Abstract P3-14-10: Shared decision-making approach in breast reconstruction in a developing country
Authors: Maciel-Miranda A , Gutierrez-Zacarias LM , Cabrera-Galeana PA , Bargallo-Rocha E 
Published: March 2017

Background

In Mexico breast cancer is the leading cause of cancer mortality in women.

The goal of reconstruction is restoration of patient's quality of life after cancer, including concerns about body image, sexuality, self-esteem and social life. Reconstruction is one of the most important determinants of long-term health.

Autologous reconstruction has been found to offer a better satisfaction in the long term, even these findings, a paradigm shift toward implant reconstruction has been described previously.

Shared decision making (SDM) is a collaborative process that allows patients and their providers to make health care decisions together. It takes into account the best clinical evidence available, as well as the patient's values and preferences. In medical treatments where several options have been found, SDM has been a useful tool, increasing patient's satisfaction and better outcomes. Through this process of informing and involving the patient, high-quality decisions that align with patient preferences are achievable.

Methods

Evaluation of particular case was made, with personalized approach depending on breast cancer stage and mastectomy type planned. On first consultation basic information about different techniques was offered: pros and cons on surgical time, recovery time, long term complications, sensation and physical appearence. We offered a second consultation if the patient wanted to go deeper in the information we presented, or even is she wanted to look out for more information on the internet and other sources. When an abdominal free flap was planned, we saw the patient in a second consultation to review the CT-angio, and to establish the definitive flap option.

For risk estimation we used www.brascore.org website, and talk about it with the patient. Then patient and plastic surgeon made decision on breast reconstruction technique. BREAST-Q questionnaries were applied in pre and postoperative setting.

Results

From 06/2014 to 06/2016 we performed 150 breast reconstructions with this SDM approach with the following techniques: 64% expander, 15% direct to implant, 11% DIEP flap, 6% lattisimus dorsi flap, 3% Becker implant, 1% TRAM flap.

BREAST-Q questionnaries showed 100% think breast reconstruction is better than do not reconstruct, and 100% would recommend reconstructive surgery. 91.7% felt included in the decision process. Satisfaction with breast (preoperative vs postoperative) 66.21 vs 81.13, Satisfaction with outcome 85.06, Psychosocial well being 80.75 vs 88.35, Physical well-being 74.92 vs 68.73, Sexual well-being 66.66 vs 72.84, Satisfaction with information 86.86, Satisfaction with surgeon 98.73, Satisfaction with medical staff 96.2.

Analysis

Implant based reconstruction (82%) was prefered due to: simplicity, less overall risk, and giving more importance to cancer treatment and leaving reconstruction in second place. It could also be a short-term vision regarding benefits, in spite of shared information.

Aesthetic improvement of the abdominal area seems to be a factor to decide for autologous abdominal flap among young adult women (7%).

Possibility of pregnancy should be considered among young women. In our breast reconstruction program for young women with breast cancer, egg preservation is offered, so abdominal flaps should be delayed after a possible pregnancy.

Conclusions

We need to encourage SDM in breast reconstruction. We need information systems available to patients prior to breast reconstruction like educational meetings, giving healthcare professionals feedback, giving healthcare professionals learning materials, and using patient decision aids.

Shared decisions leads to better outcomes and high patient's satisfaction in breast reconstruction.

Citation Format: Maciel-Miranda A, Gutierrez-Zacarias LM, Cabrera-Galeana PA, Bargallo-Rocha E. Shared decision-making approach in breast reconstruction in a developing country [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-14-10.