Development of a New Patient-Reported Outcome Measure for Breast Surgery: The BREAST-Q

I plastic surgery, the development of a reliable, valid, and responsive outcomes questionnaire is an important goal for directing clinical research. In contrast to the other specialties that use mortality as the main outcome tool, plastic surgery relies on assessing quality of life to evaluate the effectiveness of treatments. Although objective outcomes, such as breast volume measurement to assess symmetry, are useful in breast surgery, it may be more revealing to understand patients’ selfassessments of how they feel regarding the effectiveness of their treatments. Researchers are often concerned that outcomes questionnaires suffer from certain biases, such as the desire for patients to respond positively. After all, patients have invested so much in their treatments that naturally they will be reluctant to convey negative impressions of the outcomes. However, if the outcomes tool is constructed carefully, with judicious crafting of the questions and attentive choice of words, outcomes questionnaires can engage the patients to reveal their objective, truthful views of the outcomes, without concern of acquiescent bias in which the respondents feel a need to answer in a certain way. Therefore, a good outcomes questionnaire will need to undergo an extensive number of pilot testings, and the psychometric properties will need to be meticulously evaluated by having perspectives from various representative samples of respondents. Because an outcomes questionnaire is the most practical tool to derive patient-centric data for outcomes research, this field of study will continue to drive the research agenda for plastic surgery, and the data it generates will influence how we treat patients. Despite the wide applicability of outcomes questionnaires, there are a few caveats that need to be considered when applying these questionnaires. There is a general interest among researchers to propose variations of an outcomes instrument. In the early, nascent development of an outcomes questionnaire, there will naturally be a few instruments that will be developed. Some of these instruments will not pass the scrutiny of peer reviews and field trials. Over time, some questionnaires will be abandoned. A few of them, however, will go on to dominate the field due to their qualities. An example of this phenomenon is in the field of hand surgery. Over 15 years ago, hand surgery ushered in the outcomes era for this specialty with the push to develop a universal tool for hand surgery. With an intensive effort supported by various organizations, several outcomes questionnaires were proposed. Over time, the Michigan Hand Outcomes Questionnaire, which was supported by the Robert Wood Johnson Foundation, and the Disability of the Arm Shoulder and Hand, which was supported by the American Academy of Orthopaedic Surgeons, became the dominant outcomes tools in the United States and around the world. These questionnaires have been field tested for over a decade and have been shown to be good instruments for evaluating hand and upper limb outcomes. As expected, despite the applicability of these currently accepted tools, additional questionnaires are being proposed every year that are based on variations of the questions in these existing questionnaires. Should these new questionnaires be better than the currently accepted ones, these new tools should be adopted. Unfortunately, the laborious exercise to propose new hand-related questionnaires does not add much to the literature because they contain similar questions or have too narrow a focus; for example, for application to a particular occupation such as for the office worker. A few years ago, I was asked by a person in Florida whether it is permissible to alter a few questions in the Michigan Hand Outcomes Questionnaire and call this