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. Author manuscript; available in PMC: 2017 Feb 1.
Published in final edited form as: J Plast Reconstr Aesthet Surg. 2015 Nov 26;69(2):149–162. doi: 10.1016/j.bjps.2015.11.013

The BREAST-Q In Surgical Research: A Review Of The Literature 2009–2015

Wess A Cohen 1, Lily R Mundy 2, Tiffany NS Ballard 3, Anne Klassen 4, Stefan J Cano 5, John Browne 6, Andrea L Pusic 1
PMCID: PMC4995882  NIHMSID: NIHMS809391  PMID: 26740288

Abstract

Introduction

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 (HR-QOL) and patient satisfaction for use in both clinical practice and research. Now five years from its initial publication, we review how researchers have utilized 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 in 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 under utilized potential of the BREAST-Q should permit its continued use and ability to foster new innovations and improve quality of care.

Introduction

Health outcomes research in surgery has gained considerable traction over the past decade as the surgical community attempts to curb soaring health care costs and move past traditional outcome measures such as morbidity and mortality.1 As a component of this change, patient-reported outcome measures (PROMs), wherein the patient’s perception of his or her outcomes is quantified, have become increasingly important.2 In plastic surgery, patient-centered outcomes data is of particular importance as the majority of operative interventions aim to improve appearance, function and/or quality of life. Thus, while photographic analysis remains indispensable, the new focus on patient perceptions offers potentially valuable insights into the effectiveness of surgical interventions.

The BREAST-Q, a validated PROM now translated into thirty languages, quantifies the impact of cosmetic and reconstructive breast surgery (i.e., augmentation, reduction/mastopexy, mastectomy, reconstruction, and breast conserving-therapy), pre- and post-operatively, on health-related quality of life (HR-QOL; including physical, psychosocial, and sexual well-being) and patient satisfaction (including satisfaction with breasts, outcome, and care) (see Figure 1). Investigators and clinicians can choose to use only those scales that are pertinent to their research question. The questionnaire items in each scale are arranged in a clinically relevant hierarchy (e.g., Satisfaction with Breasts scale ranges from “How satisfied are you with how you look in a mirror clothed?” to “How satisfied are you with how you look in the mirror unclothed?”). While each scale produces an independent score from 0–100, there is no overall BREAST-Q score. Scores are transformed via the Q-Score program (https://webcore.mskcc.org/breastq/) or designated tables.2,3

Figure 1.

Figure 1

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BREAST-Q conceptual framework. (Pusic A, Klassen A, Scott A, et al. Development of a new patient-reported outcome measure for breast surgery: the BREAST-Q. with permission.)

In this review, we examine the use of the BREAST-Q in the surgical research literature, and in particular how use of the BREAST-Q has enhanced the understanding and the practice of plastic and reconstructive breast surgery.

Methods

An electronic literature review was performed to identify publications that used the BREAST-Q as an outcome measure. Two search engines, PubMed and EMBASE, were queried with the terms “BREAST-Q” and “BREASTQ” from inception to January 2015. Two authors (WC and LM) separately reviewed all of the titles and abstracts of all articles identified in the search to exclude non-relevant articles. Any differences in opinion were resolved by a third author (AP). Included articles described the use of the BREAST-Q in a primary research study that assessed patient outcomes in a breast surgery population. Studies developing and/or validating the BREAST-Q or an alternate PROM, review papers, conference abstracts, thesis, commentaries, letters to the editor, studies that used a modified a version of BREAST-Q, and studies not published in English were excluded. A citation review of included articles was performed to identify any additional articles.

For publications that met the study inclusion criteria, we extracted the following information: country of origin, study aim, study design, sample size, BREAST-Q module utilized, and key findings. Study design was classified as prospective cohort or cross-sectional. Prospective cohort studies were defined as studies in which patients completed the BREAST-Q at multiple time points. Cross sectional studies were defined as those in which patients completed the BREAST-Q at a single time point. BREAST-Q data collection was classified as pre-operative, post-operative, or both.

