Most breast cancer patients undergoing mastectomy are candidates for breast reconstruction. Deciding about breast reconstruction is complex and the preference-sensitive nature of this decision ...requires an approach of shared decision making between patient and doctor. Women considering breast reconstruction have expressed a need for decision support. We developed an online patient decision aid (pDA) to support decision making in women considering immediate breast reconstruction. The primary aim of this study is to assess the impact of the pDA in reducing decisional conflict, and more generally, on the decision-making process and the decision quality. Additionally, we will investigate the pDA's impact on health outcomes, explore predictors, and assess its cost-effectiveness.
A multicenter, two-armed randomized controlled trial (1:1) will be conducted. Women with breast cancer or ductal carcinoma in situ who will undergo a mastectomy and are eligible for immediate breast reconstruction will be invited to participate. The intervention group will receive access to the online pDA, whereas the control group will receive a widely available free information leaflet on breast reconstruction. Participants will complete online questionnaires at: baseline (T0), 1 week after consultation with a plastic surgeon (T1), and 3 (T2) and 12 months (T3) after surgery. The primary outcome is decisional conflict. Secondary outcomes include other measures reflecting the decision-making process and decision quality (e.g., decision regret), patient-reported health outcomes (e.g., satisfaction with the breasts) and costs.
This study will provide evidence about the impact of an online pDA for women who will undergo mastectomy and are deciding about breast reconstruction. It will contribute to the knowledge on how to optimally support women in making this difficult decision.
This study is retrospectively registered at ClinicalTrials.gov ( NCT03791138 ).
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Purpose
The aim of this study was to develop a patient decision aid (pDA) that could support patients with breast cancer (BC) in making an informed decision about breast reconstruction (BR) after ...mastectomy.
Methods
The development included four stages: (i) Establishment of a multidisciplinary team; (ii) Needs assessment consisting of semi‐structured interviews in patients and a survey among healthcare professionals (HCPs); (iii) Creation of content, design and technical system; and (iv) Acceptability and usability testing using a think‐aloud approach in patients and interviews among HCPs and representatives of the Dutch Breast Cancer Patient Organization.
Results
From the needs assessment, three themes were identified: Challenging period to make a decision, Diverse motivations for a personal decision and Information needed to make a decision about BR. HCPs valued the development of a pDA, especially to prepare patients for consultation. The pDA that was developed contained three parts: first, a consultation sheet for oncological breast surgeons to introduce the choice; second, an online tool including an overview of reconstructive options, the pros and cons of each option, information on the consequences of each option for daily life, exercises to clarify personal values and patient stories; and third, a summary sheet with patients’ values, preferences and questions to help inform and guide the discussion between the patient and her plastic surgeon. The pDA was perceived to be informative, helpful and easy to use by patients and HCPs.
Conclusion
Consistent with information needs, a pDA was developed to support patients with BC who consider immediate BR in making an informed decision together with their plastic surgeon.
Patient or Public Contribution
Patients participated in the needs assessment and in acceptability and usability testing.
Breast cancer (BC) patients who are treated with mastectomy are frequently offered immediate breast reconstruction. This study aimed to assess decisional conflict in patients considering immediate ...breast reconstruction, and to identify factors associated with clinically significant decisional conflict (CSDC).
Baseline data of a multicenter randomized controlled trial evaluating the impact of an online decision aid for BC patients considering immediate breast reconstruction after mastectomy were analyzed. Participants completed questionnaires assessing sociodemographic and clinical characteristics, decisional conflict and other patient-reported outcomes related to decision-making such as breast reconstruction preference, knowledge, information resources used, preferred involvement in decision-making, information coping style, and anxiety. Multivariable logistic regression analysis was performed to identify factors associated with CSDC (score > 37.5 on decisional conflict).
