Patient Preferences for Postmastectomy Breast Reconstruction

Authors: Shammas RL, Hung A, Mullikin A, Sergesketter AR, Lee CN, Reed SD, Fish LJ, Greenup RA, Hollenbeck ST

Affiliation: Duke University; Durham VA Health Care System; The Ohio State University; Yale University; University of Virginia

Journal: JAMA Surgery, December 2023

PMID: 37755818

Background

• 20-40% of patients experience dissatisfaction or decisional regret after breast reconstruction

• Adaptive choice-based conjoint (ACBC) analysis is a survey-based method used in marketing research to determine how consumers value different attributes of a product

• In healthcare, ACBC can theoretically help identify individual-level preferences to promote shared decision-making between patients & clinicians

Objective

Identify which attributes of breast reconstruction matter most to women considering surgery and determine how priorities differ between respondents who prefer flap versus implant-based reconstruction

Methods

• Design: Web-based, cross-sectional study from 2022-2023

• Sample: Of 730 women recruited for the study, only 406 completed the survey (Duke: 105, Love Research Army Registry: 301). Mean age = 55.8 years; 89% were White and 73% married.

• Eligibility: Women with a new diagnosis of or genetic predisposition to breast cancer who presented to Duke for consultation for postmastectomy reconstruction OR women identified through the Love Research Army Registry.

• Exclusion criteria: Age younger than 18 years, metastatic disease, or did not consider undergoing postmastectomy breast reconstruction

• Attributes: Breast appearance, abdominal morbidity (0%, 25%, 50%), recovery (2, 4, 8 weeks), additional operations (1, 2, 3), and major complications (5%, 15%, 30%).

  • Hypothetical Flap scenario: abdominal morbidity risk 25%, recovery time 8 weeks, 1 additional operation, complication risk 30%

  • Hypothetical Implant scenario: abdominal morbidity risk 0%, recovery time 4 weeks, 2 additional operations, complication risk 15%

• Outcomes: Relative importance, part-worth utilities, and maximum acceptable risks.

  

Results

• Most important attribute in decision-making process was risk of abdominal morbidity (RI 28%), followed by risk of major complications (25%), additional operations (23%), breast appearance (13%), & recovery time (11%)

• Most respondents (85%) preferred implant profile --> these respondents most valued abdominal morbidity, risk of complications, & number of additional operations

• Respondents who preferred the flap profile (15%) most valued number of additional operations, breast appearance, & complication risk

• Participants who were married or college educated were more likely to prefer the flap profile, while income over $75,000 was associated with decreased likelihood of choosing flap profile

• Among 344 respondents who preferred the implant profile, 34% actually preferred the flap appearance

  

Conclusion

This study may lay the foundation for decision support tools that can help promote shared decision making in breast reconstruction.

Key takeaways

• Abdominal morbidity, fear of complications, and the need for additional operations were the most important considerations in selecting implant vs flap reconstruction

• Most respondents (85%) preferred the study's implant scenario, largely because of lower modeled abdominal morbidity and complication risk

• Respondents who preferred the flap scenario tended to favor fewer additional operations & flap appearance

Strengths and Limitations

Strengths

• ACBC analysis seeks to examine how women value different aspects of reconstructive care

• Attributes selected in the study were identified by literature review, surgeon input, semi-structured interviews, and cognitive pretesting.

• Two recruitment sources

Limitations

• Self-reported, cross-sectional study with substantial noncompletion

• Predominantly White, upper-middle-class cohort limits generalizability

• Only simplified implant and abdominal-flap scenarios were modeled. Study failed to capture the nuances inherent in real clinical breast reconstruction

• Preferences were hypothetical. Actual choice of reconstruction, patient satisfaction, decisional regret, and clinical outcomes were not tested.

Clinical relevance

This study has limited clinical relevance given its findings were derived from hypothetical scenarios. Real-world decision-making regarding choice of breast reconstruction is highly nuanced. Not all women are in fact candidates for both implant and flap reconstruction due to comorbidities, body habitus, history of radiation, or prior reconstructive history.  While the attributes used in the ACBC were rigorously identified and tested, the authors did not explain where they came up with the hypothetical risks of complications, additional operations, or abdominal morbidity used in their survey.

Editorial notes

It is not surprising that many women preferred a 0% chance of abdominal morbidity with implants compared to a non-zero chance of abdominal morbidity with flap reconstruction.  This study likely significantly over-estimates the “implant preference” and underestimates the risk of reoperation and dissatisfaction with implants. The finding that married & college-educated women were more likely to prefer flap reconstruction but women with higher incomes were less likely to prefer flap reconstruction was contradictory.