Results

Our literature review yielded 214 unique articles. After implementing the exclusion criteria, 49 manuscripts from peer-reviewed journals met our inclusion criteria and were included in the analysis (Figure 2).

Figure 2.

Figure 2

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Article inclusions and exclusions

Since its inception in 2009, the number of publications incorporating the BREAST-Q has increased each year (Figure 3). From the 49 publications, a total of 22,457 patients completed at least one subdomain of the BREAST-Q. Of these participants, 20,390 patients completed one or more scales from the breast reconstruction module. The breast reconstruction module was utilized in 39 references; the augmentation module was reported in 7 references; the reduction module in four; and the mastectomy module in three.

Figure 3.

Figure 3

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Frequency of BREAST-Q by year.

The cross sectional study design was the most prevalent, being used in 71% of publications (n=35). The BREAST-Q was administered in a prospective study design in 29% of studies (n = 14). Two studies distributed the questionnaire only pre-operatively, 29 only post-operatively, and 18 both pre- and postoperatively. Within the augmentation module, the majority of studies included both pre- and post-operative assessments (71%), while among the reconstruction module, post-operative assessment only was more common (72%).

In all but one publication, the Satisfaction with Breasts scale was used. Within the HR-QOL domain, the sexual, physical, and psychosocial domains were used with almost equal frequency in 41, 40, and 43 studies, respectively (Figure 4).

Figure 4.

Figure 4

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Domain and subdomain frequency.

Table 1 provides a summary of findings from the 49 publications identified by this review. The comparative effectiveness of different approaches to breast reconstruction was a popular topic; authors investigated outcomes of silicone versus saline implants, and also of autologous versus implant reconstruction. The BREAST-Q was used to highlight emerging techniques in plastic surgery with fat grafting figuring prominently. It was also used in one large UK study to compare the performance of different hospital providers. Lastly, while much of the literature focused on surgical outcomes, a number of studies also used the BREAST-Q to evaluate the patient experience.

Table 1.