Of the 250 participants, 68% experienced CSDC. Patients with a slight preference for breast reconstruction (odds ratio (OR) = 6.19, p < .01), with no preference for or against breast reconstruction (OR = 11.84, p < .01), and with a strong preference for no breast reconstruction (OR = 5.20, p < .05) were more likely to experience CSDC than patients with a strong preference for breast reconstruction. Furthermore, patients with more anxiety were more likely to experience CSDC (OR = 1.03, p = .01).
A majority of BC patients who consider immediate breast reconstruction after mastectomy experience clinically significant decisional conflict. The findings emphasize the need for decision support, especially for patients who do not have a strong preference for breast reconstruction.
•A majority of patients considering immediate breast reconstruction experience decisional conflict.•Patients without a strong preference for breast reconstruction are more likely to experience decisional conflict.•Patients with more anxiety are more likely to experience decisional conflict.
Mastectomy may be needed in the context of previous radiotherapy in cases of breast carcinoma following mantle field radiotherapy for Hodgkin lymphoma or in cases of local relapse or second primary ...tumours after breast conserving therapy including whole-breast irradiation (BCT). The outcome of combined skin-sparing mastectomy and immediate implant-based breast reconstruction (SSM-IIBR) has been reported to be unfavourable in these cases.
To compare the outcome of SSM-IIBR after mantle field radiotherapy to that after BCT and to compare both to the outcome observed in non-irradiated breasts.
The prevalences of short-term events, device loss, long-term corrections and secondary reconstructions, and reversion to autologous tissue techniques of 42 SSM-IIBRs performed after mantle field irradiation were compared to those of 47 salvage SSM-IIBRs following BCT. Both outcomes were compared to the outcome in the contralateral, non-irradiated breast of the subgroup of 23 women in the BCT group.
The groups were comparable in terms of patient- and procedure-related risk factors, except for time lapse after previous therapy, intraoperative device weight, and the fraction of immediate use of a definitive implant. The outcome of SSM-IIBR after mantle field irradiation significantly differs favourably from that after BCT. It matches the outcome observed in non-irradiated breasts.
Skin-sparing mastectomy combined with immediate implant-based breast reconstruction is a fully justifiable option for women who previously underwent mantle field irradiation for Hodgkin lymphoma. We feel that the unfavourable outcome observed in women who previously underwent BCT necessitates an alternative reconstructive modality.
PURPOSE: Breast cancer patients face complex decisions about immediate breast reconstruction (BR) after mastectomy. We evaluated the efficacy of an online decision aid in improving the ...decision-making process, decision quality and health outcomes in breast cancer patients considering immediate BR. METHODS: In a multicenter randomized controlled trial, patients were allocated to either the intervention group receiving care-as-usual (CAU) with access to an online decision aid, or the control group receiving CAU with an information leaflet. The primary outcome was decisional conflict. Secondary outcomes assessed the process of decision making (e.g. preparation for decision making, satisfaction with information), decision quality (decision regret, knowledge) and health outcomes (e.g. satisfaction with BR outcomes, body image). Patients completed questionnaires at baseline (T0), 1 week after consultation with a plastic surgeon (T1), 3 months (T2), and 12 months post-surgery (T3). RESULTS: We included 250 patients. Decisional conflict decreased over time in both groups, with no between group differences. Intervention participants felt better prepared for decision making than controls ( P = .002). At T2, 87% of intervention participants were (very) satisfied with the information about BR, compared to 73% of control participants ( P = .011). No significant between group differences were observed in any other outcome. CONCLUSION: Our online decision aid was as effective in reducing decisional conflict as an information leaflet about immediate BR after mastectomy. However, the decision aid substantially improved the decision-making process by better preparing breast cancer patients for decisions about immediate BR.
Autologous breast reconstructions are increasingly being performed. While increased risks for flap loss after free tissue transfer (FTT) in sickle cell patients are known to most plastic surgeons, ...risks for patients with sickle cell trait (SCT) are less known. Unfortunately, recommendations to prevent complications after FTT in SCT are still scarce. We present additional and novel surgical measures that we took aiming to enhance probabilities for successful FTT in a SCT patient undergoing autologous breast reconstruction. This is only the second case report describing a successful FTT without flap necrosis/loss in a patient with SCT, and the first successful report involving FTT in the breast.
