New decision-making tool offers breast reconstruction options post cancer surgery

A computer-based decision-making aid may make it possible for more women to have breast reconstruction after surgical treatment for cancer. The tool has helped women play a larger role in decision-making, according to results from a new study reported at the 2009 Clinical Congress of the American College of Surgeons.

Women who used the computer-based learning module were more involved in choosing reconstruction than those who did not, and they believed they were offered a greater number of options for breast reconstruction. The study was conducted at Beth Israel Deaconess Medical Center and Harvard Medical School, both in Boston, MA.

Nearly three-quarters of 168 women who had access to the decision-making aid reported they were solely or mostly responsible for choosing breast reconstruction compared with a little over half of 87 women who did not use the tool. The women also retained more information and were more satisfied with the amount of information they received. Four times more women reported they had learned about four types of reconstruction if they had seen the computer-based learning module (24 percent) than those who had not (six percent). Eighty-four percent of women who used the tool were very satisfied compared with 75 percent of those who did not, according to Bernard T. Lee, MD, FACS, an instructor in plastic surgery, Beth Israel Deaconess Medical Center and Harvard Medical School.

The computer-based decision aid explains each of five breast reconstruction options, presents data on outcomes from the clinical literature, and includes pictures and diagrams. "It talks about what the surgery is like, the postoperative recovery, and the different stages of the operation. It is very comprehensive, almost encyclopedic, but in a very user-friendly sort of format," Dr. Lee said.

The decision-making tool was given to patients in the form of a compact disc (CD) so they could view the information at home in privacy and at their leisure. "When patients are sitting in your office and you're going through a consultation with them, they may absorb only 10 percent or 20 percent of what you're talking about. However, if you offer patients one of these computer aids, they can sit at home in front of a computer, pop in the CD, and go back and forth to look at all the available pictures and information. There is no major rush," Dr. Lee said.

Use of the CD was not tested in physicians' offices. However, it could be a valuable adjunct to the education of patients following an operation for breast cancer. Patients that did not view the CD at home were also shown the presentation in the office prior to the standard consultation. These patients found it to be a valuable educational tool in presenting the different choices in breast reconstruction. "Nowadays, it becomes difficult to spend a lot of time with patients explaining things to them during surgical consultations. We haven't looked at this [scenario] yet, but if you have a good framework for discussing the questions with patients, you could potentially reduce the time that you need to spend with patients but still increase their understanding of the problem," Dr. Lee said.

The underlying hope is to increase the number of women who have breast reconstruct-tion. Even though improvements in body image and self-esteem have been well documented following breast reconstruction, only about 20 percent of women undergo the procedure. A major reason is the lack of referrals for consultation about breast reconstruction.

In another new separate study reported at the ACS Clinical Congress, 92 percent of 313 patients who were referred for consultation underwent breast reconstruction. None of the 158 patients who were not referred had reconstructive surgery. "Patients who are being referred are much more likely to be reconstructed. If they aren't referred, the patients are not taking it upon themselves to find out about breast reconstruction. Patients should be given that option," said Beth Aviva Preminger, MD, MPH, an instructor in plastic surgery at Columbia University who conducted the study under the direction of Christine Rhode, MD, from New York Presbyterian Hospital, New York City.

The study emphasized the role of the breast surgeon as the gatekeeper for breast recon-struction procedures, Dr. Preminger said. "The breast surgeon is there for the treatment of cancer. The focus is obviously on getting the cancer out and treating the patients until they get well. Appropriately so. The question is whether breast surgeons are spending enough time discussing reconstruction with the patient, and if they're not, are they sending every patient to a plastic surgeon to be evaluated? Because breast surgeons do not necessarily always know who is or who isn't a good candidate for reconstruction," she added.

An emerging standard of care is to perform breast reconstruction immediately after cancer treatment so the patient can be spared another operation. "Patients can wake up from the operation thinking they have started on the way to recovery. But there are some instances when the patient is not a candidate for immediate reconstruction. These are issues that a plastic surgeon should have the opportunity to discuss with the patient. Our study underlines to general surgeons--breast surgeons in particular--the importance of sending patients to a plastic surgeon so patients can have that conversation and understand what their options are," Dr. Preminger explained.

The study also has a message for patients. "Patients need to be advocates for their own care. They need to ask for a referral if they are not getting one, so they make an informed decision about their care," she concluded.

Chen Chen, MD; Janet H. Yueh, MD; Minh-Doan Nguyen, MD, PhD; and Adam M. Tobias, MD, participated in the study of the computer-based decision-making aid.