Summary of BREAST-Q publications

First Author Year Country of Origin Level of Evidence Title n Study Design Relevant Key Findings
Augmentation
 McCarthy 2012 USA 2c The magnitude of effect of cosmetic breast augmentation on patient satisfaction and health-related quality of life 41 Prospective Breast augmentation was associated with an increase in satisfaction with breasts, psychosocial, and sexual well-being compared to preop.
 Coriddi 2013 USA 2c Analysis of Satisfaction and Well-Being in the Short Follow-up From Breast Augmentation Using the BREAST-Q, a Validated Survey Instrument 129 Prospective Breast augmentation was associated with higher scores for satisfaction with breasts, psychosocial and sexual well-being, and lower scores for physical well-being compared to pre-op. Satisfaction with outcome was associated most strongly with satisfaction with breasts.
 Weigert 2013 France 2c Patient satisfaction with breasts and psychosocial, sexual, and physical well-being after breast augmentation in male-to-female transsexuals 35 Prospective Breast augmentation was associated with improved satisfaction with breasts, sexual and psychosocial well-being at least 4 months post-op compared to preop.
 Alderman 2014 USA 2c Understanding the Effect of Breast Augmentation on Quality of Life: Prospective Analysis Using the BREAST-Q 611 Prospective Breast augmentation was associated with higher patient satisfaction with breasts, psychosocial, and sexual well-being, and a decrease in physical well-being compared to preop. Older patients were found to have less satisfaction with breasts compared to younger patients.
 Gryskiewicz 2014 USA 2c Transaxillary Nonendoscopic Subpectoral Augmentation Mammaplasty: A 10-Year Experience With Gel vs Saline in 2000 Patients—With Long-Term Patient Satisfaction Measured by the BREAST-Q 670 Cross-sectional Axillary augmentation compared with non-axillary augmentation was associated with higher satisfaction with breasts and outcome. Satisfaction with outcome was greater in patients with silicone gel compared with saline implants.
 Spear 2014 USA 2c A Prospective Study on Lipoaugmentation of the Breast 10 Prospective Satisfaction with breasts and sexual well-being was higher after lipoaugmentation compared to preop, however statistical significance was not reported.
Reduction/Mastopexy
 Carty 2012 USA 2c Patient satisfaction and surgeon experience: A follow-up to the reduction mammaplasty learning curve study 279 Cross-sectional Older patients compared with younger were more satisfied with breasts after reduction mammaplasty. Post-operative soft tissue necrosis was associated with lower satisfaction with breasts and outcome. No differences were found in patient satisfaction with outcomes and/or breasts based on surgeon age or experience.
 Gonzalez 2012 USA 2c Quality of life after breast reduction surgery: a 10-year retrospective analysis using the Breast Q questionnaire: does breast size matter? 178 Cross-sectional Breast reduction was associated with high satisfaction with outcome. No difference was found in satisfaction with outcome by quantity of breast tissue removed.
 Coriddi 2013 USA 2c Analysis of satisfaction and well-being following breast reduction using a validated survey instrument: The BREAST-Q 49 Prospective Breast reduction was associated with higher satisfaction with breasts, psychosocial, sexual, and physical well-being compared to preop. Satisfaction with outcome and breast after reduction were highly correlated.
 Gurunluoglu 2013 USA 2c Outcomes analysis of patients undergoing autoaugmentation after breast implant removal 20 Prospective Breast implant removal and autoaugmentation was associated with higher satisfaction with breasts, psychosocial and sexual well-being compared to preop.
Reconstruction
 Macadam 2010 Canada 2c Patient Satisfaction and Health-Related Quality of Life following Breast Reconstruction: Patient-Reported Outcomes among Saline and Silicone Implant Recipients 143 Prospective Silicone implants compared with saline implants in breast reconstruction was associated with higher satisfaction with outcome, surgeon, psychosocial and sexual well-being. Saline implants were associated with higher systemic side effects.
 McCarthy 2010 USA 2c Patient satisfaction with postmastectomy breast reconstruction a comparison of saline and silicone implants 482 Cross-sectional Silicone implants compared with saline implants in breast reconstruction was associated with higher satisfaction with breasts. Post-mastectomy radiotherapy and a longer time since reconstruction was negatively associated with satisfaction with breasts.
