Developing a Theoretical Framework to Illustrate Associations Among Patient Satisfaction, Body Image and Quality of Life for Women Undergoing Breast Reconstruction

Abstract

Within the field of breast reconstruction there is increasing focus on patient-reported outcomes related to satisfaction, body image, and quality of life. These outcomes are deemed highly relevant because the primary goal of breast reconstruction is to recreate the appearance of a breast (or breasts) that is satisfying to the patient. Prominent researchers have suggested the need to develop improved standards for outcome evaluation which can ultimately benefit patients as well as physicians. The purpose of this article is to summarize key findings in the area of patient-reported outcomes for breast reconstruction and introduce a theoretical framework for advancing research in this field. We conducted an extensive literature review of outcome studies for breast reconstruction focusing on patient-reported results. We developed a theoretical framework illustrating core patient-reported outcomes related to breast reconstruction and factors associated with these outcomes. Our theoretical model highlights domains and distinguishing features of patient satisfaction, body image, and quality of life outcomes for women undergoing breast reconstruction. This model further identifies a broad range of variables (e.g., historical/premorbid influences, disease and treatment-related factors) that have been found to influence patient-reported outcomes and need to be taken into consideration when designing future research in this area. Additional attention is given to examining the relationship between patient reported outcomes and outside evaluation of breast reconstruction. Our proposed theoretical framework suggests key opportunities to expand research in this area with the goal of optimizing body image adjustment, satisfaction, and psychosocial outcomes for the individual patient.

Assessing patient-reported outcomes in women undergoing breast reconstruction is highly relevant considering that the primary goal of this treatment is to recreate the appearance of a breast (or breasts) that is satisfying to the patient. Within this field, considerable attention has been given to evaluating the patient’s perspective as evidenced by the number of systematic reviews on patient-reported outcome measures^1–6 and continued development and refinement of these tools.^7–12

A significant challenge in reviewing this research is the variety and breadth of patient-reported outcomes pertinent to breast reconstruction, and inherent limitations in existing tools being used. These limitations include issues relevant to the content of questionnaires (i.e., degree to which they address disease- and treatment-specific variables) as well as psychometric properties (i.e., reliability, validity, and sensitivity to change). Others have suggested the need to transform the field to develop improved standards for outcome evaluation that will ultimately benefit patients and physicians.¹³ The goals of this article are to provide an overview of key findings related to patient-reported outcomes for breast reconstruction and introduce a theoretical framework for advancing research in this field.

Our proposed theoretical framework is based on a biopsychosocial model which considers biological, psychological, and social factors and their complex interaction in understanding health, illness and healthcare delivery^14,15 This approach recognizes that the relationship between mental and physical aspects of health is complex and considers it essential to evaluate the patient’s subjective experience alongside objective biomedical data. At the core of our framework are three central constructs considered essential for evaluating outcomes from breast reconstruction: patient satisfaction, body image, and quality of life. We initially focus on the primary role that patient satisfaction measures have played in outcomes research relevant to breast reconstruction. Although the construct of patient satisfaction is recognized as difficult to define,^16,17 it is considered a basic source of feedback on the patient’s views of her treatment outcome as well as a broad indicator of quality of care. Body image is a multifaceted construct that refers to perceptions, thoughts, and feelings about the body and its functioning.¹⁸ We examine body image as a central factor in the evaluation of breast reconstruction, and discuss how body image measures can be used to facilitate psychosocial care. Finally, we consider quality of life which can be defined as the patient’s appraisal and perception of her overall health status.¹⁹ Quality of life has been extensively studied in women with breast cancer with consistent attention to aspects of psychosocial, physical, and sexual well-being.^1,4,20

