The Impact of Delaying Breast Reconstruction on Patient Expectations and Health-Related Quality of Life: An Analysis Using the BREAST-Q

Abstract

Purpose:

An understanding of patient expectations predicts better health outcomes following breast reconstruction. No study to date has examined how patient expectations for breast reconstruction and preoperative health-related quality of life vary with time since breast cancer diagnosis.

Methods:

Women consulting for breast reconstruction to a single surgeon’s practice over a 13-month period were enrolled in this cross-sectional study. Patients were asked to prospectively complete the BREAST-Q expectations and preoperative reconstruction modules. A retrospective chart review was then performed on eligible patients, and patient demographics, cancer-related factors, and comorbidities were collected. BREAST-Q scores were transformed using the equivalent Rasch method. Multivariate linear regression models were constructed to assess the association between BREAST-Q scores and time since cancer diagnosis.

Results:

Sixty-five patients met inclusion criteria for analysis and are characterized by a mean age of 53 ± 11 (34-79) years and a mean body mass index of 28 ± 6 (19-49). Most patients were treated by mastectomy (58%) or lumpectomy (23%). At the time of retrospective chart review, 29 (43%) patients had undergone reconstruction, most of which were delayed (59%). The mean latency from cancer diagnosis to reconstruction was 685 ± 867 days (range: 28-3322 days). Latency from cancer diagnosis to reconstruction was associated with a greater expectation of pain (β = 0.5; standard error [SE] = 0.005; 95% confidence interval [CI]: 0.003-0.027; P < .05), and a slower expectation for recovery (β = −0.5; SE = 0.004; 95% CI: −0.021 to −0.001; P < .05) after breast reconstruction. Latency from cancer diagnosis to reconstruction was associated with an increase in preoperative psychosocial well-being (β = 0.578; SE 0.009; 95% CI: 0.002-0.046; P < .05).

Conclusion:

Delaying breast reconstruction may negatively impact patient expectations of postoperative pain and recovery. Educational interventions aimed at understanding and managing patient expectations in the preoperative period may improve health-related quality of life and patient-related outcomes following initial breast cancer surgery.

It is estimated that 11% of women will develop breast cancer in their lifetime,¹ which is a figure that is expected to rise.² In patients undergoing treatment of early-stage breast cancer, lumpectomy, a breast-conserving procedure aimed at selectively excising a localized cancer, when combined with radiation therapy, has shown similar survival outcomes to mastectomy, a surgical procedure to remove all breast tissues.³ Mastectomy and lumpectomy can lead to significant emotional distress, which has a negative impact on the overall quality of life of cancer survivors.^4-8 In half of the affected women, changes in perception of self,⁹ which has a negative impact on sexual function¹⁰ and well-being,¹¹ have been documented. Breast reconstruction has been shown to improve satisfaction, decrease pain, enhance psychological and sexual health, and improve function and well-being in patients undergoing mastectomy.¹²

Despite these well-documented benefits, historically, rates of breast reconstruction have been low.^13,14 Many variables influence the uptake of breast reconstruction, such as preference, perceived barriers, race, level of education, age, income, geographic location, hospital type, and tumor stage.^15,16 Immediate breast reconstruction (ie, at the time of the definitive cancer surgery) has been shown to have additional benefits over delaying reconstruction, including a decrease in cost, improved aesthetics, as well as psychological benefits.^17-19 However, in addition to a longer anesthetic time, it is associated with higher rates of surgical site infection, which may be a limitation for certain higher risk patients.²⁰ Also, breast reconstruction is often delayed for patients requiring adjuvant therapy.²¹ The adverse effects of radiation on both prosthetic^22-24 and autologous-based reconstruction have been well documented.²⁵ A recent prospective study demonstrated that patients with higher levels of distress, anxiety, and body concerns are more likely to choose delayed breast reconstruction.²⁶ Benefits of delayed breast reconstruction include a more stable soft tissue envelope, completion of all adjuvant therapies, and realistic patient expectations.²⁷