 Goyal 2011 UK 2c Outcomes after autologous dermal sling-assisted immediate breast reconstruction 14 Cross-sectional Breast reconstruction using a dermal sling was associated with high satisfaction with breasts and outcome.
 Huang 2011 Taiwan 2c Simultaneous scarless contralateral breast augmentation during unilateral breast reconstruction using bilateral differentially split DIEP flaps 6 Prospective Breast reconstruction was associated with higher satisfaction with breasts, psychosocial, and sexual well-being compared to preop.
 Salgarello 2012 Italy 2c Fat Grafting and Breast Reconstruction with Implant: another option for irradiated breast cancer patients 16 Cross-sectional Fat grafting followed by implant-based reconstruction of radiated breasts was associated with high patient satisfaction and well-being across all domains.
 Salgarello 2012 Italy 2c Immediate breast reconstruction after skin-nipple-sparing mastectomy for previously augmented patients: A personal technique 24 Cross-sectional Breast reconstruction in patients with previous augmentation was associated with higher satisfaction with breasts.
 Dean 2013 Australia 2c Rotation flap approach mastectomy 37 Cross-sectional Breast reconstruction compared to mastectomy only was associated with greater satisfaction with breasts and psychosocial well-being.
 Inbal 2012 Israel 2c Simultaneous Contralateral Breast Adjustment in Unilateral Deep Inferior Epigastric Perforator Breast Reconstruction 51 Cross-sectional Unilateral DIEP with simultaneous, delayed or no contralateral surgeries were compared. No differences in BREAST-Q scores between simultaneous or delayed adjustments.
 Salgarello 2012 Italy 2c Inverted-T skin-reducing mastectomy with immediate implant reconstruction using the submuscular-subfascial pocket 14 Cross-sectional Breast reconstruction was associated with high satisfaction and well-being in all subdomains except in two patients who had substantial skin necrosis.
 Zhong 2012 Canada 2c Patient satisfaction and health-related quality of life after autologous tissue breast reconstruction: A prospective analysis of early postoperative outcomes 51 Prospective Breast reconstruction was associated with an improvement in satisfaction with breasts, sexual well-being and psychosocial well being. Physical well-being of chest and abdomen was lowest at 3 weeks postoperative, with significant improvement at 3 months.
 Cha 2013 New Zealand 2c Patient-reported outcomes following breast reconstruction surgery in a public hospital: use of the Breast-Q questionnaire 75 Cross-sectional Satisfaction with medical team and office staff after breast reconstruction varied by ethnicity, with Europeans more satisfied than Maori or other ethnicities.
 Eltahir 2013 The Netherlands 2c Quality-of-life Outcomes between Mastectomy Alone and Breast Reconstruction: Comparison of patient-reported Breast-Q and other Health related QOL measures 137 Cross-sectional Breast reconstruction compared with mastectomy alone was associated with greater satisfaction with appearance of chest and breasts, and psychosocial, sexual, and physical well-being.
 Eriksson 2013 Hungary/Sweden 2c Radiotherapy in implant-based immediate breast reconstruction: risk factors, surgical outcomes, and patient-reported outcome measures in a large Swedish multicenter cohort 725 Cross-sectional Radiation therapy compared with none in patients with implant-based immediate breast reconstruction was associated with worse outcomes for satisfaction with breasts, outcome, and physical, sexual, and psychosocial well-being. Higher BMI was associated with lower satisfaction with breasts, and worse sexual and psychosocial well-being. Pre-op chemo was associated with lower satisfaction with breasts and psychosocial well-being. Psychosocial well-being was lowest in those younger than 40 years and highest in those older than 66 years.
 Ho 2013 Canada 2c Optimizing patient-centered care in breast reconstruction: the importance of preoperative information and patient-physician communication 510 Cross-sectional Satisfaction with information and the plastic surgeon was associated with higher satisfaction with breasts and outcome in breast reconstruction patients.
 Koslow 2013 USA 2c Long-term patient-reported satisfaction after contralateral prophylactic mastectomy and implant reconstruction 294 Prospective In patients with unilateral breast cancer, contralateral prophylactic mastectomy with reconstruction was associated with higher satisfaction with breasts and outcome compared to unilateral mastectomy with reconstruction. The absence of lymphedema was associated with higher satisfaction with outcome.