Developing an appreciation of the relationships among patient satisfaction, body image, and quality of life requires careful attention to the definition and distinguishing features of these constructs. There are significant challenges with reviewing the vast array of literature in this area, as relevant findings and basic information on the definition of these constructs span across multiple fields which include but are not limited to psychology, psychosocial oncology, nursing, public health, plastic surgery, and general medicine. Not surprisingly, there are numerous definitions offered which contributes to confusion and uncertainty regarding how to best distinguish these constructs from one another. Our theoretical framework is grounded by the notion that while these constructs overlap from a conceptual standpoint, each has multiple distinct dimensions which can be derived from the literature. Table 1 provides concise and commonly-accepted definitions for these constructs and identifies important distinguishing features of each construct. Figure 1 further outlines unique dimensions of patient satisfaction, body image, and quality life which are reviewed below. In this paper, we build upon this framework by delineating key variables associated with these patient-reported outcomes. Ultimately, we believe there are significant opportunities to expand research in this area with the goal of maximizing body image adjustment, patient satisfaction, and psychosocial outcomes for the individual patient.

Table 1.

Definitions and distinguishing features of patient satisfaction, body image, and quality of life outcomes.

Construct	Definition	Issues Specific to Breast Reconstruction	Distinguishing Features
Patient Satisfaction	The patient’s overall evaluation of the quality of health care services received and degree to which treatment expectations were met	Efforts have been made to distinguish between satisfaction with aesthetic outcomes of the breast, with overall treatment outcome, and with the process of care	Focused on evaluating experiences tied specifically to health care Can serve as a broad indicator of quality of care as perceived by the patient
Body Image	A multifaceted construct that refers to the patient’s perceptions, cognitions, behaviors, and emotions related to the entire body and its functioning	Encompasses the range of bodily changes a woman with breast cancer may undergo prior to, during, and following reconstructive treatment	Focused exclusively on experiences tied to the body and its functioning Provides insight into the process of adaptation to bodily changes and identifies specific targets to guide psychosocial treatment
Quality of Life	The patient’s appraisal and perception of overall health status; basic elements of quality of life include evaluation of the patient’s perspective with regards to physical, psychological, and social well-being	Incorporates symptoms specific to breast cancer, cancer treatment, and reconstructive surgery that affect all domains of quality of life Sexual well-being is often incorporated as an added domain in disease-specific quality of life instruments for breast cancer patients	The most wide-ranging patient reported outcome; encompasses nearly all aspects of a patient’s well-being

Figure 1.

Conceptual Framework Illustrating Dimensions of Patient Satisfaction, Body Image and Quality of Life Outcomes for Women Undergoing Breast Reconstruction

Patient Satisfaction

Patient satisfaction is recognized as a legitimate and important healthcare goal, an integral part of high quality healthcare, and a necessary condition of effective care.²¹ Patient satisfaction measures have also been touted as a primary and useful source of feedback about healthcare services. Advantages of utilizing these measures include minimal cost, ease of administration, and ability to provide rapid feedback about the fulfillment of expectations related to treatment. An expanding knowledge base recognizes that many distinct dimensions of satisfaction can be defined.^22,23 Within the field of breast reconstruction, efforts have been made to distinguish between satisfaction with outcome and satisfaction with care. The value of evaluating satisfaction related to overall outcome and satisfaction with specific breast features (e.g., size, shape, symmetry) has also been recognized.²⁰ Additional research supports evaluating how patient-reported outcomes are influenced by satisfaction with various aspects of care during breast cancer treatment. Variables found to affect a wide range of patient-reported outcomes include degree of surgeon specialization, patient’s trust in their provider, and patient’s perceived involvement in the treatment decision making process.^20,24–26

A number of problems have been identified with the use of, and overreliance on, patient satisfaction measures. Methodological issues involving uniformly high levels of satisfaction and limited variability in outcomes have led many researchers to criticize the sensitivity of these instruments and ability to provide useful information to remedy dissatisfaction.^22,27,28 Significant concerns have also been raised about potential influences of social desirability, recall bias and response bias.^21,22,29 Studies have indicated that wording of questions and timing of satisfaction surveys can differentially impact responses. Considerable differences have been found in satisfaction outcomes when utilizing negative descriptive statements as compared to positive statements,³⁰ qualitative versus quantitative study designs²³ or using unstructured compared with more direct questions²². With regards to the timing of surveys, outcomes are influenced by the time lag between use of services and evaluation of satisfaction.²²