An understanding of a patient’s expectations for breast reconstruction is important in order to develop a customized approach and achieve a satisfactory result²⁸ and is an important predictor of health outcomes and health-related quality of life.²⁹ Unrecognized or unfilled expectations have been shown to correlate with lower patient satisfaction in other types of surgery.³⁰ The measurement of patient expectations appears to improve patient education, shared medical decision-making, and patient perception of outcomes,²⁹ and instruments have therefore been developed for this purpose.³¹ Despite its importance, no study to date has examined how preoperative health-related quality of life measures, and patient expectations of breast reconstruction, relate to time from breast cancer diagnosis to breast reconstruction. The primary objective of this study was to address these issues. We hypothesized that shorter time between breast cancer diagnosis and breast reconstruction would be associated with higher scores on the BREAST-Q preoperative quality-of-life scales and positive expectations of breast reconstruction.

Methods

Data Acquisition and Patient Selection

Institutional ethics approval was obtained from the Nova Scotia Health Authority (Halifax, Nova Scotia, Canada) prior to commencing this cross-sectional study. All research activities took place at the IWK Women’s Health Centre, 1 of the 2 main referral centres in Nova Scotia, Canada. All women consulting for breast reconstruction to a single surgeon’s practice (S.F.) between April 2016 and May 2017, inclusive, were asked to complete the BREAST-Q Expectations Module and BREAST-Q Pre-Operative Reconstruction Module. Patients were eligible for study if they were 18 years or older, consulting for breast reconstruction, and would undergo or had previously undergone ablative surgery for breast cancer. Both patients having undergone lumpectomy and mastectomy were included. Both immediate and delayed reconstructions were considered, allowing us stratify latency as a continuous variable in our model. Those undergoing immediate reconstruction were assigned a latency of 0 days. We classified delay as any nonimmediate reconstruction. The authors hypothesized that these 2 cohorts share numerous similarities including a common diagnosis of breast cancer and similar goals for seeking plastic surgery consultation. Additionally, this inclusion strategy aimed to limit selection bias.

Patients who had previously undergone cosmetic breast surgery, declined all surgical intervention, who underwent surgery for nonmalignant indications, or had chest wall malignancies were excluded. Patients consulting for revision reconstruction, or augmentation of the contralateral breast that had not undergone ablative surgery, were also excluded. As the BREAST-Q questionnaire specifically elucidates patients’ attitudes and satisfaction with their breasts, as well as their overall experience with breast surgery, we aimed to recruit only naive patients. We believe that previous noncancer-related breast surgery, including augmentation, may confound scores on the BREAST-Q in these specific domains. The authors were compliant with the STROBE checklist³² for cross-sectional studies.

Questionnaire

The BREAST-Q, a validated and widely used questionnaire developed for the assessment of patient-reported outcomes in breast reconstruction, was completed prospectively by patients consulting for breast reconstruction.³³

Two BREAST-Q modules were utilized: BREAST-Q Expectations module and BREAST-Q Pre-Operative Reconstruction module. The former has been specifically designed to assess patient’s expectations of the process and outcome of breast reconstruction (BREAST-Q Expectations Version 1). This module is composed of 6 scales and assesses: (1) support from medical staff, (2) pain, (3) recovery, (4) coping, (4) breast appearance and outcome, (5) expectations about self-perception, and (6) sexuality. The module also contains stand-alone scales assessing expectations of implant-based reconstruction and autologous-based reconstruction, which were not considered in this analysis. Response options for all scales are on a 3-point Likert-type scale, where 1 represents unlikely, 2 likely, and 3 very likely.

The BREAST-Q Pre-Operative Reconstruction module contains 5 scales and assesses: (1) satisfaction with breast, (2) psychological well-being, (3) physical well-being, (4) abdominal well-being, and (5) sexual well-being. Response options for satisfaction with breast are on a 4-point Likert-type scale, where 1 represents very dissatisfied and 4 represents very satisfied. Psychological well-being, physical well-being, abdominal well-being, and sexual well-being are on a 5-point Likert-type scale, where 1 represents none of the time and 5 represents all of the time.

