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The Quality of Decisions about Breast Reconstruction
Yuen-Jong Liu, M.D.1, Allison Deal, M.S.1, Michael Pignone, M.D., M.P.H.1, Peter Ubel, M.D.2, Lillian Burdick, B.S.1, David W. Ollila, M.D.1, Clara Lee, M.D., M.P.P.1.
1University of North Carolina at Chapel Hill, Chapel Hill, NC, USA, 2Duke University, Durham, NC, USA.

PURPOSE:
To evaluate the quality of decisions about breast reconstruction, defined as the extent to which patients are informed and treatments are concordant with their preferences.
METHODS:
Single-center, prospective cross-sectional study. Adult women undergoing mastectomy for stage I-III breast cancer, DCIS, or prophylaxis were enrolled over 18 months. Knowledge was measured with the Decision Quality Instrument. Preferences about appearance, amount of surgery, recovery time, and complication risk were elicited using conjoint analysis, a marketing research method that measures the importance of product attributes for consumer choices. Hierarchical Bayesian modelling was used to calculate the utility, or relative importance, of each attribute. Market share estimation was used to calculate a patient’s preferred treatment based on her utilities. Preferred treatment was compared to actual treatment with a kappa statistic to assess preference concordance.
RESULTS:
126 patients were enrolled (83% participation). Overall knowledge was 57%. Knowledge about complications was only 14%. 27% of patients had treatment that was not concordant with preferences (kappa = 0.44): 18% of patients preferred reconstruction but underwent no reconstruction, and 9% preferred no reconstruction but underwent reconstruction. For 66% of patients, complication risk was the most important attribute, but only 16% of those patients knew the approximate complication rate after reconstruction, with most underestimating the rate.
CONCLUSIONS:
Patients undergoing mastectomy had significant gaps in knowledge about reconstruction. Patients were highly concerned about complications but had very low knowledge about it. A substantial proportion of patients did not receive the treatment they preferred.


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