For African American patients undergoing mastectomy, the risk of complications and the postoperative appearance of the breast are among the important drivers of preferences about breast reconstruction, according to a new report published by Shammas et al in Plastic and Reconstructive Surgery.
"Especially in light of policies emphasizing shared decision-making between patients and physicians, our findings highlight the need for tools to elicit treatment preferences and the importance of discussing treatment goals and preferences," commented lead author Ronnie L. Shammas, MD, MPH, of Memorial Sloan Kettering Cancer Center. The study's senior author is Clara N. Lee, MD, MPP, of the University of North Carolina.
ACBC Analysis
In the new study, investigators used an interactive method called adaptive choice-based conjoint (ACBC) analysis to elicit individual-level treatment preferences for breast reconstruction care. The ACBC tool presented patients with information on expected outcomes and potential risks of implant-based breast reconstruction or autologous reconstruction using the patient’s own tissues. Autologous reconstruction, which uses a flap of tissue from the patient's abdomen, has implications for recovery time and complication risks.
The survey included actual patient photos to help patients understand the expected outcomes of reconstruction, including possible scarring as well as the appearance of the reconstructed breast. ACBC analysis provided a means of ranking the personal values and trade-offs influencing patients’ reconstruction preferences. The study included 181 African American women undergoing mastectomy for breast cancer treatment or for prevention in patients at high genetic risk of breast cancer.
"We hope that this method can translate to the improved communication of patient values to the physician, and better inform a shared treatment decision," Dr. Shammas explained.
Results
The results showed that the risk of major complications was the most important factor affecting preferences about breast reconstruction, with an average relative importance of 26% on ACBC analysis. For the appearance of the reconstructed breast, relative importance was 15%. Other significant factors included the need for additional surgeries, the potential impact of flap reconstruction on abdominal appearance and function, and recovery time.
After considering all of these factors, 85% of women expressed a preference for implant-based reconstruction. Patients with better health status and no previous complications were more likely to opt for implant reconstruction. Patients undergoing preventive mastectomy were also more likely to choose implants.
The remaining 15% of women opted for autologous reconstruction. In this group, one-fourth of patients said they preferred the appearance of the breast after flap reconstruction compared to implants. Women choosing flap reconstruction were willing to accept some increase in risks: up to an 8% increase in the risk of major complications and a 6% increase in the risk to abdominal well-being. Above these levels, patients indicated that they would opt for implants instead.
Based on previous studies, about 20% of patients reported inadequate discussions concerning their breast reconstruction options—a rate that may be even higher for non-White women. The new study is one of the first to focus on breast reconstruction among African American women.
The findings suggest that "African American patients prioritize similar considerations as White patients when weighing their reconstructive options," with some differences in relative importance. Two-thirds of women in the study said they found the ACBC exercise "very or extremely helpful" in their decision-making process.
Tools to elicit patient values and treatment preferences such as ACBC analysis can enhance shared decision-making, especially when one treatment is not clearly superior to the other options.
The authors concluded: "The active engagement of patients and purposeful solicitation of values is even more critical in historically marginalized groups who report lower rates of shared decision-making and involvement in treatment decisions."
Disclosure: For full disclosures of the study authors, visit journals.lww.com.
