Abstract
This study examines the concerns of patients with nonmelanoma skin cancer regarding nasal reconstruction after Mohs surgery to develop an intervention to improve the shared decision-making process of patients and practitioners.
Approximately 5.5 million new diagnoses of nonmelanoma skin cancer (NMSC) are estimated annually in the United States.1 The rising incidence of NMSC and its associated costs are an increasing public health burden.2 More patients require excision of NMSC followed by reconstructive surgery. As life expectancy continues to increase, the aging population may present with more comorbidities and additional social and financial considerations when weighing treatment choices.
Reconstructive options after NMSC treatment range from wound healing by secondary intention to free tissue transfer. Decisions about choices are complex for patients, patients’ families, and physicians. Patients undergoing nasal reconstruction after Mohs surgery in particular share concerns, such as financial burden, appearance, and the invasiveness of reconstructive surgery. This mixed-methods study examines these patient concerns to develop an intervention to improve the shared decision-making process for patients with NMSC.
Methods
Adults (≥18 years) who were planning to undergo nasal reconstruction after Mohs surgery for an NMSC of the nose from September 1, 2016, through December 31, 2017, and could read and write English were included in the study. Patients with a previous diagnosis of skin cancer or whose planned Mohs excision would likely extend beyond the nose were excluded from the study. Oral informed consent was obtained from all patients, and data were deidentified. This research study was approved by the institutional review board of Washington University in St Louis, Missouri.
At the initial prereconstruction office visit with the facial plastic surgeon (J.J.C.), the patients completed a form with the following open-ended request: “Please list any concerns you have about your nasal reconstruction surgery.” As part of clinical care, the principal investigator (J.J.C.) then reviewed the responses with the patients in a structured interview. The interview explored the role of nasal reconstruction in NMSC treatment followed by a review of the patients’ responses and a discussion of options for reconstruction. A summative content analysis of the written and interview responses was performed by 2 reviewers (A.R., J.J.C.) with NVivo software, version 11 (QSR International), using a line-by-line coding approach to establish the major themes and subthemes.
Results
All patients presenting for nasal reconstruction were prescreened for study eligibility. Twenty-six patients were approached; 25 patients completed the form and interviews (8 men and 17 women; mean [SD] age, 63.3 [10.7] years). One patient was ineligible because of a previous undocumented skin cancer diagnosis. Five major areas of concern were identified: appearance, surgery, cancer outcomes, financial cost, and recovery process (Table). Appearance-related concerns were most common (17 of 25 patients [68%]). In addition, 12 of the 25 patients (48%) inquired about recovery, including recovery time, activity limitations, and likelihood of restoring normal breathing after surgery, and 10 of the 25 patients (40%) described concerns about nasal reconstruction after Mohs surgery.
Table. Patient Concerns Regarding Nasal Reconstruction After Mohs Surgery.
| Major Themes and Subthemes | No. of Responses | Representative Patient Statements |
|---|---|---|
| Appearance | ||
| Scar | 3 | “I want my scar to be unnoticed.” |
| Hole | 3 | “I want the hole to be filled in.” |
| Asymmetry | 3 | “Will my nose be symmetrical?” |
| Change from baseline | 2 | “I’d like my nose to look as close to what I was born with as possible.” |
| Uncertainty | 2 | “Fear of unknown about the defect after Mohs surgery and my final appearance.” |
| Graft source | 2 | “If you take cartilage from my ear, will that need reconstructing?” |
| Bandages | 1 | “What type of bandages will I have?” |
| Surgery | ||
| Length | 2 | “How long is the surgery?” |
| Setting | 1 | “Where is the surgery taking place?” |
| Pain | 2 | “Will the procedure be painful?” |
| Anesthesia | 3 | “Can I be put completely out?” |
| Surgeon | 1 | “Competence of the surgeon–are you any good? How many of these have you done?” |
| Blood thinners | 1 | “Do I have to stop [clopidogrel] and aspirin before surgery?” |
| Recovery | ||
| Recovery time | 7 | “How long before I look “normal”? Days? Weeks?” |
| Activity limits | 3 | “What is the healing process? What restrictions will I have? For how long?” |
| Breathing | 2 | “Will I develop breathing difficulties?” |
| Financial cost | ||
| Time off work | 4 | “When can I return to work?” |
| Insurance | 2 | “How much does my insurance cover?” |
| Cancer outcome | ||
| Full removal | 2 | “My primary concern is removal of all the cancer.” |
| Recurrence | 2 | “I don’t want it [skin cancer] to come back.” |
Discussion
Quality of life after plastic surgery has gained increasing attention from patients, payers, and physicians.3,4,5 Appropriate counseling and education are critical components of the preoperative discussion, especially for reconstructive operations in which there are often multiple available treatment options. Shared decision making is a process in which practitioners and patients make decisions together using the best available evidence.6 Patients are encouraged to weigh the pros and cons of each treatment or intervention.
The goal of this study was to investigate the factors that can affect patients’ decisions about nasal reconstruction after Mohs surgery to build a patient-centered intervention to address these concerns. A limitation of the study is that it is a single-institution experience with a single facial plastic surgeon. To draw broader conclusions, a multicenter study would be appropriate. However, information gained from this project may help advance the development of shared decision-making tools and resources in plastic and reconstructive surgery.
Adequate counseling of patients with skin cancer on the various reconstructive options for their facial defects can be challenging. Each patient’s circumstances are unique, and the best reconstructive choice for each patient must be individualized and consistent with the patient’s values and preferences.6
References
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