Body Image

Body image is a multidimensional construct that extends beyond the evaluation of an individual’s appearance,³¹ and encompasses a wide range of experiences tied to an individual’s body. This includes perceptions, cognitions, behaviors, and emotions related to the body and its functioning. It is widely accepted that body image experiences are entirely subjective, and as such are not necessarily reflective of objective reality. Many have argued that body image is strongly influenced by the degree to which an individual is invested in or places a high degree of importance on physical attributes (i.e., body image investment).^32–34

It is important to recognize the range of bodily changes that a woman with breast cancer may undergo prior to, during the process of, and following treatment that can affect her psychosocial functioning.³⁵. Body image tools can provide valuable and extremely useful information about the process of adaptation to bodily changes from breast reconstruction. More specifically, knowledge about the patient’s perceptions, thoughts, feelings, and behaviors tied to her appearance and bodily changes can be used as targets for psychosocial treatment to ameliorate dissatisfaction with treatment outcome and improve quality of life. Fingeret³⁶ has reviewed a variety of empirically-supported treatment strategies for treating body image difficulties of cancer patients.

Within the oncology setting, a key barrier to conducting conceptually driven research in the area of body image has been the use of inconsistent, unclear or simplistic definitions of this construct.^32,37 As discussed elsewhere, body image cannot be adequately captured with a single-item measure and extends well beyond satisfaction with appearance.^32,36 Few body image instruments are specific to oncology populations, though many of these were developed for women with breast cancer or included breast cancer patients in their validation studies. Unfortunately, significant limitations with regards to the psychometric properties of many existing tools have been identified.^31,32,37

Quality of Life

Our discussion of patient-reported outcomes relevant to breast reconstruction would not be complete without considering the broad construct of quality of life. Similar to patient satisfaction and body image, quality of life is recognized to be multidimensional in nature and entirely subjective. Quality of life outcomes, however, are extremely wide-ranging, and have been described as encompassing nearly all aspects of a patient’s well-being.³⁸ Cella has argued that basic elements of quality of life assessment include evaluation of the patient’s perspective with regards to physical, psychological, and social well-being.¹⁹

Health-related quality of life refers more specifically to the extent to which one’s physical, emotional, and social well-being are affected by a medical condition or its treatment.³⁹ The benefits of incorporating disease and treatment-related factors as part of an assessment of quality of life in medical populations have been widely recognized. In breast cancer patients, another aspect of quality of life routinely considered is sexual well-being. Difficulties with sexual functioning have been reported to be among the most common and distressing symptoms experienced by breast cancer survivors.^35,40,41 Furthermore, problems with sexual functioning are less likely to resolve compared to other side effects of cancer treatment, persisting and potentially worsening into survivorship.³⁵

Overview of Patient-Reported Outcomes Research in Breast Reconstruction

Considerable attention has been given to evaluating patient-reported outcomes based on the type of ablative breast surgery as well as timing and method of reconstruction. When comparing outcomes among treatment with breast conservation therapy (BCT), mastectomy, and mastectomy plus reconstruction, BCT patients generally report the highest levels of satisfaction with cosmetic results.^42–44 Some research, however, suggests that those undergoing reconstructive procedures rate their cosmetic outcomes better than BCT^45,46. When considering quality of life only, findings suggest women undergoing BCT may have comparable long-term outcomes to those undergoing mastectomy with immediate reconstruction.⁴⁷ A more comprehensive review found limited differences between those with mastectomy versus mastectomy with reconstruction across a broad array of studies on measures of body image, sexuality, and quality of life.³