Item responses for each section of the modules are summed and transformed to give a score for each scale that ranges from 0 to 100, using a standardized conversion template. Higher scores on the expectations module indicated greater expectations. For the preoperative reconstruction module, higher scores indicated greater quality of life.

Dependent Variables

The primary outcome measures were patient-reported expectations of breast reconstruction (expectations of support from medical staff, expectations of pain, expectations for recovery, expectations for breast appearance and outcome, expectations of self-perception, and expectations of sexuality) and preoperative quality-of-life measures (satisfaction with breast, psychosocial well-being, physical well-being, abdominal well-being, and sexual well-being).

Independent Variables

Independent variables, which were collected retrospectively after the recruitment period was closed, including patient and care-related characteristics (age, comorbidities, date of diagnosis, date of ablative surgery, date of plastic surgery consultation, date of reconstruction, and latency from diagnosis to reconstruction), cancer-related factors (laterality, cancer type, cancer grade, receipt of radiation, receipt of neoadjuvant chemotherapy, receipt of adjuvant chemotherapy/ hormonal therapy, and recurrence), and reconstructive details (autologous vs implant-based, timing of reconstruction, and flap-type). Factors associated with reconstruction could only be calculated for patients who had completed reconstruction at the time the retrospective data for this study were collected (August 2017). Mean latency from diagnosis to reconstruction thus represents only women who had completed reconstruction.

The amount of time elapsed from diagnosis to reconstruction was selected as our primary latency variable as to best standardize the potentially confounding period of time between cancer diagnosis and mastectomy. First, patients diagnosed with early-stage breast cancer may not be required to undergo emergent mastectomy or lumpectomy. On the contrary, a patient with more advanced disease may be seen on a more urgent basis and subsequently undergo ablative surgery. Second, patients having undergone ablative surgery in a peripheral centre who are referred for plastic surgery consultation may have a differential delay between mastectomy and reconstruction relative to those seeking treatment at our tertiary breast reconstruction centre. Finally, we hypothesize that the emotional and psychosocial stress experienced by patients, as measured by the BREAST-Q, begins at the time of cancer diagnosis.

Statistical Analysis

Data were collected using a standardized template developed a priori on Microsoft Excel Microsoft Excel Version 14.6.2 (Microsoft, Redmond, Washington). Statistical analyses were done in SPSS Version 24.0.0 (IBM SPSS Statistics, Armonk, New York). Means and frequencies were calculated for continuous variables and categorical data, respectively. Transformed BREAST-Q scores were described using median (M) and interquartile range (IQR). We constructed multiple linear regression models to determine how expectations of breast reconstruction and health-related quality-of-life measures change with time since cancer diagnosis. Only patients for whom latency was calculated were included in the final regression analysis. Each subset of the BREAST-Q Expectations and Pre-operative Reconstruction modules served as dependent variables. Covariates remained the same for each model and were selected from previous studies describing their impact on BREAST-Q scores²⁸ and our a priori assessment of the literature.

Power and Sample Size

To categorize effect size, Cohen ƒ2 was used, where 0.02 indicates a “small” effect size, 0.15 a “medium’’ effect size, and 0.35 and above indicate a “large” effect size. As previously described,³⁴ the minimal detectable difference in scores is approximately 10, half of the standard deviation.³³ Thus, when power is set to 80%, with an effect size of 0.15 and a type 1 error rate of 0.05, a sample size of 63 is required.

Results

Ninety-seven patients completed the BREAST-Q Expectations and Pre-operative Reconstructive modules prospectively. Following a retrospective chart review, 32 patients were excluded (Figure 1).

Figure 1.

Flow diagram showing patient selection and chart review process.

The 65 patients who met inclusion criteria for analysis were characterized by a mean age of 53 ± 11 (34-79) years, and a mean body mass index of 28 ± 6 (19-49). Patient comorbidities are summarized in Table 1. Patients presenting for breast reconstruction consultations were most likely to have the diagnosis of infiltrating ductal carcinoma (72%), with a nuclear grade of 3 (46%). Most patients were treated by mastectomy (58%) or lumpectomy (23%). Adjuvant chemotherapy and radiation therapy were indicated in 71% and 60% of patients, respectively. There were 9 (14%) documented cases of recurrence (Table 2).