 Macadam 2013 Canada 2c Patient-reported satisfaction and health-related quality of life following breast reconstruction: a comparison of shaped cohesive gel and round cohesive gel implant recipients 128 Cross-sectional The use of shaped versus round silicone based-implants in breast reconstruction was not associated with differences on any satisfaction and well-being scale.
 Rosson 2013 USA 2c Quality of life before reconstructive breast surgery: A preoperative comparison of patients with immediate, delayed, and major revision reconstruction 170 Cross-sectional Satisfaction with breasts, psychosocial, sexual, and physical well-being prior to breast reconstruction was highest in patients undergoing immediate reconstruction, followed by patients undergoing delayed reconstruction, and lastly in patients undergoing major revision reconstruction.
 Sugrue 2013 Ireland 2c An evaluation of patient reported outcomes following breast reconstruction utilizing the Breast Q 30 Cross-sectional There were no differences in satisfaction with breasts, physical, psychosocial and sexual well-being for breast reconstruction patients who retrospectively reported their pre- and post-operative results.
 Tadiparthi 2013 UK 2c An analysis of the motivating and risk factors for conversion from implant-based to total autologous breast reconstruction 118 Prospective Conversion to autologous reconstruction from failed implant reconstruction was associated with increased satisfaction with breasts.
 Wu 2013 USA 2c Human acellular dermal matrix (AlloDerm) dimensional changes and stretching in tissue expander/implant breast reconstruction 76 Cross-sectional Breast reconstruction with acellular dermal matrix compared to no acellular dermal matrix was not associated with differences in satisfaction with breasts, outcomes, information, or physical or psychosocial well-being in patients at 3 months postop.
 Zhong 2013 Canada 2c Decision regret following breast reconstruction: the role of self-efficacy and satisfaction with information in the preoperative period 100 Cross-sectional Higher satisfaction with information was associated with lower regret after breast reconstruction. Increased self-efficacy was associated with higher satisfaction with information.
 Albornoz 2014 USA 2c Implant breast reconstruction and radiation: A multicenter analysis of long-term health-related quality of life and satisfaction 633 Cross-sectional Patients who had undergone implant-based breast reconstruction with radiation therapy had lower scores for satisfaction with breasts, outcome, psychosocial, sexual, and physical well-being compared to non-radiated patients.
 Atisha 2014 USA 2c A National Snapshot of Satisfaction with Breast Cancer Procedures 7619 Cross-sectional Women who underwent autologous tissue reconstruction reported the highest breast satisfaction scores compared to prostheses, breast-conserving- therapy, or mastectomy only. Women undergoing mastectomy without reconstruction reported the lowest satisfaction with breasts.
 Chao 2014 Taiwan 2c Monitoring patient-centered outcomes through the progression of breast reconstruction: a multicentered prospective longitudinal evaluation 100 Prospective Satisfaction with breasts, psychosocial, physical, and sexual well-being were higher pre-operatively for women with mastectomy only compared to mastectomy with reconstruction. Scores across all domains were initially lower in patients with delayed compared to immediate reconstruction, with equalization at 9 months post-op.
 Davis 2014 USA 2c Breast reconstruction satisfaction rates at a large county hospital 65 Cross-sectional A major complication versus no complication was associated with lower scores for satisfaction with breasts and outcome. Delayed versus immediate reconstruction was associated with increased satisfaction with breast.
 Howes 2014 Australia 2c Autologous fat grafting for whole breast reconstruction 1 Prospective Case report of one woman who underwent single-stage large-volume breast reconstruction with autologous fat grafting, with an increase in satisfaction with breasts, outcome, psychosocial, sexual and physical well-being after fat grafting.
 Jeevan 2014 England 2c Findings of a national comparative audit of mastectomy and breast reconstruction surgery in England 7110 Prospective Women who underwent immediate reconstruction had higher satisfaction with breasts and overall well-being compared to mastectomy only.
