Shaghayegh Bagher

Decision regret following breast reconstruction: the role of self-efficacy and satisfaction with information in the preoperative period.

Background: The relationship between satisfaction with information and decision regret has not been previously studied in breast reconstruction patients. The objective of this study, therefore, was to assess this relationship and the factors that may influence satisfaction with preoperative information, including self-efficacy (confidence with seeking medical knowledge). Methods: All patients who underwent breast reconstruction between January of 2009 and March of 2011 were approached to complete the Modified Stanford Self-Efficacy Scale (1 to 10), the satisfaction with information subscale of the BREAST-Q (1 to 100), and the Decision Regret Scale (1 to 100). Two multinomial logistic regression models were built to assess the relationship between patient-reported satisfaction with information and decision regret, and to evaluate the relationship among satisfaction with information, self-efficacy level, and sociodemographic characteristics. Results: In 100 participants (71 percent response rate), the mean Decision Regret Scale score was 9.3 ± 17.3 of 100, and the majority of patients experienced no regret (60 percent). We found that regret was significantly reduced when patients were more satisfied with the preoperative information that they received from their plastic surgeons (&bgr; = 0.95; 95 percent CI, 0.93 to 0.96). Furthermore, patients reported higher satisfaction with information when they possessed more self-efficacy irrespective of their sociodemographic characteristics (&bgr; = 1.06; 95 percent CI, 1.04 to 1.09). Conclusions: Patients who possess lower levels of self-efficacy are at greater risk for experiencing dissatisfaction with the information that they receive in the preoperative period, and ultimately suffered more regret over their decision to undergo breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

A Comparison of Psychological Response, Body Image, Sexuality, and Quality of Life between Immediate and Delayed Autologous Tissue Breast Reconstruction: A Prospective Long-term Outcome Study

Background: This is the first study to use generic distress, cancer-specific, and procedure-specific measures to prospectively evaluate psychological responses, body image, sexuality, and health-related quality of life in immediate compared with delayed breast reconstruction. Methods: Consecutive patients undergoing autologous immediate and delayed breast reconstruction (June of 2009 to December of 2010) completed the Hospital Anxiety and Depression Scale, Body Image Scale, Sexuality Scale, and BREAST-Q preoperatively and postoperatively (6, 12, and 18 months). Linear mixed-effects analyses between each outcome and time point were performed. Results: One hundred six women underwent mastectomy with immediate (n = 30) and delayed breast reconstruction (n = 76). Before reconstruction, 26 percent of patients had abnormal anxiety scores and 9 percent had abnormal depression scores, with no significant differences between groups. Patients awaiting delayed breast reconstruction had significantly impaired prereconstruction body image (p = 0.01) and sexuality (p = 0.01) and worse satisfaction with breast (p < 0.01), psychological (p < 0.01), and sexual well-being (p < 0.01). At 18 months after immediate and delayed breast reconstruction, there was significant improvement in anxiety, depression, body image, sexuality, and health-related quality of life. Conclusions: This single-center study shows that mastectomy with immediate breast reconstruction may protect breast cancer patients from a period of psychosocial distress, poor body image, and diminished sexual well-being compared with those waiting for delayed breast reconstruction. In patients who are oncologically eligible and strongly interested in breast reconstruction, efforts should be made to provide immediate breast reconstruction to decrease the interval of psychosocial distress, poor body image, and impaired sexuality.

Using propensity score analysis to compare major complications between DIEP and free muscle-sparing TRAM flap breast reconstructions.

Background: Previous studies comparing muscle-sparing transverse rectus abdominis myocutaneous (TRAM) versus deep inferior epigastric artery perforator (DIEP) free flaps have not considered procedure selection bias. Propensity score analysis provides a statistical approach to consider preoperative factors in flap selection, and was used to compare major complications (breast and abdominal) between these microsurgical breast reconstruction (free muscle-sparing TRAM versus DIEP). Methods: This study evaluated major breast and abdominal complications in 292 consecutive patients (428 free abdominal flaps). Propensity scores were calculated for patient differences affecting flap selection (DIEP versus free muscle-sparing TRAM). Multivariate logistic models using selected covariates separately analyzed breast and abdominal complications between flap methods. Results: There were 83 major complications (28 percent): breast, 20 percent; abdomen, 8 percent. Using propensity scores, the adjusted odds of abdominal complications were significantly higher in free muscle-sparing TRAM than in DIEP flaps (OR, 2.73; 95 percent CI, 1.01 to 7.07). With prior chemotherapy, body mass index significantly increased abdominal complications (OR, 1.16; 95 percent CI, 1.01 to 1.34). Using propensity scores, there was no significant association between reconstruction method and breast complications; diabetics had significantly increased breast complications (OR, 4.19; 95 percent CI, 1.14 to 15.98). Previous abdominal operations (OR, 1.77; 95 percent CI, 0.96 to 3.30) and immediate reconstruction (OR, 1.86; 95 percent CI, 0.94 to 3.71) approached significance. Conclusions: Propensity score analysis indicated significantly higher abdominal complications in free muscle-sparing TRAM compared with DIEP flaps. This study highlights the importance of separately evaluating recipient breast and donor abdominal complications and use of propensity scores to minimize procedure selection bias. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The influence of dispositional optimism on decision regret to undergo major breast reconstructive surgery