With regards to the timing of reconstruction, both immediate and delayed procedures have been found to provide substantial and lasting psychosocial benefits.^48–50 Some research indicates that overall satisfaction and psychosocial well-being are higher among those with immediate as compared to delayed reconstruction.⁵¹ Many studies have found that method of reconstruction has a limited effect on psychosocial outcomes especially when this is considered over time and following completion of the reconstructive process.^48,50,52 However, there are numerous reports of significant associations between procedure type and satisfaction rates, with autologous tissue-based procedures tending to have higher satisfaction rates than implant-based procedures.^53–55

Other evaluations of patient-reported outcomes with breast reconstruction have focused on disease- and treatment-related factors such as the influence of concomitant therapies, complications, and the stage of reconstruction. Patients undergoing adjuvant radiation therapy tend to report significantly higher rates of reconstructive failure and complications and lower levels of satisfaction.^56–58 Colakoglu et al⁵⁹ found that although the development of a complication increased the overall odds of aesthetic dissatisfaction, patients undergoing prophylactic mastectomy and reconstruction were the most likely to be dissatisfied when complications occurred. Not surprisingly, satisfaction rates are also significantly affected by the stage of completion with the reconstructive process. Buck et al.⁶⁰ found lower satisfaction with cosmesis during the initial stages of tissue-expander breast reconstruction, whereas maximal satisfaction was achieved after addition of the nipple and areola.

A considerable amount of research has examined the influence of obesity on reconstruction outcomes and resulting patient satisfaction. Obese patients present challenges with obtaining optimal cosmetic results following reconstruction due to well documented risks of higher complication rates as well as the general involvement of larger breast volumes and greater degree of ptosis.^61,62 Although there have been few studies to date evaluating patient-reported outcomes based upon BMI, some research suggests there may be limited differences for obese patients as compared to normal-weight patients. Kulkarni et al found that patient satisfaction with surgical outcomes were similar across BMI categories, with obese patients more likely to receive an autologous reconstruction compared to an implant-based reconstruction.⁶¹ Similarly, Atisha et al found no differences in general satisfaction with outcome for either expander/implant or TRAM flap based on BMI.⁶³ However, obese patients were found to have lower levels of aesthetic satisfaction with implant-based reconstruction as compared to normal weight patients

Variables outside the healthcare system, such as demographics, personality, and psychological traits also influence adjustment, satisfaction, and quality of life.^23,64 Among demographic variables age is the most frequently considered and evaluated, with mixed findings. Alderman et al⁵⁴ found that age was not significantly associated with overall or aesthetic satisfaction one year following reconstruction. In their retrospective study, Colakoglu et al⁵⁹ found older age predicted dissatisfaction with reconstruction. By contrast, Harcourt et al⁶⁵ found that younger age predicted declines in body image at 6 and 12 months after surgery among a mixed sample of women undergoing mastectomy with and without reconstruction.

With regards to psychological functioning, difficulties involving depressed mood, distress, and anxiety have been found to be predictive of decreased satisfaction with reconstructive outcomes.^66,67 Associations among psychological functioning, body image outcomes, and patient-perceived aesthetic outcomes have also been demonstrated. For example, Harcourt et al found that higher levels of anxiety and depression predicted poorer body image scores at 6 months and 12 months after surgery.⁶⁵ Nicholson et al found lower levels of depression and reduced self-consciousness about appearance were significantly related to cosmesis scores as rated by patients.⁴⁵

Theoretical Framework to Facilitate Understanding of Patient-Reported Outcomes

Figure 2 expands our theoretical framework to highlight core patient-reported outcomes in the field of breast reconstruction and identifies numerous factors associated with these outcomes. This framework is intended to enhance understanding of the complex array of variables that can impact a patient’s psychosocial adjustment to breast reconstruction, and involves consideration of historical/premorbid influences, disease/treatment related factors, and external evaluation of outcomes. Further attention is given to delineating key variables within these broad categories that have been found to influence outcomes involving patient satisfaction, body image, and quality of life (see Table 2) Findings related to many of these key variables have been discussed above.

