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Originally published as Ann Surg Oncol Early Release 10.1245/ASO.2004.11.027 on July 12, 2004

Annals of Surgical Oncology 11:762-771 (2004)
© 2004 Society of Surgical Oncology
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ORIGINAL ARTICLES

Determinants of Patients’ Choice of Reconstruction with Mastectomy for Primary Breast Cancer

P. Ananian, MD, G. Houvenaeghel, MD, C. Protière, PhD, P. Rouanet, MD, S. Arnaud, MD, J.P. Moatti, PhD, A. Tallet, MD, A.C. Braud, MD and C. Julian-Reynier, MD

From Inserm U379 (PA, CP, SA, JPM, CJ-R), Institut Paoli-Calmettes (PA, GH, AT, ACB), Marseilles; Centre Val d’Aurelle (PR), Montpellier; Observatoire Régional de la Santé (SA), Marseilles; and Université de la Méditerranée (JPM), Marseilles, France.

Correspondence: Address correspondence and reprint requests to: Claire Julian-Reynier, MD, INSERM U379, Institut Paoli-Calmettes, 232 Boulevard Sainte Marguerite, 13273 Marseille Cedex 9, France; Fax: 33-491-223-504; E-mail: julian{at}marseille.inserm.fr


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: The aim of the study was to measure women’s decisions about breast reconstruction (BR) after mastectomy and to assess the factors contributing to their decisions, in a context involving shared decision-making and maximum patient autonomy.

Methods: Women who were about to undergo mastectomy for primary breast cancer were systematically offered choices concerning BR and time of reconstruction (intervention always covered by the French National Insurance System). Self-administered questionnaires were used prior to the operation.

Results: Among the 181 respondents, 81% opted for BR and 19% for mastectomy alone. In comparison with those who chose mastectomy alone, those opting for BR more frequently recognized the importance of discussing these matters with the surgeon and their partner (adjusted odds ratio [ORadj] = 13.45 and 3.59, respectively; P < .05) and realized that their body image was important (ORadj = 10.55, P < .01); fears about surgery prevented some of the women from opting for BR (ORadj = 0.688, P < .05). Among the women opting for BR, 83% chose immediate breast reconstruction (IBR) and 17% chose delayed breast reconstruction (DBR). The preference for IBR was mainly attributable to the fact that these women had benefited more frequently from doctor–patient discussions (ORadj = 3.49, P < .05) but was also attributable to the patients’ physical and functional characteristics: they were in a poorer state of health (P < .05). The surgeons predicted their patients’ preferences fairly accurately.

Conclusions: In a context of maximum autonomy, the great majority of the women chose IBR. The patients’ choices were explained mainly by their psychosocial characteristics. The indication for BR should be properly discussed between patients and surgeons before mastectomy.

Key Words: Breast cancer • Mastectomy • Preferences • Reconstruction • Shared decision-making


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
In the treatment of breast cancer, surgery is always the first and foremost way of curing the disease. It has been clearly established that breast-conserving surgery is as effective as mastectomy for curing early stage breast cancer1,2 and that it can improve the psychosocial outcome.3 However, mastectomy can still be necessary for patients in the more advanced stages of the disease, in those cases in which breast-conserving treatment is ruled out for medical reasons, and for patients who prefer mastectomy to conservation.

In the United States, more than 190,000 women are diagnosed with breast cancer annually,4 and approximately 69,000 undergo mastectomy.5 A similar mastectomy rate of 40% among all women with breast cancer in Great Britain has been reported.6 In France, the incidence of mastectomy for breast cancer has not yet been assessed. For women who have to undergo mastectomy, breast reconstruction (BR) is a surgical option that is generally thought to improve the quality of life (QOL) and the psychosocial outcome without decreasing the patients’ chances of survival, regardless of the stage of the disease.7–12

The incidence of early or immediate BR after mastectomy for breast cancer differs from one country to another, and this incidence also differs from one hospital to another within each country.5,6 It has been estimated that 8.3% of the women in the United States had BR after breast cancer surgery between 1994 and 1995.5 In the United Kingdom and Ireland, this figure was about 18% in 2000.6 In other industrialized countries, some specialized hospitals have reported BR rates as high as 50%.13,14

Given the potential advantages of BR, all women about to undergo mastectomy should be given the opportunity of deciding whether or not to have BR and how it should be timed, i.e., at the same time as the mastectomy or some time after this operation.

The French context provides an excellent opportunity of testing patients’ reactions to BR proposals. The French national health care system makes BR available free to all patients undergoing mastectomy for breast cancer.