 Lee 2014 Australia 2c The scarless latissimus dorsi flap provides effective lower pole prosthetic coverage in breast reconstruction 32 Cross-sectional Scarless latissimus dorsi flap and traditional latissimus dorsi flap techniques are not significantly different for satisfaction with breasts, outcome, psychosocial, sexual and physical well-being.
 Liu 2014 China/USA 2c Quality of life and patient satisfaction after microsurgical abdominal flap versus staged expander/implant breast reconstruction: a critical study of unilateral immediate breast reconstruction using patient-reported outcomes instrument BREAST-Q 119 Cross-sectional Microsurgical abdominal flap breast reconstruction compared to staged implant-based reconstruction was associated with higher satisfaction with outcome, breasts, information, plastic surgeon, psychosocial, and sexual well-being.
 Matros 2014 USA 2c Cost-effectiveness analysis of implants versus autologous perforator flaps using the BREAST-Q 309 Cross-sectional BREAST-Q scores and cost of care were higher for DIEP reconstruction compared to implants.
 McCarthy 2014 USA 2c Chest and upper body morbidity following immediate postmastectomy breast reconstruction 308 Cross-sectional Women who underwent autologous reconstruction had the highest physical well-being scores, while women who underwent prosthetic based reconstruction had decreased chronic physical morbidity.
 Mestak 2014 Czech Republic 2c Centrifugation versus puregraft for fatgrafting to the breast after breast-conserving therapy 30 Prospective Satisfaction with breasts, psychosocial and sexual well-being improved after fat grafting. Satisfaction with breasts was higher with pure graft compared with centrifugation.
 Ng 2014 Australia 2c Breast reconstruction post mastectomy: patient satisfaction and decision making 143 Cross-sectional Reconstruction compared with mastectomy alone was associated with higher satisfaction with breasts, psychosocial, and sexual well-being. Patients who underwent reconstruction reported higher self-image, more clothing choices, and feelings of overcoming cancer.
 Peled 2014 USA 2c Patient-reported outcomes and satisfaction after total skin-sparing mastectomy and immediate expander-implant reconstruction 28 Prospective Satisfaction with breasts, psychosocial, and sexual well-being after breast reconstruction was lowest at 1 month post-op, but returned to baseline by 1 year.
 Simpson 2014 Canada 2c Multidisciplinary assessment for immediate breast reconstruction: A new approach 26 Prospective Prior to reconstruction, women who would undergo delayed reconstruction had lower satisfaction with breasts, psychosocial, and sexual well-being compared to women who would undergo immediate delayed reconstruction. Post-operative satisfaction with breasts, physical, and sexual well-being between immediate and delayed reconstruction patients were not significant.
 Sun 2014 USA 2c Assessing Women’s Preferences and Preference Modeling for Breast Reconstruction Decision-Making 36 Cross-sectional The risk averse multiplicative model was the best fit for modeling the theoretical breast reconstructive preferences of women.
 Eltahir 2015 The Netherlands 2c Which Breast Is the Best? Successful Autologous or Alloplastic Breast Reconstruction: Patient-Reported Quality-of-Life Outcomes 92 Cross-sectional Women with autologous versus implant-based reconstruction were more satisfied with their breasts.
 Sisco 2015 USA 2c The quality-of-life benefits of breast reconstruction do not diminish with age 315 Cross-sectional Older women (>=65 years) undergoing post-mastectomy breast reconstruction versus mastectomy alone had higher reported satisfaction with breasts and psychosocial well-being. There were no differences in satisfaction with breasts, outcome, or psychosocial well-being between younger and older women undergoing post-mastectomy breast reconstruction.
 Susarla 2015 USA 2c Comparison of Clinical Outcomes and Patient Satisfaction in Immediate Single-Stage versus Two-Stage Implant-Based Breast Reconstruction 268 Cross-sectional Women undergoing direct to implant reconstruction versus two-stage reconstruction with tissue expander had higher sexual well-being, but lower satisfaction with medical and office staff.
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n = number of study participants; Country of Origin determined using corresponding author’s address; USA = United States of America; UK = United Kingdom Level of Evidence based off of the Oxford Centre for Evidence Based Medicine, 2009 guidelines (http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/)