Figure 2.

Conceptual framework illustrating core patient-outcomes related to breast reconstruction and factors associated with these outcomes

Table 2.

Key Variables that May Influence Patient-Reported Outcomes Related to Breast Reconstruction

Historical/Premorbid Influences	Disease/Treatment Related Factors
Demographics	Tumor Characteristics
Age	Cancer type
Socioeconomic status	Tumor stage
Ethnicity	Biomedical markers (BRCA)
Race
Marital status
Psychological/Social Factors	Cancer Treatment
Personality traits	Prophylaxis
Depression	Mastectomy
Anxiety	Radiation therapy
Social support	Chemotherapy
Coping style	Other
Medical factors	Reconstruction
Body mass index	Preoperative expectations
Comorbidities	Type of reconstruction
Smoking status	Timing of reconstruction
History of cosmetic procedures	Laterality
Previous breast surgery	Time point in process
	Other
	Complications
	Pain

Historical/Premorbid Influences

Historical factors and premorbid influences refer to attributes and past events that have a strong potential to influence how a women responds and adapts to bodily changes resulting from breast reconstruction. These influences can be considered within three broad subcategories reflecting demographic variables, psychological/social factors, and medical factors. With regards to demographic variables, numerous studies identify unique psychosocial experiences and challenges for women with breast cancer based upon age.^68–71 A growing body of literature is focused on “the ethnic divide in breast reconstruction”.⁷² This work highlights issues with access to care based upon socioeconomic status and other demographic variables.^72–74 Marital status and relationship satisfaction have been included in our model because of research identifying these as strong predictors of sexual functioning and psychological adjustment for women with breast cancer.^40,69

Medical factors relevant to our model include body mass index (BMI), smoking status, comorbidities, and history of cosmetic procedures including previous breast surgery. BMI and smoking status were included based on research demonstrating that both significantly increase the odds of experiencing a complication with reconstruction.^75–77 There is also a large body of literature linking BMI, smoking, and cosmetic surgery to body image outcomes in the general population.⁷⁸ Further work reveals unique issues to consider when performing breast reconstruction in patients who have previously undergone augmentation.⁷⁹ We have thus included previous breast surgery along with history of cosmetic procedures as potentially important variables for further study.

More recent attention has been given to identifying personality features that are significantly associated with quality of life in women undergoing breast reconstruction as well as psychological issues to consider for this patient population. Personality dimensions related to temperament and interpersonal style have been found to predict quality of life outcomes for women undergoing breast reconstruction.⁸⁰ As previously discussed, there is a growing body of research dedicated to examining the psychological impact of breast reconstruction.^{45,65–67,81} This includes work demonstrating the significant influence that complications can have on psychological outcomes⁸² which further reinforces the importance of being able to provide psychological support and counseling to patients undergoing breast reconstruction. Two final psychosocial variables we consider are social support and coping style, due to a vast array of literature demonstrating the influential role of these variables on psychosocial adjustment to cancer⁸³ and other disfiguring conditions.^84,85 Coping styles are dynamic cognitive, emotional, and behavioral strategies to manage threats that are appraised as stressful.⁸⁶ Within the context of breast cancer, various coping styles have been shown to predict outcomes such as psychological and physical adjustment⁸⁷ and posttraumatic growth⁸⁸.