The objectives of this study were to describe the women’s preferences about BR and then to look for the determinants. It was therefore proposed to estimate women’s preferences about BR and the time of reconstruction by carrying out an experimental study in which women with breast cancer were presented with a twofold choice before having their mastectomy. First they had to indicate whether they preferred mastectomy with or without BR. Second, they were asked to indicate whether they preferred immediate or delayed reconstruction. This survey was also designed to assess the clinical and psychosocial factors contributing to these decisions, in the present context of shared decision-making between patients and surgeons.


   PATIENTS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Inclusion Criteria
Women who were about to undergo mastectomy for primary breast cancer at four hospitals in the South of France (regional cancer centers in Marseille, Montpellier, and Bordeaux and a private hospital in Puyricard) during a period of 2 years (January 2000 to January 2002) were eligible to take part in this study.

Exclusion Criteria
Patients who either refused to participate or failed to complete their questionnaires prior to surgery were not included in the study.

Assessment of Patients’ Decisions About Breast Reconstruction
During the first consultation at which surgeons prescribed mastectomy, each patient was systematically offered the possibility of having no reconstruction at all (MA), immediate breast reconstruction (IBR), or delayed breast reconstruction (DBR). The surgeons informed their patients about mastectomy and BR at this consultation. In addition, the patients were given a standard leaflet informing them about the risks and benefits associated with each option and stating that the patients’ choice of procedure would not affect their chances of survival. This two-page leaflet presented the three choices available and detailed current knowledge about them available from the literature at the time of the survey: first, that reconstruction would not interfere with medical follow-up; second, that there were different approaches concerning the timing of BR, with a list of respective advantages and disadvantages; and third, that the consensus in the literature was to promote each patient’s right to choose and share decision-making in medical intervention. The processes involved in the different reconstruction techniques were described, including hospitalization-related consequences and complications.

Patients were given at least 72 hours to make their final decision. When BR was chosen, the general and plastic surgeons responsible decided which specific BR technique was to be used, on the basis of patients’ morphological and clinical characteristics and, in particular, the potential indication of adjuvant radiotherapy. At the time of the survey there was no clinical evidence in favor of modifying the time and/or the technique for BR according to the anticipated radiotherapy.15

Surgeons’ Questionnaire
Immediately after the consultation, before the patient had made a decision, each surgeon had to answer a questionnaire about the patient’s medical status and predict the patient’s decision.

The medical information requested included the patient’s morphological characteristics (brassiere size, height, and weight, on which to base the body mass index [BMI]), medical risk factors (tobacco consumption, high blood pressure, diabetes mellitus), and history of breast cancer (previous surgery, present breast tumor characteristics, any previous cases of breast cancer in the family).

The surgeon’s predictions about the patient’s decision focused on whether BR would be desired and its timing. The question proposed to the surgeon was this: "What do you think will be the woman’s choice: mastectomy alone, immediate breast reconstruction, or delayed breast reconstruction?" This assessment was carried out without the surgeons having any knowledge of the answers given by the patients on their questionnaires.

Patients’ Questionnaire
After the decision to operate (mastectomy) and prior to the operation, the patients who agreed to participate in the study had to fill out a self-administered questionnaire designed to determine their decision and their sociodemographic and psychosocial characteristics.

Patients’ Preferences
The patients were asked to choose between the following three options: mastectomy alone (MA), immediate breast reconstruction (IBR), and delayed breast reconstruction (DBR). The question was, "What option have you chosen: to have no breast reconstruction, to have immediate breast reconstruction (at the same time as mastectomy), or to have breast reconstruction later (after mastectomy)?"

Patients’ sociodemographic information included age and level of education and whether they had a partner and/or children and a profession.

Patients’ psychosocial information included their QOL and depression profile as well as the reasons for their preferences/decisions and their approach to the decision-making process.

Patients’ QOL was investigated with the validated multidimensional EORTC QLQ-C30 and BR23 QOL scales.16,17

Patients’ depression profiles were assessed with the validated French version of the CES-D scale.18,19

Patients’ reasons for their choice of BR were previously explored in a pilot qualitative study using face-to-face open interviews with women. "Fear of surgery," "sexuality," and "body image" were found to contribute to the choice of BR. "Sexuality" and "body image" were investigated with use of the specific BR23-EORTC breast cancer–oriented QOL scale scores16 as well as direct questions with a four-point scale to assess the importance personally attributed by the patients to these two psychosocial factors. Since no scales have been previously validated for measuring the "fear of surgery" factor, we used four questions (also on a Likert four-point scale) specially designed for this survey, involving fear of additional surgical procedure, fear of prolonged operation time, fear of prosthesis, and fear of getting tired. The sum of all these items was taken to be a fairly reliable index to "the fear of surgery" (Cronbach alpha coefficient value = 0.8033).

