title: Barriers to Completing Delayed Breast Reconstruction Following Mastectomy: a Critical Need for Patient and Clinician Education.
abstract: Rates of breast reconstruction following mastectomy vary widely, and little is known about why women who originally express an interest in breast reconstruction do not receive it. Improved documentation of clinical decision-making is one of the potential benefits of the electronic health record (EHR), and may serve as a tool to enhance patient-centered, clinical outcomes research. The goals of this study were to explore patterns in delayed reconstruction (DR), identify barriers to follow through, and to determine the adequacy of EHR documentation in providing information about decision-making for breast reconstruction. Retrospective EHR review of women undergoing mastectomy, 2008-2012, was conducted in an academic medical center in New England. Data included patient demographics, cancer stage, co-morbidity index, post-mastectomy reconstruction status, and documented decision-making regarding reconstruction. Of 367 women who had undergone a total mastectomy, 219 did not receive immediate reconstruction. Of these, 24.6 % expressed no interest in DR, 21.9 % expressed interest but were still pending the procedure, and 5.9 % had completed DR. Of decision-making regarding breast reconstruction, 47.5 % lacked documentation. Median follow-up was 34 months. Reasons for not following through with DR included poor timing (25 %), indecision (17 %), desired method of reconstruction not available at treating facility (10 %), persistent obesity (8.3 %), continued smoking (4 %), and reason not specified (35 %). Many women do not receive breast reconstruction despite expressing an initial interest in the procedure. Reasons were multi-factorial and the extent of documentation was inconsistent. Further exploration of potential barriers to breast reconstruction as well as opportunities to enhance shared decision-making may serve to improve patient experience and satisfaction following mastectomy.
authors.affiliation: Department of Surgery, Danbury Hospital, Danbury, CT, USA.|Department of General Surgery Residency, 24 Hospital Ave, Danbury, CT, 06810, USA.
authors.forename: Aleksandra
authors.initials: A
authors.lastname: Ogrodnik
authors.affiliation: Department of Surgery, University of Vermont, 89 Beaumont Ave, Given Building, Burlington, VT, 05405, USA.|Department of Surgery, University of Vermont College of Medicine, 111 Colchester Ave, Burlington, VT, 05401, USA.
authors.forename: Susan
authors.initials: S
authors.lastname: MacLennan
authors.affiliation: Department of Pathology, University of Vermont, Burlington, VT, 05405, USA.|Department of Pathology and Laboratory Medicine, University of Vermont College of Medicine, 89 Beaumont Avenue, Courtyard at Given S269, Burlington, VT, 05405, USA.
authors.forename: Donald
authors.initials: D
authors.lastname: Weaver
authors.affiliation: Department of Surgery, University of Vermont, 89 Beaumont Ave, Given Building, Burlington, VT, 05405, USA. ted.james@uvm.edu.
authors.forename: Ted
authors.initials: T
authors.lastname: James
mesh_terms: D000328:Adult; D001943:Breast Neoplasms / Q000601:surgery*; D003657:Decision Making; D057286:Electronic Health Records / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D016462:Mammaplasty / Q000523:psychology / Q000592:standards*; D008408:Mastectomy; D008875:Middle Aged; D009367:Neoplasm Staging; D009511:New England; D010353:Patient Education as Topic; D012189:Retrospective Studies; D055815:Young Adult
keywords: Breast cancer; Breast reconstruction; Decision-making; Quality improvement