Disease/Treatment Factors

Previous research suggests that when evaluated individually, certain disease and treatment-related factors may not have a strong relationship with patient-reported outcomes. However, findings are equivocal and one must consider the complex interplay between these factors and effects they may have on different dimensions of patient satisfaction, body image, and quality of life outcomes. Our proposed framework delineates a broad array of disease- and treatment-related variables that may impact a woman’s psychosocial adjustment to breast cancer (see Table 2). Cancer treatment and reconstruction factors given the most attention in the literature on patient-reported outcomes include type of ablative surgery (BCT versus total mastectomy), type and timing of reconstruction, stage of reconstruction, complications and radiation therapy as already discussed above. Additional research supporting the inclusion of other disease/treatment factors include studies demonstrating that nipple sparing mastectomy^89,90, prophylactic procedures^59,91,92, type of implant used^57,93, laterality of reconstruction⁹⁴, and expectations of surgery⁹⁵ can significantly affect patient-reported outcomes. Although limited attention has been given to studying the effects of tumor characteristics on patient-reported outcomes, research suggests that patient education and counseling needs to be more targeted to enhance communication and alleviate unnecessary confusion and distress regarding prognosis.⁹⁶

External Evaluation of Reconstruction Outcomes

Our theoretical framework further identifies the importance of considering the relationship between patient reported outcomes and external evaluation of breast reconstruction outcomes. This component reflects a key aspect of the biopsychosocial model in recognizing the benefit of evaluating the patient’s subjective experience alongside external data from experts, other observers, and objective outcomes. Numerous studies have found that patient’s assessments of aesthetic outcomes following breast reconstruction differ significantly from clinician’s assessments.^97,98 Current methods used by physicians or other observers to assess breast reconstruction outcome typically involve rating breast aesthetics from photographs, digital images, or direct viewing of the patient. These methods are widely used in the field of breast reconstruction though they have been criticized for demonstrating low interrater and intrarater reliability and being susceptible to observer bias.^98–100 Additionally, substantial variability has been found across studies with regards to what aspects of breast aesthetics are being evaluated.¹⁰⁰ There is growing interest and attention to incorporating objective measures of reconstructive outcome, which typically involve conducting physical measurements of breast features. We found numerous studies reviewing information on developing technologies for quantifying surgical outcomes in the field of breast reconstruction.^98,101–104 The growth of literature in this area is promising and reflects considerable opportunities for future research to develop a more sophisticated understanding of the relationship between patient’s subjective assessment of her reconstructive outcome as compared an external evaluation.

Discussion

Within the field of breast reconstruction, evaluating the patient’s perspective of her treatment outcome is of paramount importance. However, current approaches to examining patient-reported outcomes have been widely criticized as being of limited benefit and value.^13,100 Three particular issues raised repeatedly in the literature are the lack of prospective randomized trials, lack of uniformity with regards to outcome measures being used, and poor quality of measures in terms of psychometric properties. In this paper, we synthesized research findings across the fields of plastic surgery, psychology, and psychosocial oncology, and presented a conceptual model to facilitate future advancements in the field of breast reconstruction pertinent to patient-reported outcomes. We consider this to be an introductory model that will benefit from further development and refinement with additional research. At the heart of our model are three fundamental constructs: patient satisfaction, body image and quality of life. Each of these is recognized to play a valuable and unique role in evaluating outcomes of breast reconstruction. Particular emphasis was placed on delineating clear and concise definitions of these constructs, discussing distinguishing features, and identifying additional issues with these constructs that are specific to the field of breast reconstruction (see Table 1). We believe this can provide a useful guide to reconstructive surgeons and others conducting research in this field who may not be as familiar with psychosocial outcomes.

When considering patient-reported outcomes for women undergoing breast reconstruction, it is of ultimate interest and value to understand how the patient adapts to bodily changes resulting from reconstructive treatment. This underscores the need to highlight and emphasize body image as a core outcome alongside patient satisfaction and quality of life. As seen in Table 1, a distinguishing feature of body image is that it is focused exclusively on experiences tied to the body and its functioning. The significance of body image has at times been overlooked in the breast reconstruction literature with some research failing to draw distinctions between body image and patient satisfaction outcomes, and other work only considering body image within the broader umbrella of quality of life outcomes. Body image tools have distinct advantages in providing information on how women adapt to bodily changes resulting from breast reconstruction. They can also provide specific targets to ameliorate dissatisfaction with treatment outcome. We seek to draw further attention to a rich and robust literature within the field of psychology illustrating the complex nature of body image and identifying particular attitudes, behaviors, emotions, and coping strategies which contribute to body image disturbance^31,78 Research in this area encompasses medical populations with disfiguring conditions and attends to concepts involving body image investment (i.e., degree of importance placed on appearance)^32,34 somatic/sensory awareness (i.e, attentiveness to bodily sensations),³¹ and bodily integrity (i.e., valuing one’s body as an intact and functional entity).¹⁰⁵

