Shared decision-making: applying a person-centered approach to tailored breast reconstruction information provides high satisfaction across a variety of breast reconstruction options.

BACKGROUND: A person-centered approach to co-decision-making using tailored information respects each woman's preferences and may heighten breast reconstruction satisfaction. METHODS: Women seeking breast reconstruction underwent initial and follow-up consultations wherein suitable options were discussed, and take-away material, balanced website links, and access to a nurse specialist and peer volunteers was provided. After reconstruction, the BRECON-31(©) was administered and analyzed in three groups: autologous, alloplastic, and latissimus dorsi (LD)/implant. BRECON-31(©) subscale scores were compared between the groups, and multiple regression used to determine if the type of reconstruction independently predicted satisfaction. RESULTS: One hundred twenty three of 176 (70%) women completed the questionnaire (43% autologous, 47% alloplastic, and 10% LD/implant reconstructions). The LD/implant group had a low rate of immediate reconstruction (8.3%, P = 0.04), and the highest rate of chemotherapy (91.7%, P = 0.002) and radiation (100%, P = 0.003). The alloplastic group had a high rate of bilateral reconstruction (86.8%, P = 0.01). All groups scored well on the self-image, arm concerns, intimacy, satisfaction, and expectations subscales. All groups scored moderately on the self-consciousness, appearance, and nipple subscales. The autologous group scored the lowest on recovery (51 vs. 68 and 65, P < 0.0001) and only moderately well on the abdomen subscale (67). Multiple regression analysis showed that satisfaction was not driven by type of reconstruction (P > 0.05). CONCLUSION: High satisfaction can be achieved using a person-centered approach by providing detailed information, appreciating each woman's unique features, and tailoring the reconstruction plan to the individual. Recovery remains a particular challenge, especially for women undergoing autologous reconstruction.

The breast reconstruction satisfaction questionnaire (BRECON-31): an affirmative analysis.

OBJECTIVE: To verify the subscale structure of the BRECON-31 using a test sample of women naïve to the questionnaire. METHODS: The BRECON-31 was administered to women following breast reconstruction. Their responses were subjected to principal components analysis (PCA) with a varimax rotation. Components were maintained with an Eigenvalue greater than one. Internal consistency reliability was measured with Cronbach's Alpha (CA). Components on the test pool analysis were then compared with the subscales developed on 128 women who completed the questionnaire during the development phase. RESULTS: Fifty women completed the BRECON-31. Development and test pools of women were similar across demographics, pathology, and surgical details, except the development sample was somewhat older (53 yo vs. 49 yo, P = 0.02). Using PCA, eight subscales again emerged: self-image, arm concerns, intimacy, satisfaction, recovery, self-consciousness, expectations, and breast appearance. A nipple, and abdominal strength and appearance subscales also emerged. Forty-one of the 45 items loaded similarly in the development and test pools. Internal consistency reliability was high, with CA in the test pool equaling or exceeding CA in the development pool in the majority of the subscales. CONCLUSIONS: The BRECON-31 factor structure identified in the development pool was supported by the test pool, with similar reliability.

Development of a breast reconstruction satisfaction questionnaire (BRECON-31): principal components analysis and clinimetric properties.

BACKGROUND: A reliable, valid questionnaire is essential to assess patient satisfaction with breast reconstruction. METHODS: A 105-item pilot BRECON questionnaire was previously developed. One hundred eighty-one women with breast reconstruction were mailed the pilot BRECON, BREAST-Q, and EQ-5D questionnaires. Fifty women were re-mailed the BRECON. Based on the responses, the BRECON was refined using statistical means and principal components analysis (PCA). Reliability was assessed using the intraclass correlation coefficient (ICC) and Cronbach's alpha. Validity was assessed by comparing subscales of the BRECON to the BREAST-Q and comparing a summary score of the BRECON-31 to the EQ-5D using the Pearson's correlation coefficient (PCC). RESULTS: A total of 71% (128/181) of women completed the three questionnaires, and 86% (43/50) of women responded to the re-mailed BRECON. Statistical methods and PCA maintained 31 items covering eight components including self-image, arm concerns, intimacy, satisfaction, recovery, self-consciousness, expectations, and breast appearance. A 4-item "nipple" subscale and a 10-item "abdominal" subscale were developed for use where applicable. Measures of reliability and validity were high: Cronbach's alpha ranged from 0.67 to 0.91, ICC ranged from 0.55 to 0.85, and PCC ranged from 0.42 to 0.76. CONCLUSIONS: A reliable, valid 31-item breast reconstruction satisfaction questionnaire was developed.

Development of a breast reconstruction satisfaction questionnaire (BRECON): dimensionality and clinical importance of breast symptoms, donor site issues, patient expectations, and relationships.