Patients’ approach to the decision-making process was assessed by means of a set of yes-or-no closed questions. First, patients had to specify whether the choice with which they were faced induced "hesitation," "need for psychological support," or "the wish to meet mastectomized women." Second, the patients were asked to specify which health professionals (a surgeon, general practitioner, nurse, or psychologist), which person in their social environment (a friend, colleague, or somebody previously treated for breast cancer), and which of their close relations (their partner and family members) they usually talked to about their "personal problems" and which people they actually discussed their decision with. Third, the patients were asked whether they "decided alone," "shared the decision with the surgeon," or "delegated the decision to [the surgeon]." Fourth, the patients had to state whose advice was the most important in making their decision. Finally, the patients had to rate how satisfied they were with the information process.

The questionnaires were handed back individually to the research team. This study proceeded with the approval of the Commission Nationale Informatique et Libertés.

Statistical Analysis
The SPSS 11.0 statistical software package (SPSS, Inc., Chicago, IL) was used for the descriptive statistics and analysis. The {chi}2 test and Student’s t-test were performed to compare percentages and means in univariate comparisons (type 1 error, <0.05). Multivariate adjustment was carried out with backward logistic regression (Wald test) to adjust for the determinants and any confounding factors. The variables included in the logistic model had to have a P value of <.05 to be potential confounders. The center effect was systematically included in the multivariate adjustment procedure.

Dependent Variables: Patients’ Choices
We took the reconstruction variable (MA vs. BR) as the first dependent variable and the time of reconstruction (IBR vs. DBR) as the second dependent variable. The possible relationships between medical, sociodemographic, and psychosocial characteristics and patients’ choices were systematically investigated.

Agreement Between Surgeon’s Prediction of Patient’s Choice and Actual Patient’s Choice
We estimated the surgeons’ ability to predict their patients’ choice with the {kappa} coefficient and the surgeon’s accuracy in the case of positive predictions.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
During the 2 years covered by the study, BR was proposed to 251 eligible women. Thirteen women explicitly refused to participate (5.2%), and 57 did not answer the questionnaire before surgery (22.7%). In this latter group the percentage of IBR (67.3%) was comparable to that in the final sample studied (67.4%). Among the 181 women finally included for analysis (72.1%), 147 women (81%) opted for BR and 34 (19%) for MA. Among the 147 women opting for BR, 122 chose IBR (83%) and 25 chose DBR (17%). The nonrespondents (N = 57) differed in age and educational level from the respondents (N = 181). They were younger (50 ± 10) and more highly educated (60.5% higher than high school) than the respondents (54 ± 12 and 42.5%, respectively; P < .05). However, these two groups did not differ in clinical characteristics (comorbidity, number of biopsies, brassiere size).

Sociodemographic Characteristics
The mean age of the respondents (N = 181) was 53.9 years (SD = 12 years); 130 women were living with a partner (71.8%), 92 had an occupational activity (50.8%), and 76 were educated above high school level (43%). Details of these characteristics are given along with the respondents’ first decision (reconstruction or not) in Table 1Go.


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  		TABLE 1. Characteristics of patients in terms of their breast reconstruction preferences
 

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  		TABLE 1A. Continued.
 
Medical Characteristics
A substantial minority of the women (33.7%) had relatives with breast cancer, and more than one in 10 (12.9%) had a first-degree relative (mother or sister) with a history of breast cancer. Most women were diagnosed with early stage breast cancer at postmastectomy pathologic exploration. Diameter of the invasive tumor component was <20 mm in 98 cases (54%), while 35 women had diffuse in situ carcinoma (19%). Axillary lymph node metastases were present in 35.5% of the cases. Table 1Go details the patients’ medical characteristics along with their first decision.

Patients’ Approach to the Decision-Making Process
Most of the women said they had no hesitation in making their decision (83%). The surgeon’s counseling was said by 83 patients (48%) to be the most important factor, while 34 (19% of the sample as a whole, and 26% of the women living with a partner) said that their partner’s advice was the most important.

