Wess A. Cohen

The BREAST-Q in surgical research: A review of the literature 2009–2015

BACKGROUND Health outcomes research has gained considerable traction over the past decade as the medical community attempts to move beyond traditional outcome measures such as morbidity and mortality. Since its inception in 2009, the BREAST-Q has provided meaningful and reliable information regarding health-related quality of life (HRQOL) and patient satisfaction for use in both clinical practice and research. In this study, we review how researchers have used the BREAST-Q and how it has enhanced our understanding and practice of plastic and reconstructive breast surgery. METHODS An electronic literature review was performed to identify publications that used the BREAST-Q to assess patient outcomes. Studies developing and/or validating the BREAST-Q or an alternate patient-reported outcome measure (PROM), review papers, conference abstracts, discussions, comments and/or responses to previously published papers, studies that modified a version of BREAST-Q, and studies not published in English were excluded. RESULTS Our literature review yielded 214 unique articles, 49 of which met our inclusion criteria. Important trends and highlights were further examined. DISCUSSION The BREAST-Q has provided important insights into breast surgery highlighted by literature concerning autologous reconstruction, implant type, fat grafting, and patient education. The BREAST-Q has increased the use of PROMs in breast surgery and provided numerous important insights in its brief existence. The increased interest in PROMs as well as the underutilized potential of the BREAST-Q should permit its continued use and ability to foster innovations and improve quality of care.

The Impact of Travel Distance on Breast Reconstruction in the United States.

Background: Inadequate access to breast reconstruction was a motivating factor underlying passage of the Women’s Health and Cancer Rights Act. It remains unclear whether all patients interested in breast reconstruction undergo this procedure. The aim of this study was to determine whether geographic disparities are present that limit the rate and method of postmastectomy reconstruction. Methods: Travel distance in miles between the patient’s residence and the hospital reporting the case was used as a quantitative measure of geographic disparities. The American College of Surgeons National Cancer Database was queried for mastectomy with or without reconstruction performed from 1998 to 2011. Reconstructive procedures were categorized as implant or autologous techniques. Standard statistical tests including linear regression were performed. Results: Patients who underwent breast reconstruction had to travel farther than those who had mastectomy alone (p < 0.01). A linear correlation was demonstrated between travel distance and reconstruction rates (p < 0.01). The mean distances traveled by patients who underwent reconstruction at community, comprehensive community, or academic programs were 10.3, 19.9, and 26.2 miles, respectively (p < 0.01). Reconstruction rates were significantly greater at academic programs. Patients traveled farther to undergo autologous compared with prosthetic reconstruction. Conclusions: Although greater patient awareness and insurance coverage have contributed to increased breast reconstruction rates in the United States, the presence of geographic barriers suggests an unmet need. Academic programs have the greatest reconstruction rates, but are located farther from patients’ residences. Increasing the number of plastics surgeons, especially in community centers, would be one method of addressing this inequality.

Cost-Effectiveness Analysis of Breast Reconstruction Options in the Setting of Postmastectomy Radiotherapy Using the BREAST-Q.

Background: A consensus is lacking on a uniform reconstructive algorithm for patients with locally advanced breast cancer who require postmastectomy radiotherapy. Both delayed autologous and immediate prosthetic techniques have inherent advantages and complications. The study hypothesis is that implants are more cost effective than autologous reconstruction in the setting of postmastectomy radiotherapy because of immediate restoration of the breast mound. Methods: A cost-effectiveness analysis model using the payer perspective was created comparing delayed autologous and immediate prosthetic techniques against the do-nothing option of mastectomy without reconstruction. Costs were obtained from the 2010 Nationwide Inpatient Sample database. Effectiveness was determined using the BREAST-Q patient-reported outcome measure. A breast quality-adjusted life-year value was considered 1 year of perfect breast health-related quality of life. The incremental cost-effectiveness ratio was calculated for both treatments compared with the do-nothing option. Results: BREAST-Q scores were obtained from patients who underwent immediate prosthetic reconstruction (n = 196), delayed autologous reconstruction (n = 76), and mastectomy alone (n = 71). The incremental cost-effectiveness ratios for immediate prosthetic and delayed autologous reconstruction compared with mastectomy alone were

Tradeoffs Associated With Contralateral Prophylactic Mastectomy in Women Choosing Breast Reconstruction: Results of a Prospective Multicenter Cohort.