It is not known if optimism influences regret following major reconstructive breast surgery. We examined the relationship between dispositional optimism, major complications and decision regret in patients undergoing microsurgical breast reconstruction.

Why Some Mastectomy Patients Opt to Undergo Delayed Breast Reconstruction: Results of a Long-Term Prospective Study

Background: Delayed breast reconstruction is an option for women who have undergone mastectomy; however, uptake is low. The purpose of this study was to identify premastectomy and postmastectomy demographic, clinical, and psychosocial predictors of uptake of delayed breast reconstruction in the long-term survivorship period. Methods: This was a prospective longitudinal survey study of mastectomy patients in which a repeated measures design was used to evaluate uptake of delayed breast reconstruction. Demographic, clinical, and psychosocial variables were collected before mastectomy and 1 year after mastectomy. Information regarding uptake of delayed breast reconstruction was collected at approximately 6 years after mastectomy. A predictive model was designed using a multivariate logistic regression model and Akiake information criterion stepwise algorithm. Results: Ninety-six mastectomy patients were followed from before mastectomy to 75.2 months after mastectomy, and 35 women (36.5 percent) underwent delayed breast reconstruction. Women who elected for delayed breast reconstruction experienced worsening of body concerns from before mastectomy to 1 year after mastectomy, compared with women who did not elect to undergo delayed breast reconstruction (p = 0.03). Mean scores for psychological distress were significantly worse both before mastectomy and 1 year after mastectomy in women who went on to undergo delayed breast reconstruction compared with those who did not undergo delayed breast reconstruction (p = 0.034 and p = 0.022, respectively). A predictive model for the uptake of delayed breast reconstruction was developed using demographic, clinical, and psychosocial characteristics. The area under the receiver operating characteristic curve was 85 percent, indicating good precision. Conclusions: Women who are experiencing higher levels of distress, anxiety, and body concerns both before and after mastectomy appear to be significantly likely to select delayed breast reconstruction. This may have implications for postreconstruction satisfaction and psychosocial functioning. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Predicting Complications in Immediate Alloplastic Breast Reconstruction: How Useful Is the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator?

Background: Complications following immediate breast reconstruction can have significant consequences for the delivery of postoperative chemotherapy and radiation therapy. Identifying patients at higher risk of complications would ensure that immediate breast reconstruction does not compromise oncologic treatment. The American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator is an online tool in the public domain that offers individualized preoperative risk prediction for a wide range of surgical procedures, including alloplastic breast reconstruction. This study evaluates the usefulness of this tool in patients undergoing immediate breast reconstruction with tissue expanders at a single institution. Methods: Details of 278 patients who underwent immediate breast reconstruction with tissue expander placement were entered into the calculator to determine the predicted complication rate. This was compared to the rate of observed complications on chart review. The predictive model was evaluated for calibration and discrimination using the statistical measures used in the original development of the calculator. Results: The predicted rate of complications (5.2 percent) was significantly lower that the observed rate (16.2 percent; p < 0.01). The Hosmer-Lemeshow test confirmed lack of fit of the model. The C statistic was 0.62 and the Brier score was 0.173, indicating that the model had poor predictive power and could not discriminate between those who were at risk for complications and those who were not. Conclusions: The American College of Surgeons National Surgical Quality Improvement Program universal Surgical Risk Calculator underestimated the proportion of patients that would develop complications in this cohort. In addition, it was unable to effectively identify individual patients at increased risk, suggesting that this tool would not make a useful contribution to preoperative decision-making in this patient group.

Abstract 16: The Analgesic Efficacy of the Transversus Abdominis Plane (TAP) Block on the Abdominal Donor Site Following Autologous Tissue Breast Reconstruction: A Double-Blind, Placebo-Controlled Randomized Trial.

Methods: To characterize EPCs, our lab developed a transgenic mouse, vav-cre RFP-GFP, with cells of the hematopoietic lineage expressing GFP and non-hematopoietic cells, expressing RFP. In parallel, we established a microfluidicsbased single cell transcriptional analysis technique to identify cell surface markers for these elusive cell-populations. Combining these novel techniques in a parabiotic model of neovascularization, we aimed to isolate unique EPC populations and determine their origin, hierarchy and cell surface characteristics.