of complications. If the patient has few fears in this respect, she tends to decide on her own and in this case prefers autologous tissue reconstruction. Quite understandably, if she expects complications or a prolonged stay in hospital she seeks advice from healthcare providers, which leads in this case to favor silicone implants. In a previous study it was also found that thoughts about complications are of great importance during decision making [53]. It also has been shown that the decision for the type of reconstruction is correlated with patient participation in decision making and information from healthcare providers [38].

The decision for or against reconstruction, for the mode and timing of surgery is strongly influenced by information from healthcare providers; however, based on this information women decided on their own at least when they considered the procedure as relatively safe. Earlier studies underline the importance of information especially for autologous tissue reconstruction [24, 25, 38, 44, 52, 54, 55]. It has also been emphasized that the mental situation for decisions concerning surgery affords informational support [5, 28, 32, 56‐59]; however, technical possibilities and optimal solutions for the women concerned are not always the focus of counselling but preferences and practices of the clinic and the personal opinion and expertise of the surgeons [14, 24, 25, 44, 52, 56, 60].

Although the limited number of patients included in this study prohibits far-reaching conclusions, the strength of this study is its focus on patients of a single department avoiding too much heterogeneity in treatment, information provided to the women and the counselling process. On the other hand, restricting the analysis to women treated at a single center may limit generalizability, although structural relationships can be less affected by the sample chosen; however, the fact that in Austria BR is fully covered by the mandatory general health insurance will make the results less applicable to regions where costs for BR could be a relevant obstacle for the choice. The limited sample size also prohibited conclusions about the tissue chosen for autologous tissue BR. Furthermore, the women in our study were comparatively young and predominantly in a partnership, limiting conclusions about older or single women. This study focused on the decision process from the perspective of the woman, including the views of family members. Our study was retrospective, which could introduce bias as in hindsight the view on the decision process could have been changed by the outcome. Another limitation is the lower participation rate than expected. As nonparticipants did not differ according to type of BR and age, and reason for nonparticipation was likely unrelated to the outcome of BR, it might be assumed that no substantial bias was introduced from the imperfect participation rate.

Personal expectations determine the decision-making process of women with breast cancer concerning BR. Consultations with healthcare providers are of great importance in particular if there are concerns of the women about complications and length of stay in hospital. Providing detailed information about the options and consideration of the individual’s medical, social and personal situation are important, while the personal opinion of the medical staff is of little help to the women.