title: Formal analysis of the surgical pathway and development of a new software tool to assist surgeons in the decision making in primary breast surgery.
abstract: BACKGROUND
  The increased complexity of the decisional process in breast cancer surgery is well documented. With this study we aimed to create a software tool able to assist patients and surgeons in taking proper decisions.
  
  
  METHODS
  We hypothesized that the endpoints of breast cancer surgery could be addressed combining a set of decisional drivers. We created a decision support system software tool (DSS) and an interactive decision tree. A formal analysis estimated the information gain derived from each feature in the process. We tested the DSS on 52 patients and we analyzed the concordance of decisions obtained by different users and between the DSS suggestions and the actual surgery. We also tested the ability of the system to prevent post breast conservation deformities.
  
  
  RESULTS
  The information gain revealed that patients preferences are the root of our decision tree. An observed concordance respectively of 0.98 and 0.88 was reported when the DSS was used twice by an expert operator or by a newly trained operator vs. an expert one. The observed concordance between the DSS suggestion and the actual decision was 0.69. A significantly higher incidence of post breast conservation defects was reported among patients who did not follow the DSS decision (Type III of Fitoussi, N = 4; 33.3%, p = 0.004).
  
  
  CONCLUSIONS
  The DSS decisions can be reproduced by operators with different experience. The concordance between suggestions and actual decision is quite low, however the DSS is able to prevent post- breast conservation deformities.
authors.affiliation: U.O. C. Senologia - Azienda Ospedaliera Cannizzaro, Via Messina 829, Catania, Italy; Scuola di Oncologia Chirurgica Ricostruttiva - Onlus, Milano, Italy. Electronic address: giuseppecatanuto@gmail.com.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Catanuto
authors.affiliation: Università degli Studi di Catania, Catania, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Pappalardo
authors.affiliation: Dipartimento di Medicina Clinica e Chirurgia, Università di Napoli 'Federico II', Napoli, Italy.
authors.forename: Nicola
authors.initials: N
authors.lastname: Rocco
authors.affiliation: Università degli Studi di Catania, Catania, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Leotta
authors.affiliation: U.O. C. Senologia - Azienda Ospedaliera Cannizzaro, Via Messina 829, Catania, Italy.
authors.forename: Venera
authors.initials: V
authors.lastname: Ursino
authors.affiliation: Unità di Statistica Medica, Seconda Università di Napoli, Napoli, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Chiodini
authors.affiliation: U.O.C. Senologia - Ospedale Morgagni-Pierantoni, Forlì, Italy.
authors.forename: Federico
authors.initials: F
authors.lastname: Buggi
authors.affiliation: U.O.C. Senologia - Ospedale Morgagni-Pierantoni, Forlì, Italy.
authors.forename: Secondo
authors.initials: S
authors.lastname: Folli
authors.affiliation: U.O. C. Senologia - Azienda Ospedaliera Cannizzaro, Via Messina 829, Catania, Italy.
authors.forename: Francesca
authors.initials: F
authors.lastname: Catalano
authors.affiliation: Scuola di Oncologia Chirurgica Ricostruttiva - Onlus, Milano, Italy.
authors.forename: Maurizio B
authors.initials: MB
authors.lastname: Nava
mesh_terms: D001940:Breast / Q000473:pathology / Q000601:surgery; D001943:Breast Neoplasms / Q000523:psychology / Q000601:surgery*; D003657:Decision Making; D003658:Decision Making, Computer-Assisted; D003661:Decision Support Techniques; D023381:Endpoint Determination / Q000379:methods; D005260:Female; D006801:Humans; D008408:Mastectomy / Q000523:psychology*; D008875:Middle Aged; D011183:Postoperative Complications / Q000517:prevention & control; D015203:Reproducibility of Results; D012984:Software; D066231:Surgeons / Q000523:psychology
keywords: Breast reconstructive surgery; Cosmetic outcome; Decision making in breast surgery; Oncoplastic surgery; Prevention of defects