Joint decision-making with the surgeon was reported by 86 women (48.5%), while 85 women (48%) declared they had made their decision alone, without the surgeon. Only six women (3.5%) said they had been unable to make the decision themselves and preferred to delegate the decision to the surgeon.

The level of agreement between "joint decision-making with the surgeon" and the statement that "surgeon’s counsel was the most important" was good ({kappa} = 0.527, P < .0001). The information process was rated "good" or "very good" by 71.8% and "rather unsatisfactory" or "not good at all" by 25.4%.

First Choice: Mastectomy Alone Versus Breast Reconstruction
The great majority of the women (81%) decided to have BR. Table 1 Go gives detailed results of the univariate analysis of characteristics significantly related to the choice of BR. The women who opted for BR were much younger, were more highly educated, and tended to be more active, to have children in their care, and to live with a partner more frequently than those who did not choose BR (P < .05). Women treated at hospital center number four chose MA more often than those treated at the other hospital centers (P < .05). Women who chose MA had a higher BMI, were more likely to suffer from high blood pressure, and were less likely to smoke (P < .05). They had tumors of a more advanced pathologic stage, and a first-degree relative with breast cancer was reported more frequently in this subgroup (P < .05).

Women who chose BR had discussed their decision more frequently with their partner but were also more frequently of the opinion that the surgeon’s advice was the most important (P < .05). However, women opting for BR tended to be more dissatisfied with the information provided and to express greater interest in meeting people who had already undergone mastectomy (P < .05). Women opting for BR more frequently expressed the need for psychological support than those opting for MA, but these results were only borderline significant (45.5% vs. 28%, P = .069). The QOL assessment showed that the women who chose BR were in better physical and sexual condition, and the financial impact of the disease was perceived as being higher in this group than in the group opting for MA (P < .04). The women who chose BR declared that body image and sexuality were important more frequently than the women who chose MA (P < .001). The former were also less afraid of surgery than the women who chose MA (P < .001). Depression was not correlated with the women’s decisions, whereas perception of the body image was lower, but not significantly, in the BR group than in the MA one (P = .07).

After multivariate adjustment to allow for the effects of the noncolinear variables found to be significant in the univariate comparisons (P < .05), the choice of BR was found to be explained mainly by the responders’ psychosocial characteristics (Table 2). The statement that body image was important and having a lower score "because of the fear of surgery" were found to be psychological characteristics positively (cor)related with the decision to have BR (adjusted odds ratio [ORadj] = 10.55 and ORadj = 0.688 per unit, respectively; P < .05). The statement that "the surgeon’s counseling was the most important" and that the "choice was discussed with my partner" were independently positively correlated with the decision to have BR (ORadj = 13.45 and ORadj = 3.59, respectively; P < .05).


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  		TABLE 2. Factors affecting the patients’ choice as to breast reconstruction vs. mastectomy alone (multivariate analysis by logistic regression, n = 156)
 
Second Choice: Immediate Breast Reconstruction Versus Delayed Breast Reconstruction
Among those women who chose to have BR (n = 147), the great majority (83%) chose IBR. Table 3 gives the characteristics found in the univariate analysis to be significantly related with the responders’ decision about the timing of the BR. Women who chose DBR had a higher BMI and a larger brassiere size (P < .01), and their daily tobacco consumption was lower than those who chose IBR (P = 0.04). Some symptomatic dimensions of the QOL multidimensional scale were related with the responders’ BR timing preferences. The scores on appetite loss, diarrhea, and breast symptoms were higher among those who chose IBR (P < .05), while the scores on arm symptoms were lower in this group (P = 0.031). Borderline effects were noted with tumor stage, education, and psychosocial relationships. The women who chose DBR had been diagnosed at a more advanced tumor stage (diameter of invasive tumor component ≥20 mm: 54% vs. 36%, P = .095), were less highly educated (high school: 52% vs. 75%; P = .054), and declared more frequently that they talked about their personal problems with their family (88% vs. 71%, P = .071) and less frequently with their doctor (48% vs. 66%, P = .082). No significant correlations were found between the patients’ preferences about the timing of BR and their sociodemographic characteristics or approach to the decision-making process.


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  		TABLE 3. Characteristics of patients vs. their preferences as to the timing of the reconstruction
 
After multivariate adjustment, three patients’ psychological and QOL characteristics, along with their BMI, mainly explained their preferences about the timing of the reconstruction (Table 4). Having "talked about personal problems with doctors" (ORadj = 3.49, P < .05) and having higher scores for appetite loss and breast symptoms (ORadj = 1.061 per unit and ORadj = 1.042 per unit, respectively; P < .04) were positively related to a preference for IBR, while a higher BMI was negatively related to this preference (ORadj = 0.814 per unit; P = 007).