Our conceptual framework illustrates significant overlap and interrelationships among patient satisfaction, body image, and quality of life. One way this model can be used in practice is to evaluate the nature of associations among these constructs to clarify the degree of overlap and establish empirically that each plays a unique role in evaluating outcomes of breast reconstruction. This will help to resolve any controversy as to whether body image stands alone or should be subsumed by the broader construct of quality of life. We offer preliminary evidence from work conducted with other cancer patients that associations between quality of life and body image outcomes are indeed significant (rs between −0.32 and −0.54) but not of a magnitude to indicate that are entirely overlapping.¹⁰⁶ When considering key findings in the area of patient-reported outcomes for breast reconstruction, it is clear that a myriad of factors have been shown to influence a patient’s perspective on her reconstructive outcome and warrant consideration in future studies.. While many of these factors are tied specifically to breast cancer treatment and the reconstructive surgery process, others fall well outside this scope such as demographic characteristics and underlying personality/psychological features. Our conceptual framework is designed to raise awareness about the complex interplay of factors that can impact a patient’s psychosocial adjustment to breast reconstruction and facilitate further research to maximize adjustment. We offer a variety of different ways this framework could be used in a practical manner to help advance the field. Further work is needed to better understand which patients are at greatest risk for being dissatisfied with reconstructive outcome and experiencing poor body image and quality of life during and following treatment. One could also argue the need to consider which factors protect against adverse outcomes thereby promoting optimal psychosocial adjustment. The proposed framework can be used to aid in selection of variables to study/consider and has the benefit of providing greater structure and organization to research in this area. We fully intend for this model to evolve over time as future research is conducted. Specific attention must be paid to variables that are potentially modifiable and may therefore constitute the components of an intervention to improve outcomes. Additional focus should be given to factors that are unmodifiable as some of these may be indicators of patients who are more likely to benefit from particular types of intervention and support.

This framework can also be used to facilitate studies involving the development, delivery and effectiveness of interventions to facilitate psychosocial adjustment to breast reconstruction. Specific attention must be paid to determining the optimal timing of intervention delivery and to evaluating whether and how body image, patient satisfaction and quality of life may change throughout the course of reconstructive treatment. A key variable addressing this issue is time point in the reconstructive process. It would be particularly value to determine the degree to which this model is dynamic, and to understand how relationships among variables of interest change during the course of treatment and into long-term survivorship. Further work can investigate the tailoring of interventions based on factors in the model, and developing and testing novel intervention strategies targeting modifiable factors in the model.

Our framework also suggests a need to enhance research examining the relationship between patient-reported outcomes and objective evaluation of breast reconstruction. We currently do not have an adequate understanding of the potential disconnect between how a patient evaluates her outcome compared to how others view her reconstructive outcome. This disconnect has been studied more specifically between patients and healthcare providers, but there would be significant value to evaluating concordance between patient’s views and significant others’ views as this has implications for intimacy and marital functioning. Work is also needed to understand how the opinions and coping mechanisms of the significant other contribute in a positive or negative way to the patient satisfaction, body image, and quality of life. Future work must also entail examination of factors that impact the relationship between a patient’s views of her reconstructive outcome and more objective measures of reconstructive outcome. Further advancements in the field of quantifying oncologic surgical outcomes cannot be made unless these outcomes are examined in conjunction with the patient’s perspective