57,906 and

Defining a Research Agenda for Patient-Reported Outcomes in Surgery: Using a Delphi Survey of Stakeholders

102,509, respectively. Sensitivity analysis showed that the incremental cost-effectiveness ratio for both treatment options decreased with increasing life expectancy. Conclusions: For patients with advanced breast cancer who require postmastectomy radiotherapy, immediate prosthetic-based breast reconstruction is a cost-effective approach. Despite high complication rates, implant use can be rationalized based on low cost and health-related quality-of-life benefit derived from early breast mound restoration. If greater life expectancy is anticipated, autologous transfer is cost effective as well and may be a superior option.

Understanding and Optimizing the Patient Experience in Breast Reconstruction

Objective: Assess postoperative morbidity and patient-reported outcomes after unilateral and bilateral breast reconstruction in patients with unilateral breast cancer. Background: Relatively little is known about the morbidity associated with and changes in quality of life experienced by patients who undergo contralateral prophylactic mastectomy (CPM) and breast reconstruction. This information would be valuable for decision making in patients with unilateral breast cancer. Methods: Women undergoing mastectomy and breast reconstruction for unilateral breast cancer were recruited for this prospective observational study. Postoperative complications after implant and autologous breast reconstruction in patients undergoing unilateral or bilateral mastectomy were recorded. Preoperative and 1 year patient-reported outcomes were measured. Univariate tests and logistic regression analyses were performed, studying the effects of reconstructive method, laterality, and risk factors on surgical complication rates, patient satisfaction, and anxiety. Results: We identified 1144 women who underwent either unilateral (47.2%) or bilateral (52.8%) mastectomies with reconstruction. Bilateral autologous (odds ratio 1.73, 95% confidence interval 1.07–2.81) and implant reconstructions (odds ratio 1.73, 95% confidence interval 1.22–2.47) were associated with a higher risk of complications compared with unilateral reconstructions. Baseline anxiety was greater in women who chose bilateral compared with unilateral implant reconstructions (P = 0.001). There was no difference in anxiety levels between groups postoperatively. Postoperatively, women who chose CPM with implant reconstructions were more satisfied with their breasts than women with unilateral reconstructions (P = 0.034). Conclusions: Although higher postoperative complications were observed after CPM and reconstruction, these procedures were associated with decreased anxiety levels and improved satisfaction with breasts for women who underwent implant reconstructions.

Health-Related Quality of Life following Reconstruction for Common Head and Neck Surgical Defects.

Importance Identifying timely and important research questions using relevant patient-reported outcomes (PROs) in surgery remains paramount in the current medical climate. The inaugural Patient-Reported Outcomes in Surgery (PROS) Conference brought together stakeholders in PROs research in surgery with the aim of creating a research agenda to help determine future directions and advance cross-disciplinary collaboration. Objective To create a research agenda to help determine future directions and advance cross-disciplinary collaboration on the use of PROs in surgery. Design, Setting, and Participants An iterative web-based interface was used to create a conference-based, modified Delphi survey for registrants at the PROS Conference (January 29-30, 2015), including surgeons, PRO researchers, payers, and other stakeholders. In round 1, research items were generated from qualitative review of responses to open-ended prompts. In round 2, items were ranked using a 5-point Likert scale; attendees were also asked to submit any new items. In round 3, the top 30 items and newly submitted items were redistributed for final ranking using a 3-point Likert scale. The top 20 items by mean rating were selected for the research agenda. Main Outcomes and Measures An expert-generated research agenda on PROs in surgery. Results Of the 143 people registered for the conference, 137 provided valid email addresses. There was a wide range of attendees, with the 3 most common groups being plastic surgeons (28 [19.6%]), general surgeons (19 [13.3%]), and researchers (25 [17.5%]). In round 1, participants submitted 459 items, which were reduced through qualitative review to 53 distinct items across 7 themes of PROs research. A research agenda was formulated after 2 successive rounds of ranking. The research agenda identified 3 themes important for future PROs research in surgery: (1) PROs in the decision-making process, (2) integrating PROs into the electronic health record, and (3) measuring quality in surgery with PROs. Conclusions and Relevance The PROS Conference research agenda was created using a modified Delphi survey of stakeholders that will help researchers, surgeons, and funders identify crucial areas of future PROs research in surgery.

