The article summarizes the available evidence regarding clinical decision making in breast reconstruction from the patient perspective of satisfaction and health-related quality of life. A review of generic and specific patient reported outcome measures is provided. Important components of breast reconstruction care are compared, such as timing of reconstruction, autologous and implant-based reconstruction, and the use of nipple-sparing and skin-sparing mastectomy. This evidence-based summary will be useful to guide clinicians when discussing breast reconstruction with their patients.
Key points
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Both immediate and delayed breast reconstruction patients experience increased satisfaction and quality of life after reconstruction, and both groups have reported similar satisfaction and quality of life scores at long-term follow-up.
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Autologous reconstruction demonstrates superior patient-reported outcomes over the long-term follow-up period when compared with implant-based reconstruction.
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Silicone implant reconstruction is associated with superior satisfaction and quality of life when compared with saline implant reconstruction.
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Nipple-sparing mastectomy with immediate breast reconstruction is associated with increased satisfaction and quality of life compared with skin-sparing mastectomy with immediate reconstruction.
Patient-reported outcome measures
The goal of reconstruction in plastic surgery is to restore form and function, and how close one comes to achieving this goal must be understood from the patients’ perspective. A patient-reported outcome measure (PROM) is such a research instrument that is designed to measure patient satisfaction and quality of life after medical interventions. Because traditional measures are insufficient to capture the benefits of breast reconstruction, the utilization of PROMs has become an important tool to measure the effects of breast reconstruction and allow comparison of different methods of breast reconstruction in a meaningful way from the perspective of the patient.
Patient-Reported Outcome Measures Specific to Breast Reconstruction
Four PROMs (BREAST Q, Breast Reconstruction Satisfaction Questionnaire [BRECON-31], Michigan Breast Reconstruction Outcomes Study [MBROS], European Organization for Research and Treatment of Cancer Quality of Life Breast Reconstruction [EORTC QLQ-BRR26] questionnaire) are specific to breast reconstruction. They have been developed to specifically measure the quality-of-life domains most affected by breast reconstruction and are discussed in more detail in the following sections.
BREAST Q
The BREAST-Q is a preoperative and postoperative measure of patient satisfaction and quality of life for reconstructive and cosmetic breast surgery patients. This questionnaire is designed and validated following international patient-reported outcome measure guidelines. There are 3 quality of life domains (physical, psychosocial, and sexual well-being), and 3 satisfaction domains (satisfaction with breasts, overall outcome, and process of care). Because of its robust methodology, validation across different populations, ability to capture many of the nuances of different types of breast surgery, and widespread use, the BREAST-Q has contributed significantly to the evidence base that assists clinicians and patients with making well-informed decisions around breast reconstruction.
Breast Reconstruction Satisfaction Questionnaire
BRECON-31 is a breast-reconstruction specific questionnaire that assesses 8 domains: self-image, arm concerns, intimacy, satisfaction,recovery, self-consciousness, expectations, and appearance. There are 2 additional domains if relevant: nipple and abdomen. Development of this questionnaire began shortly after the BREAST-Q by a different group of investigators. The methodology differs from the BREAST-Q, but its development is equally robust and evidence-based. The BRECON-31 and the BREAST-Q demonstrate good-to-excellent correlation.
Michigan Breast Reconstruction Outcomes Study
MBROS aimed to systematically assess the influence of type and timing of reconstruction on patient satisfaction and body image. Included in the battery of questionnaires were 2 generic quality-of-life instruments (the 36-item short-form health survey [SF-36] and FACT-B), as well as 2 condition-specific instruments designed by the authors to assess body image and satisfaction related to breast reconstructive procedures. At the time of development, there were no other breast reconstruction-specific PROMs. However, development did not follow international guidelines, and its development was limited to implant-based and pedicled/free TRAM reconstructive techniques.
European Organization for Research and Treatment of Cancer Quality of Life Breast Reconstruction questionnaire
There is a new breast reconstruction-specific PROM being developed by the European Organization for Research and Treatment of Cancer to be used alongside the other EORTC breast cancer instruments. This instrument is being developed among breast cancer patients specifically, in contrast to the BREAST-Q, which includes all breast surgery patients. The EORTC QLQ-BRR26 has completed phase 3 development, and the results of multinational psychometric evaluation are pending. It will be interesting to learn how this instrument will contribute to the evidence base.
Generic Patient-Reported Outcome Measures Used Among Breast Reconstruction Patients
A generic PROM is a tool that has been developed to measure a concept (eg, general satisfaction, anxiety/depression, or body image) across several different populations or contexts. The main disadvantage is that a generic PROM may not discriminate among issues that are pertinent to a specific population, or capture specific changes related to an intervention. For example, issues that pertain specifically to the breast reconstruction patient such as sexuality, recovery from surgery, or satisfaction with appearance and physical well-being of the breast and abdomen may not be comprehensively captured by a generic PROM. However, an advantage that promotes the ongoing use of generic PROMs is that they allow comparison of similar concepts across different patient populations. Korus and colleagues recently evaluated the use of generic PROMs among breast reconstruction patients and found that generic PROMs still predominate in the breast reconstruction literature. The authors identified 4 generic PROMs most commonly reported: SF-36, the Hospital Anxiety and Depression Scale (HADS), the Rosenberg Self-Esteem Scale, and the Hopwood Body Image Scale (HBIS). The SF-36 was able to detect changes reliably from preoperative to postoperative periods among social function, emotional role, mental health, and general health domains among breast reconstruction patients across many studies. The other generic PROMs were inconsistent in their ability detect changes in health status among breast reconstruction patients.