Summary Background Local relapse after breast-conserving therapy including whole breast irradiation is typically treated by salvage mastectomy. Immediate reconstruction by pedicled transfer of a ...latissimus dorsi flap in combination with implantation of a definitive prosthesis or temporary tissue expander following skin sparing salvage mastectomy has been shown to be feasible. However, it has never been shown to be justifiable. Aim The aim of the study was to compare the outcome of this procedure to the widely accepted secondary breast reconstruction by combined latissimus dorsi flap and implant after mastectomy and adjuvant radiotherapy. Methodology The surgical outcome of 93 immediate latissimus dorsi and implant reconstructions after skin-sparing salvage mastectomy performed from 2007 to 2011 after radiotherapy was compared to that of 83 secondary reconstructions with the latissimus dorsi and an implant. The follow-up duration was 3.5 years in both groups. Complications were categorized as minor (conservative treatment sufficed) or major (flap loss, mammary skin loss, implant loss, seroma or haematoma indicating repeat surgery). Results The salvage group scored significantly less on half of the patient-related and procedure-related risk factors. Nevertheless, we observed 27% of short-term major surgical complications and an ultimate success rate of 94% in the salvage group compared to those observed in our series of secondary reconstruction in post-radiation women (27% and 93%, respectively). Conclusion Skin-sparing salvage mastectomy combined with immediate reconstruction by transfer of a latissimus dorsi flap with an implant is a justifiable reconstructive option for women with a recurrence after irradiation as part of breast-conserving therapy.
Objective: Dissection of the latissimus dorsi (LD) flap may have a distinct impact on upper extremity function and strength. To date, insufficient differentiation has been made between loss of ...muscular strength and shoulder function by dissection of the LD muscle per se and loss of function resulting from all excisional surgery, radiation therapy, and reconstructive procedures at the donor site and the recipient site that may have been combined near the shoulder region. Methods: This study determines the long-term effect of the LD breast reconstruction on the strength profiles of the upper extremity by measuring the isometric torque strength both in seven synergistic- and two contra-movement directions. The Biodex System 3 Pro (Biodex Medical Systems, New York, NY) was used in 12 patients at a mean of 3.5 years after surgery, and in 20 matched controls. Because loss of LD muscle may not result in significant impairment of activities of daily live (ADL) even in cases where objective measurements are decreased, this study simultaneously assessed the subjective function by use of the standardised Disability of Arm, Shoulder and Hand (DASH) questionnaire. Results: This study observed a significant long-term loss of 8.8 Nm or 19% LD torque strength in synergistic movement directions after transplantation of the LD muscle. This loss correlated significantly with an increase of the mean DASH score among the patients. Conclusions: Because no significant loss of contra-movement torque strength was observed, it was concluded that the loss of synergistic torque strength appears to result from the loss of LD function per se.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Background
Breast-conserving therapy is defined as a breast-conserving wide local excision (WLE) of a mammary tumour combined with postoperative radiotherapy. Immediate restoration of the mammary ...shape by use of breast reduction techniques (volume displacement) or tissue replacement techniques (volume replacement) is gaining popularity to prevent breast malformation.
Methods
To date, using the internal mammary artery perforator (IMAP) flap has been suggested for immediate volume replacement after WLE, but has never been evaluated in a published study.
Results
We applied this flap in 12 women (mean age, 56.1 years) after WLE (mean specimen weight, 46.5 g) of the medial aspect of the breast. Over a median follow-up of 35.3 months (standard deviation, 1.2 months), 4 women needed repeated surgery for dog-ear correction of the donor site.
Conclusions
In our experience, the use of an IMAP flap was a reliable technique with good cosmetic outcomes after oncoplastic reconstruction. In this series, donor site revision often proved necessary initially, but we showed that this may easily be prevented.
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