Discussion

Since its inception in 2009, the BREAST-Q has been used to study breast surgery providing meaningful and reliable information regarding HR-QOL and patient satisfaction when used in clinical practice, in surgical research and quality improvement initiatives. This condition-specific PROM has been rapidly accepted by academic and private clinicians alike. Use of the BREAST-Q will continue to expand as HR-QOL and patient satisfaction becomes increasingly important as a metric for evaluating patient care from clinical, policy, and research perspectives. Below we consider five key areas of surgical practice, and elaborate upon the findings of this review to more fully describe where the BREAST-Q has and can be further used to better understand evidence-based, patient-centered surgical practice.

Why choose autologous reconstruction?

Reconstructive surgeons and their patients must choose between autologous and implant-based reconstruction following mastectomy. While traditional outcomes, such as rates of failure and re-operation have been well studied, the BREAST-Q has been used to provide a better understanding the impact of this decision on patients.4–6 There are now a number of studies that suggest the outcomes are better for patients receiving autologous reconstruction in comparison to implants.7–11 While the studies did not make a distinction between microsurgical techniques, the authors report that patients had higher levels of satisfaction, increased HR-QOL, and less chest and upper body morbidity with autologous reconstruction compared to implants.

The superior outcomes in the autologous reconstruction patients is additionally supported by previous studies not utilizing the BREAST-Q, which demonstrated superior aesthetic results when comparing transverse rectus abdominis myocutaneous (TRAM) reconstruction with implant-based reconstruction. 6,12–17 Additionally, Matros et al conducted a cost-effectiveness analysis, and reported that the more expensive procedure (autologous reconstruction) is worthwhile when cost and quality of life were factored together.17 The BREAST-Q provides researchers with the ability to quantify and compare patient perspectives, which is essential to demonstrate the value of potentially more time intensive or costly reconstructive options, such as free-tissue flap based reconstruction.

Which is better – saline or silicone?

With the moratorium on silicone implants now lifted,18 patients are presented with an option of silicone or saline implants. While some surgeons recommend silicone implants for their natural feeling and appearance, studies using the BREAST-Q provide evidence that can be used to help guide patients in their decision making process.4,19 In augmentation patients, Gryskiewicz et al. demonstrated that patients who received silicone implants were more satisfied with their overall outcome than patients who received saline. 20 In breast reconstruction patients, multiple studies have demonstrated similar findings with higher overall satisfaction, psychological well-being, sexual well-being, physical function, and satisfaction with their surgeon in patients receiving silicone implants in comparison to saline. 20–23 The BREAST-Q has been instrumental in helping to demonstrate greater patient satisfaction with silicone implants compared to saline, providing essential information to help future patients make educated decisions about reconstructive options.

Why perform fat grafting?

The use of fat grafting in breast surgery is becoming increasingly popular. 24 Multiple authors demonstrated high rates of satisfaction with breasts using the BREAST-Q in fat grafting for both reconstruction and augmentation. 24,25 Salgarello et al. demonstrated that fat grafting followed by autologous or implant-based reconstruction produced high satisfaction with breasts among patients who had previously undergone breast radiation, while Spear and Pittman found high patient satisfaction with breasts following fat grafting when used for breast augmentation.24,25 In a case report, Howes et al demonstrated the potential for autologous fat grafting as an option for whole breast reconstruction.24 While multiple questions remain regarding fat grafting’s safety, efficacy, and post-operative breast cancer screening, the BREAST-Q should help assess patient satisfaction with the procedure.

Why focus on patient education?

An important component of overall patient satisfaction is the patient experience of care, which can be measured using the BREAST-Q scales, satisfaction with information; surgeon; medical team; and office staff. These scales were utilized in only 49% of studies. In order to deliver patient-centered care and improve patient outcomes, surgeons and their teams should make the patient feel at ease and provide adequate pre-operative information. Ho et al. demonstrated that when a patient is satisfied with the information provided to her and also with the plastic surgeon, she is more likely to be satisfied with her surgical outcome. 26 These findings are supported by expectancy theory, which hypothesizes that pre-operative expectations play an important role in the patient’s assessment of outcomes and strongly predicts satisfaction and HR-QOL. 27–29

While most institutions track patient satisfaction, current methods using questionnaires, like those employed by Press-Ganey, which are not condition-specific, are often used for promotional advertising. The BREAST-Q, developed based on patient interview data, with its inclusion of different features of the patient experience, imparts providers with a surgery specific metric to improve their weaknesses, while reinforcing their strengths.

Is the BREAST-Q feasible in large-scale studies?

The National Health Service (NHS) audit on mastectomy and breast reconstruction included data from more than 8,000 women seen at 270 different hospitals throughout the United Kingdom.9 Postal surveys utilizing the BREAST-Q were returned at a rate of 81% during the study. This audit provided clinicians with important HR-QOL and patient satisfaction data, while highlighting the importance of adequate pre-operative information to patients. 9

In another study, Atisha et al conducted a study utilizing the Love/AVON Army of Women program.10 The cross sectional study surveyed women who had previously undergone surgery for breast cancer to compare different reconstructive procedures and how satisfaction changes over time for specific patient populations. 7,619 patients completed the BREAST-Q, electronically with an 82% response rate. Women who underwent autologous tissue reconstruction reported the highest breast satisfaction, while women who underwent a mastectomy without reconstruction reported the lowest.