Sociodemographic Predictors of Breast Reconstruction Procedure Choice: Analysis of the Mastectomy Reconstruction Outcomes Consortium Study Cohort

BackgroundOptimizing the patient experience is a central pillar in healthcare quality. Although this may be recognized as important in breast reconstruction, surgeons are often unaware of how well they and members of their team achieve this goal. The objective of our study was to evaluate patient satisfaction with the experience of care in a multicenter, prospective cohort of patients undergoing breast reconstruction. Specifically, we sought to determine which aspects of the care experience might be most amenable to quality improvement. MethodsAs part of the Mastectomy Reconstruction Outcomes Consortium Study, 2093 patients were recruited from 11 centers in North America. Of these, 1534 (73.3%) completed the BREAST-Q Satisfaction with Care scales (satisfaction with information, surgeon, medical team, and office staff) at 3 months after reconstruction and were included in the analysis. ResultsPatients scored lowest on ‘Satisfaction with Information’ (mean = 72.8) compared to all other Satisfaction with Care scales (mean, 89.5-95.5). Patients with immediate reconstruction were less satisfied with their plastic surgeon compared to those with delayed reconstruction. The racial category, “Other” (Asians, Pacific Islanders, Hawaiians, American Indians), was the least satisfied group across all Satisfaction with Care scales. ConclusionsPatients undergoing breast reconstruction perceive significant gaps in their knowledge and understanding of expected outcomes. Immediate reconstruction patients and minority racial groups may require additional resources and attention. As a means to improve quality of care, these findings highlight an important unmet need and suggest that improving patient education may be central to providing patient-centered care.

Breast Reconstruction in Patients with Unilateral Breast Cancer Who Choose Contralateral Prophylactic Mastectomy - An Assessment of Postoperative Morbidity.

Background: Improved understanding and management of health-related quality of life represents one of the greatest unmet needs for patients with head and neck malignancies. The purpose of this study was to prospectively measure health-related quality of life associated with different anatomical (head and neck) surgical resections. Methods: A prospective analysis of health-related quality of life was performed in patients undergoing surgical resection with flap reconstruction for stage II or III head and neck malignancies. Patients completed the European Organization for Research and Treatment of Cancer Core Quality-of-Life Questionnaire-30 and the European Organization for Research and Treatment of Cancer Head and Neck Cancer Module-35 preoperatively, and at set postoperative time points. Scores were compared with a paired t test. Results: Seventy-five patients were analyzed. The proportion of the cohort not alive at 2 years was 53 percent. Physical, role, and social functioning scores at 3 months were significantly lower than preoperative values (p < 0.05). At 12 months postoperatively, none of the function or global quality-of-life scores differed from preoperative levels, whereas five of the symptom scales remained below baseline. At 1 year postoperatively, maxillectomy, partial glossectomy, and oral lining defects had better function and fewer symptoms than mandibulectomy, laryngectomy, and total glossectomy. From 6 to 12 months postoperatively, partial glossectomy and oral lining defects had greater global quality of life than laryngectomies (p < 0.05). Conclusions: Postoperative health-related quality of life is associated with the anatomical location of the head and neck surgical resection. Preoperative teaching should be targeted for common ablative defects, with postoperative expectations adjusted appropriately. Because surgery negatively impacts health-related quality of life in the immediate postoperative period, the limited survivorship should be reviewed with patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Sociodemographic and Clinical Variables Impacting Procedure Choice in Breast Reconstruction.

Background. To promote patient-centered care, it is important to understand the impact of sociodemographic factors on procedure choice for women undergoing postmastectomy breast reconstruction. In this context, we analyzed the effects of these variables on the reconstructive method chosen. Methods. Women undergoing postmastectomy breast reconstruction were recruited for the prospective Mastectomy Reconstruction Outcomes Consortium Study. Procedure types were divided into tissue expander-implant/direct-to-implant and abdominally based flap reconstructions. Adjusted odds ratios were calculated from logistic regression. Results. The analysis included 2,203 women with current or previous breast cancer and 202 women undergoing prophylactic mastectomy. Compared with women <40 years old with current or previous breast cancer, those 40 to 59 were significantly more likely to undergo an abdominally based flap. Women working or attending school full-time were more likely to receive an autologous procedure than those working part-time or volunteering. Women undergoing prophylactic mastectomy who were ≥50 years were more likely to undergo an abdominal flap compared to those <40. Conclusions. Our results indicate that sociodemographic factors affect the reconstructive procedure received. As we move forward into a new era of patient-centered care, providing tailored treatment options to reconstruction patients will likely lead to higher satisfaction and better outcomes for those we serve.