Patient-reported outcome measures
The goal of reconstruction in plastic surgery is to restore form and function, and how close one comes to achieving this goal must be understood from the patients’ perspective. A patient-reported outcome measure (PROM) is such a research instrument that is designed to measure patient satisfaction and quality of life after medical interventions. Because traditional measures are insufficient to capture the benefits of breast reconstruction, the utilization of PROMs has become an important tool to measure the effects of breast reconstruction and allow comparison of different methods of breast reconstruction in a meaningful way from the perspective of the patient.
Patient-Reported Outcome Measures Specific to Breast Reconstruction
Four PROMs (BREAST Q, Breast Reconstruction Satisfaction Questionnaire [BRECON-31], Michigan Breast Reconstruction Outcomes Study [MBROS], European Organization for Research and Treatment of Cancer Quality of Life Breast Reconstruction [EORTC QLQ-BRR26] questionnaire) are specific to breast reconstruction. They have been developed to specifically measure the quality-of-life domains most affected by breast reconstruction and are discussed in more detail in the following sections.
BREAST Q
The BREAST-Q is a preoperative and postoperative measure of patient satisfaction and quality of life for reconstructive and cosmetic breast surgery patients. This questionnaire is designed and validated following international patient-reported outcome measure guidelines. There are 3 quality of life domains (physical, psychosocial, and sexual well-being), and 3 satisfaction domains (satisfaction with breasts, overall outcome, and process of care). Because of its robust methodology, validation across different populations, ability to capture many of the nuances of different types of breast surgery, and widespread use, the BREAST-Q has contributed significantly to the evidence base that assists clinicians and patients with making well-informed decisions around breast reconstruction.
Breast Reconstruction Satisfaction Questionnaire
BRECON-31 is a breast-reconstruction specific questionnaire that assesses 8 domains: self-image, arm concerns, intimacy, satisfaction,recovery, self-consciousness, expectations, and appearance. There are 2 additional domains if relevant: nipple and abdomen. Development of this questionnaire began shortly after the BREAST-Q by a different group of investigators. The methodology differs from the BREAST-Q, but its development is equally robust and evidence-based. The BRECON-31 and the BREAST-Q demonstrate good-to-excellent correlation.
Michigan Breast Reconstruction Outcomes Study
MBROS aimed to systematically assess the influence of type and timing of reconstruction on patient satisfaction and body image. Included in the battery of questionnaires were 2 generic quality-of-life instruments (the 36-item short-form health survey [SF-36] and FACT-B), as well as 2 condition-specific instruments designed by the authors to assess body image and satisfaction related to breast reconstructive procedures. At the time of development, there were no other breast reconstruction-specific PROMs. However, development did not follow international guidelines, and its development was limited to implant-based and pedicled/free TRAM reconstructive techniques.
European Organization for Research and Treatment of Cancer Quality of Life Breast Reconstruction questionnaire
There is a new breast reconstruction-specific PROM being developed by the European Organization for Research and Treatment of Cancer to be used alongside the other EORTC breast cancer instruments. This instrument is being developed among breast cancer patients specifically, in contrast to the BREAST-Q, which includes all breast surgery patients. The EORTC QLQ-BRR26 has completed phase 3 development, and the results of multinational psychometric evaluation are pending. It will be interesting to learn how this instrument will contribute to the evidence base.
Generic Patient-Reported Outcome Measures Used Among Breast Reconstruction Patients
A generic PROM is a tool that has been developed to measure a concept (eg, general satisfaction, anxiety/depression, or body image) across several different populations or contexts. The main disadvantage is that a generic PROM may not discriminate among issues that are pertinent to a specific population, or capture specific changes related to an intervention. For example, issues that pertain specifically to the breast reconstruction patient such as sexuality, recovery from surgery, or satisfaction with appearance and physical well-being of the breast and abdomen may not be comprehensively captured by a generic PROM. However, an advantage that promotes the ongoing use of generic PROMs is that they allow comparison of similar concepts across different patient populations. Korus and colleagues recently evaluated the use of generic PROMs among breast reconstruction patients and found that generic PROMs still predominate in the breast reconstruction literature. The authors identified 4 generic PROMs most commonly reported: SF-36, the Hospital Anxiety and Depression Scale (HADS), the Rosenberg Self-Esteem Scale, and the Hopwood Body Image Scale (HBIS). The SF-36 was able to detect changes reliably from preoperative to postoperative periods among social function, emotional role, mental health, and general health domains among breast reconstruction patients across many studies. The other generic PROMs were inconsistent in their ability detect changes in health status among breast reconstruction patients.
Evidence-based review of patient reported outcome measures after breast reconstruction
Timing of Breast Reconstruction
Both immediate and delayed breast reconstruction patients experience increased satisfaction and quality of life after reconstruction, and both groups report similar satisfaction and quality-of-life scores at long-term follow-up. However, patients undergoing immediate breast reconstruction may be protected from a period of decreased satisfaction and quality of life associated with the mastectomy defect in a delayed reconstruction patient.
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