Finally, the BREAST-Q is featured prominently in the Mastectomy Reconstruction Outcomes Consortium (MROC) Study, a five-year prospective, multicenter cohort study of mastectomy reconstruction patients funded by the National Cancer Institute. Over 60 plastic surgeons from 10 centers in the USA and Canada have contributed nearly 4,000 patients to the study, which began in February 2012.

These studies illustrate that the BREAST-Q is scalable to national and international levels and is able to achieve high response rates even with web-based administration. Large-scale studies such as those highlighted above will continue to produce generalizable PROs that clinicians and patients can utilize in future decision making.30

Where do we go from here?

While there has been a focus on breast reconstruction, relatively few studies have utilized the augmentation or reduction/mastopexy modules. The reconstruction module is the most frequently utilized, both in the number of studies and total number of patients, most likely secondary to its duration of availability and the academic and public interest in breast cancer and reconstruction.

However, over 290,000 breast augmentations and over 125,000 breast reductions were performed in 2013 compared to 95,000 breast reconstructions.31 This disparity in usage of the BREAST-Q provides an opportunity for research to enhance understanding of patient satisfaction and HR-QOL for patients undergoing breast augmentation or reduction.

The BREAST-Q’s multiple domains, which provide a near comprehensive view of patient HR-QOL and satisfaction, are also not consistently being utilized to their full potential. Investigators were most interested in the patients’ satisfaction with their breasts, reflecting a common primary endpoint of the reconstructive breast surgeon. Increased attention on the remaining domains, including psychosocial, sexual, and physical well-being, may provide an opportunity to optimize outcomes and deliver comprehensive patient-centered care.

When combined with a rigorous study design, the BREAST-Q can provide reliable evidence based data. The BREAST-Q was used most frequently as a cross sectional tool, assessing patient outcomes at a snapshot in time, often post-operatively. While this design allows a straightforward, singular administration of the BREAST-Q and provides clinicians and researchers the opportunity to compare patient outcomes and quantify potential causal associations between treatment variables, this approach does not provide information regarding changes in outcomes over time.32 Greater usage of prospective study designs, while often more cumbersome, allows data findings to be translated more reliably to patient-centered care.

The BREAST-Q and our review of studies have several limitations. We did not include non-peer reviewed studies, or those from conferences, which may provide additional meaningful clinical data. Also, in order to minimize bias, survey response rates need to be high. While this has been achieved in large-scale studies,9,10 local staff, both clinical and non-clinical, may need practical and methodological support, including training, when they are asked to assist in the collection of BREAST-Q data, which may be an even greater challenge in multicenter trials. Also, inherent in its use is selection bias – patients who fill out questionnaires may be more likely to either be very satisfied or very dissatisfied.33

Our review was not systematic and therefore there may be some omissions. However, we did not set out to conduct a systematic review, as the goal of this article was to provide surgeons with a general overview of the current published surgical research, as opposed to answering a specific research question. In addition, as is the case with most plastic surgery literature, studies that used the BREAST-Q were unlikely to be randomized controlled trials, as it is often not feasible to randomize patients. Furthermore, as the BREAST-Q becomes more ubiquitous, it is important that it is used as intended: changing questions, merging scales, and not using the scoring system as instructed will invalidate results.

Conclusion

The BREAST-Q is a PROM that allows both researchers and clinicians to answer important questions on patient satisfaction and HR-QOL. Its multiple modules and domains allow researchers and clinicians to comprehensively answer clinical questions specific to mastectomy, breast reconstruction, augmentation, and reduction/mastopexy patient populations. The standardized scoring methodology is simple to use and allows for comparisons between studies. The BREAST-Q has greatly improved our ability to understand PROs in patients undergoing breast surgery, and while it has already provided numerous important insights to date, the increased interest in PROs guarantees its continued use and ability to foster new innovations and standards of care.

Footnotes

Confliction of Interest

Drs. Pusic, Klassen, and Cano are co-developers of the BREAST-Q, which is owned by Memorial Sloan-Kettering Cancer Center. They receive a portion of licensing fees (royalty payments) when the BREAST-Q is used in industry sponsored clinical trials.

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