January 12, 2016
A study by researchers at the University of North Carolina at Chapel Hill Lineberger Comprehensive Cancer Center and their collaborators has called for the provision of better information about the pros and cons of breast reconstructive surgery to breast cancer patients who undergo mastectomy.
In a study published in the journal Annals of Surgery, researchers report that breast cancer patients surveyed about their knowledge of breast reconstruction were informed only moderately about the procedure, and their knowledge of complications was low.
Michael Pignone, MD, MPH, adjunct professor of health behavior at the UNC Gillings School of Global Public Health, professor of medicine in the UNC School of Medicine and UNC Lineberger member, is one of the study’s co-authors.
“Breast reconstructive surgery can help a breast cancer survivor feel more whole and recover from the surgery,” said Clara Lee, MD, a UNC Lineberger member and associate professor in the UNC School of Medicine’s Division of Plastic and Reconstructive Surgery. “It has a great potential benefit, but it has to be considered alongside the disadvantages, including the risks of complications. [O]ur general conclusion after this study is not that breast reconstruction is good or bad, but that patients don’t fully understand it, and we need ways to improve that.”
Breast reconstructive surgery is an option for women who have had one or both breasts surgically removed through mastectomy. The number of early-stage breast cancer patients choosing post-mastectomy reconstruction rose to 36.4 percent in 2011, but studies also have pointed to variation in reconstruction rates by race, issues of regret about the decision, and gaps in discussions between women and their providers about the procedure. One study found that as many as 47 percent of women surveyed reported regret about their decision.
Lee said women should know about both risks and benefits of breast reconstruction surgery whether or not they plan to undergo it. Complications from breast reconstructive surgery can include issues with wound healing or infection, swelling, and flap or implant complications. In some cases, complications can delay cancer treatment.
“The decision about breast reconstruction is a type of medical decision that we call ‘preference-sensitive,’ in that the best or right choice depends mostly upon patient preference,” Lee said. “For these types of decisions, whether or not it was a ‘good’ decision is whether or not the decision was informed, and whether or not the treatment matches what the patient prefers.”
In the study, researchers surveyed 126 breast cancer patients planning to undergo mastectomy at the N.C. Cancer Hospital. They surveyed both women who planned to undergo reconstructive surgery after mastectomy and women who did not. Women were asked to answer general-knowledge questions about reconstructive surgery as well as a question about complication risk.
Researchers found that the average knowledge score about breast reconstruction was 58.5 percent, which Lee called a “moderate” level of knowledge. Seventy percent of participants answered at least 50 percent of the questions correctly.
“Patients should have a score of at least 50 percent, which means they know at least half of the important facts,” Lee said. “By that metric, patients did OK – but I do think that’s a pretty low bar for surgery that’s purely optional.”
Some patients completed the survey before seeing a plastic surgeon and some completed it after. While the study found that overall knowledge among women who completed the survey before seeing a plastic surgeon was higher, it was not statistically significant.
Only 14.3 percent of women correctly answered a question about the risk of major complications, a number that researchers said reflected “low” knowledge about potential surgical complications of reconstruction.
The survey also found that most participants (92 percent) discussed breast reconstruction with their providers, but more women (60 percent) reported only discussing the advantages than also discussed the disadvantages (27.8 percent).
The researchers call for an intervention that could help women better make the important decision about reconstructive surgery.
“I really care about making the lives of cancer patients better,” Lee said. “A critical part of that is helping them to make good choices. I [also] have a very strong passion for fairness in surgery and in medicine. People who value treatment should get it, and people who don’t actually want it, or really are worried about complications for elective procedures, shouldn’t have it.”
The study was supported by the National Institutes of Health, a UNC Lineberger Comprehensive Cancer Center Population Sciences Cancer Research Award and a NC TraCS Institute 50K Pilot Award.
In addition to Lee and Pignone, other authors include Peter Anthony Ubel, MD, Department of Marketing, Fuqua School of Business, Duke University; Allison Deal, MS, Lineberger Comprehensive Cancer Center Biostatistics Core Facility; Lillian Burdick Blizard, BA, Lineberger Comprehensive Cancer Center; Karen R. Sepucha, PhD, Department of Medicine, Massachusetts General Hospital. Department of Medicine, Harvard Medical School; and David W. Ollila, MD, Department of Surgery, School of Medicine, Lineberger Comprehensive Cancer Center.