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  		TABLE 4. Patients’ characteristics influencing the choice for immediate breast reconstruction vs delayed reconstruction (multivariate analysis by logistic regression, n = 115)
 
Agreement Between Surgeon’s Prediction of Patient’s Decision and Actual Patient’s Decision
Details of the surgeons’ predictions about their patients’ decision are given in Table 5. The overall {kappa} coefficient value was 0.542 (P < .0005), which corresponds with a fairly good agreement. The overall accuracy of the surgeons’ predictions in the case of positive predictions was 79%. This value depended on which of the two choices the prediction was made about. When the surgeon predicted that the patient would opt for IBR, this prediction turned out to be accurate in 86.4% of all the cases. When the surgeon predicted that the patient would opt for DBR, however, this prediction turned out to be accurate in only 28.6% of all the cases.


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  		TABLE 5. Match between actual patient’s choice and surgeon’s forecast of patients’ choice
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The main aim of this study was to assess patients’ decisions about BR after mastectomy under conditions in which they benefited from maximum autonomy.

The results show that in this context, the great majority of the women chose BR (81%). The great majority of the latter group (83%) opted for immediate BR, whereas the minority (17%) preferred delayed BR. The surgeons were able to predict the patients’ decision/preferences accurately in 79% of all the cases but mainly when the patients chose immediate BR and not when they chose delayed BR.

After multivariate adjustment, the choice of BR was found to be entirely explained by the patients’ psychological characteristics and by contextual factors. Greater awareness perception of their own body image and being less afraid of surgery were found to be significant predictors of choosing BR, as well as having discussed this problem with the partner and being of the opinion that the surgeon’s counseling was the most important advice.

After multivariate adjustment, the decision/preference about the timing of reconstruction was explained by the type of doctor–patient relationship and by the patients’ physical characteristics and perceived symptoms. A more patient-centered relationship, greater appetite loss, and more frequently perceived breast symptoms turned out to be the patients’ characteristics that were most highly positively correlated with the decision to have an immediate BR. A lower BMI was also positively correlated with opting for an immediate BR.

The most striking findings obtained in this study were the high rate of occurrence of the decision to have immediate BR and the fact that the patients’ psychosocial characteristics explained their reactions to both of the choices proposed.

We can assume there was no major selection bias in including in our study mostly women opting for IBR, since a comparable IBR percentage was observed among the women excluded.

We will first discuss the factors accounting for the decision to have BR or not and then those accounting for the patients’ preferences about the timing of the reconstruction.

The possibility of having BR usually depends on the health care system and the surgery providers. Morrow,5 in a retrospective national survey of nearly 70,000 women who had undergone mastectomy in the United States, reported that the occurrence of BR after mastectomy depended, after multivariate adjustment, on the tumor stage, age, income, ethnicity, and type of hospital and its geographical location. In a study of nearly 400 surgeons in the United Kingdom and Ireland, Callaghan6 observed that the practice of BR and immediate BR in particular was clearly explained by the hospital location and the surgeons’ characteristics. In our survey, access to BR was available at no extra cost to the patient, since the French national health insurance system covers the procedure, and BR was systematically proposed by the surgeon regardless of the tumor stage. Negative factors such as the tumor stage, the financial coverage of the procedure, and the surgeons’ characteristics therefore did not come into play here. The high proportion of women opting for BR observed herein and for immediate BR in particular may therefore have been due to the fact that the patients had maximum autonomy.

As far as we know, women’s decisions to have BR or not have never been investigated in a prospective quasi-experimental study. Most previous surveys have been observational and retrospective. The fact that we assessed the patients’ decisions prospectively made it possible to reliably determine the patients’ characteristics at the actual moment when they had to choose what treatment they wanted.

Besides the medical and personal characteristics discussed earlier, psychosocial characteristics have been found to be involved in the decision to have BR. "The body image," "the fear of surgery," and "to get rid of external prostheses" are psychosocial perceptions and personal beliefs known to be associated with BR.