It is important to acknowledge and consider other conceptual models recognized in the literature that are of relevance to women’s psychosocial adjustment to breast reconstruction. Rumsey and colleagues have produced an extensive report of findings designed to investigate psychosocial factors and processes contributing to successful adjustment to disfiguring conditions.⁸⁵ They present a conceptual model to explain the complex and multivariate nature of adjustment that can be applied to individuals with a range of disfiguring conditions, including cancer. Our framework is unique in that it specific to cancer patients undergoing breast reconstruction and incorporates a large number of disease and treatment-related variables. This Rumsey model shares many similar features with our conceptual framework with its inclusion of age and social support and its considerable focus on personality and psychological factors. The Rumsey model, however, offers insight into social and cognitive processes that help to explain adjustment to a broad spectrum of disfiguring conditions. Their findings reveal that optimism, feelings of social acceptance, satisfaction with social support, concerns about negative evaluation by others, salience and valence afforded to appearance-related information, and social comparison all play a strong and significant role in predicting adjustment to disfigurement. These are all variables to be considered in future research specifically with women undergoing breast reconstruction.

There are other conceptual models reported in the literature that contributed more directly to our framework, due to their exclusive focus on one of our main constructs of interest. These include Cash’s cognitive behavioral model of body image development,³⁴ White’s heuristic cognitive behavioural model of body image disturbance among cancer patients,³² and Klassen and colleagues conceptual model of patient satisfaction and quality of life in breast surgery patients.²⁰ Our model has distinct advantages of bringing together patient satisfaction, body image, and quality of life and delineating a wide range of additional factors that have been found to influence outcomes specifically for women undergoing breast reconstruction.

A key variable we include that is receiving increasing attention in the literature involves patient expectations for breast reconstruction. One group of researchers has conducted several qualitative studies to further examine the informational needs and expectations of patients undergoing different forms of breast surgery. Spector et al described many aspects of the postsurgical experience women felt they were not adequately prepared for by their healthcare providers which related to unexpected postoperative physical sensations and unanticipated outcomes.¹⁰⁷ This study also identified specific information found helpful and unhelpful by women, and provides useful recommendations for healthcare providers with regards to preparing women both before and after breast surgery. Snell and colleagues used a similar study design to investigate preoperative expectations for women undergoing implant-based reconstruction.¹⁰⁸ Comparable findings were reported such that patients often had unclear expectations regarding physical outcomes of the reconstructed breast. They also found more specific concerns regarding appearance outcomes with inaccurate expectations corresponding to dissatisfaction with final cosmetic results. Pusic and colleagues have developed a preliminary conceptual framework of patient expectations in breast reconstruction that identifies specific concerns of patients deemed important to address and further evaluate, which include appearance and outcome of the breasts, psychosocial impact, physical impact, and process of care and recovery.¹⁰⁹ This work clearly identifies the importance of understanding and managing patient expectations for breast reconstruction, and recognizes the value of evaluating the relationship between expectations and patient-reported outcomes.

Conclusions

There are considerable opportunities to expand and improve research with patient-reported outcomes in the field of breast reconstruction. We introduce a theoretical framework based upon an extensive literature review of findings that span across the fields of psychology, psychosocial oncology, and plastic/reconstructive surgery. This framework is rooted in a biopsychosocial model highlighting the importance of the patient’s perspective of her outcomes and recognizes that the relationship between mental and physical aspects of heath is complex. Our framework has a number of advantages in that it is specific to breast reconstruction and can be used to help guide and structure multidisciplinary research. We offer a number of ways our framework can be used in practice. We did not specifically address the broader methodological issues in the field as many other review articles have focused on these problems and offered guidance in this arena.^1–3,5,100 Ultimately, we believe our framework has important implications for developing and delivering psychosocial interventions to maximize satisfaction, body image, and quality of life. These interventions may be of particular value prior to beginning reconstruction to set and manage appropriate expectations for aesthetic outcome. However, targeted interventions to facilitate psychosocial adjustment during reconstructive treatment and into survivorship are also needed.