OBJECTIVES: To develop a valid, reliable and responsive, self-administered questionnaire to assess women's satisfaction with breast reconstruction. METHODS: Item generation: Three sources for item inventory were utilized: focus groups, expert panel, and literature review.Item reduction: Item impact scores were derived from patients and experts each ranking the importance and frequency of each item. Correlation between patient and expert scores was calculated. The highest impact questions were maintained. RESULTS: Four focus groups comprising 20 women generated 515 items, 10 experts developed 171 items, and literature review produced 227 items. These 913 potential items were reduced to 183 by combining redundancy. The 183 items underwent formal reduction by assessing importance and frequency of each item. Thirty-two of 40 reconstructed women and 19 of 19 experts responded to the mail-out. Seventy-seven items of the women's top 100 also made the experts' top 100 list. Intraclass correlation between patients and experts was 0.71 [0.62 0.77], indicating "good" but not "excellent" agreement, reinforcing the importance of patient involvement in questionnaire development. Women rated abdominal donor site issues higher than experts, and experts rated breast softness and symmetry higher than women. CONCLUSIONS: A 100-item pilot questionnaire for breast reconstruction satisfaction was developed for psychometric testing.

Sensibility following innervated free TRAM flap for breast reconstruction: Part II. Innervation improves patient-rated quality of life.

BACKGROUND: Restoring sensory innervation may be a useful adjunct in free flap head and neck reconstruction but, as yet, has not been shown to improve outcomes of breast reconstruction. The authors' previous study demonstrated objectively improved sensation in a group of innervated transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction patients relative to noninnervated flaps. This study compared patient-rated outcomes of free TRAM breast reconstruction in innervated versus noninnervated flaps. METHODS: Twenty-seven women were randomized prospectively to undergo either innervated or noninnervated free TRAM flap breast reconstruction. For innervated flaps, the T10 intercostal nerve was harvested with the TRAM flap and neurotized to the T4 sensory nerve at the recipient site. Three validated outcome tools were administered after surgery: the Medical Outcomes Study 36-Item Short Form Health Survey, the Body Image after Breast Cancer Questionnaire, and the Functional Assessment of Cancer Therapy-Breast. Results were correlated with previously reported objective sensibility outcomes. RESULTS: Eighteen of 27 women returned their questionnaires a mean 48 months after free TRAM flap reconstruction. Demographic analysis revealed no significant differences in patient age, height, smoking, radiation therapy, and nipple-areola complex reconstruction between randomized patient groups. There was a statistically significant improvement in all three measures in patients who were randomized to receive innervated free TRAM flaps compared with those receiving noninnervated flaps. CONCLUSION: This study demonstrates that innervation of free TRAM flaps used for breast reconstruction not only improves sensibility but also has a positive effect on patient-rated quality of life.

Telephone contact intervention in women undergoing treatment for breast cancer.

The chemotherapy received by breast cancer patients is complicated by many side effects. At our centre, a health care professional is accessible at all times, yet we hypothesize that most breast cancer patients suffer in silence rather than phone for assistance. This study sought to assess the value of and perceived need for a telephone call to breast cancer patients following the initiation of chemotherapy. The women's side effects were also documented, and the level to which they were educated about symptoms to expect and available assistance was evaluated. Overall, the weekend calls were well received because they provided information and support to the patients. It was determined that further research is required to determine if and how such a call should be best implemented at our cancer centre.

Sensibility following innervated free TRAM flap for breast reconstruction.

BACKGROUND: The free transverse rectus abdominis musculocutaneous (TRAM) flap has proven to be a reliable means of recreating the aesthetic breast form after mastectomy. The purpose of this study was to determine whether neurotization of the free TRAM flap improved sensation of the reconstructed breast. METHODS: Twenty-seven patients undergoing 37 free TRAM flap reconstructions were randomized to receive either an innervated (12 patients, 18 breasts) or a noninnervated flap (15 patients, 19 breasts). A nerve repair between the T10 intercostal of the TRAM flap and the anterior sensory branch of the fourth intercostal nerve was performed for innervation. Sensory testing (Semmes-Weinstein monofilaments, hot-cold discrimination, two-point discrimination) was performed by one blinded examiner in a standardized pattern. RESULTS: Mean follow-up was 16 months. Demographic analysis revealed no significant differences in patient age, height, smoking, radiation therapy, and nipple-areola reconstruction between patient groups (p > 0.3). Patients in the noninnervated group, however, were heavier (p = 0.03). Preoperative sensation was not significantly different in the noninnervated and innervated groups. Postoperative pressure threshold and temperature discrimination were significantly improved in the innervated flaps (p < 0.05). Noninnervated flaps displayed a pattern of increasing sensibility from the center toward the periphery while innervated flaps regained sensation throughout. CONCLUSIONS: Innervation of the free TRAM flap provides improved sensation to the reconstructed breast and is a simple adjunct to breast reconstruction.