Breast cancer has a destructive impact on a woman’s body image and sexual identity. Although BR after mastectomy has not been found to improve the QOL on the whole, it appears to improve the "self-perceived body image."3,7,20–27 To assess the relationship between having BR and the patients’ body image, most previous surveys have used direct questions about the "importance of the body image," since more specific points could not be rated retrospectively.28 Significant but conflicting results have been obtained. Some authors have noted the "importance of body image" among women applying for BR,13,22,29 while others have observed that "importance of body image" was greater for women who did not opt for BR.30 No prospective surveys reliably assessing the declared "importance of the body image" have been carried out before at the actual moment when patients have to make their choice. In our study, after multivariate adjustment, the decision to have BR was positively related to the declaration that the "body image was important" (OR = 10.55, P = .001). The self-conception of the body image can therefore be said to be an important predictor of the decision to have a BR.

"The fear of surgery" is another factor contributing to women’s decision to have BR after mastectomy.31,32 Patients’ scores on "the fear of surgery" were higher among those choosing mastectomy alone than among those who chose BR, even after multivariate adjustment for age and level of education. On the standard information fact sheet we gave the patients, it was mentioned that BR does not increase the overall percentage of complications in comparison with mastectomy alone.33–35 Specific support might be helpful for women before surgery, especially when their fears about surgery are known to be high.

Women have reported that the preoperative period is one of the most stressful times during the experience of breast cancer,13,36 and offering them the possibility of BR surgery might alleviate their depression and anxiety at this time.36 Immediate reconstruction appears to induce more concern about self-perception of body image, functional well-being, and mood state at the time of initial mastectomy,37,38 but these issues can be deferred to the second surgical stage in the case of the delayed group. In our study, the only QOL factors found to be related with the decision to have immediate reconstruction were appetite loss and breast symptoms, whereas depression was not significantly related.

Patients’ BMI was the only objective physical characteristic related to the patients’ decision, since after multivariate adjustment, patients’ age and pathological tumor stage were no longer significant. The relationship between the clinical outcome of the BR procedure and the patients’ morphological characteristics was not specifically mentioned in the standard information sheet given to the patients. However, BR with implants is not recommended for patients with a large brassiere size, whereas obesity is a common risk factor in BR with a flap.39 In addition, it has been established that the patient’s age does not affect the clinical outcome of BR40 and that BR does not reduce the patient’s chances of survival, regardless of tumor stage.9–12 Therefore, the effects of these obvious characteristics on the patients’ decisions may simply reflect the way in which the attitude of the medical staff and the information with which patients were provided contributed to the decision-making process.

There is some evidence that shared decision-making can improve outcomes.36,41,42 In connection with curative treatment in general, a three-stage gradient of participation has been defined. The patient’s participation can be active, collaborative, or passive. The authors of some large-scale surveys have reported that one of every four patients prefers to play a passive role and that the same proportion prefers an active role, while nearly one-half prefer a collaborative role.43,44 We examined the patients’ answers to the questions about having a functional treatment that would not affect their chances of survival. The overwhelming majority of the sample (96.5%) declared that they had participated in the decision-making, and only 3.5% of the patients declared that they had completely delegated the decision to the surgeon. Nearly half of the patients made their decision alone (48%), while the other half shared the decision with the surgeon (48.5%). In the case of functional treatment, the patients’ participation in the decision-making process seems to be really necessary. Having discussions with the patient’s partner also seems to be a decisive factor in this process.

In conclusion, the results of the present study show that when the possibility of having BR is really proposed and when the economic constraints are released, the majority of women having to undergo mastectomy for breast cancer are ready to choose immediate BR. The patients’ willingness to undergo this procedure was explained mainly by certain psychosocial characteristics, whereas some medical and sociodemographic characteristics previously thought to be related to undergoing BR were no longer found to be significant. The decision to have BR, especially immediate BR, seems to relieve the patients’ psychological distress and functional symptoms during the preoperative period. This decision requires efficient environmental relationships. Surgeons were found here to be the best source of medical information, whereas the partner constituted the most frequently used source of nonmedical advice.


   ACKNOWLEDGMENTS
 
The authors thank Dr. Conte (R2C network), Dr. Bautrant (R2C network), and Dr. Dunon De Lara (CLCC, Bordeaux), as well as Mrs. Jessica Blanc for English-language revisions of the manuscript.

The acknowledgments are available online in the fulltext version at www.annalssurgicaloncology.org. They are not available in the PDF version.


   FOOTNOTES
 
In a context of maximum autonomy, the majority of 181 women chose immediate breast reconstruction. Patients’ choices were explained mainly by their psychosocial characteristics. The indication for breast reconstruction should be properly discussed by patients with their surgeons before mastectomy.

Received for publication November 17, 2003. Accepted for publication May 7, 2004.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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