Table 1.

Characteristics of Breast Reconstruction Patients Who Completed the BREAST-Q.

Variable	Value (%)
Number of patients	65
Age, years
Mean ± SD	53 ± 11
Range	34-79
BMI
Mean ± SD	28 ± 6
Range	19-49
Comorbidities
Alcohol use	19 (29%)
History of smoking	15 (23%)
Hypertension	15 (23%)
Psychiatric diagnosis	13 (20%)
Diabetes	9 (9%)
Illicit drug use	2 (3%)
Anticoagulant use	1 (2%)
Coronary artery disease	0 (0%)
Steroid use	0 (0%)

Abbreviation: SD, standard deviation.

Table 2.

Cancer and Treatment-Related Factors of Breast Reconstruction Patients Who Completed the BREAST-Q.

Variable	Value (%)
Number of patients	65
Cancer diagnosis
Infiltrating ductal	47 (72%)
DCIS	12 (19%)
Infiltrating lobular	5 (8%)
LCIS	1 (12%)
Nuclear grade
1	7 (11%)
2	26 (40%)
3	30 (46%)
Surgical modality
Mastectomy	38 (58%)
Lumpectomy	15 (23%)
Lumpectomy + axillary dissection	9 (14%)
Lumpectomy + mastectomy	1 (2%)
Localized biopsy	1 (2%)
Gland removal + lumpectomy	1 (2%)
Neoadjuvant therapy	3 (5%)
aAdjuvant therapy	46 (71%)
Radiation	39 (60%)
Recurrence	9 (14%)

Abbreviations: DCIS, ductal carcinoma in situ; LCIS, lobular carcinoma in situ; SD, standard deviation

^aAdjuvant therapy refers to adjuvant chemotherapy and targeted therapy.

At the time of retrospective chart review, 29 (43%) patients had undergone reconstruction, most of which were delayed (59%). The mean latency from cancer diagnosis to reconstruction was 685 ± 867 days (range 28-3322 days). Most patients underwent implant-based reconstruction (59%; Table 3).

Table 3.

Reconstructive Details of Breast Reconstruction Patients Who Completed the BREAST-Q.

Variable	Value (%)
Number of patients who had undergone reconstruction	29 (43%)
Timing of reconstruction
Delayed	17 (59%)
Immediate	12 (41%)
Latency (days) from diagnosis to reconstruction
Mean ± SD	685 ± 867
Range	28-3322
Laterality
Unilateral	19 (66%)
Bilateral	10 (34%)
Type of reconstruction
Autologous	10 (34%)
Implant based	17 (59%)
Reduction	1 (3%)
Revision of chest wall	1 (3%)
Flap type
DIEP	8 (80%)
DIEP + MSTRAM	1 (10%)
DIEP + DCIA	1 (10%)
Flap with implant	0 (0%)

Abbreviations: DIEP, deep inferior epigastric perforator flap; MSTRAM, muscle sparing transverse rectus abdominis muscle flap; DCIA, deep circumflex iliac artery flap; SD, standard deviation.

Expectations of Breast Reconstruction

Overall, patient expectations of support from medical staff (M = 54, IQR = 38-78) and expectations of recovery after breast reconstruction (M = 54, IQR = 43-65) fell within the 50th percentile.

Expectations of pain after breast reconstruction neared the 75th percentile (M = 64, IQR = 54-80). Expectations of coping (M = 100, IQR = 82-100), expectations of appearance (M = 100, IQR = 83-100), expectations of self-perception (M = 100, IQR = 86-100), and expectations of sexuality (M = 82, IQR = 62-82) in women consulting for breast reconstruction were high (Table 4).

Table 4.

Expectations of Breast Reconstruction and Health-Related Quality-of-Life Scales in Patients Who Completed the BREAST-Q Expectations and Preoperative Reconstruction Modules.^a

Scale	Median (IQR)
Expectations of coping	100 (82-100)
Expectations of appearance (clothed)	100 (83-100)
Expectations of pain after breast reconstruction	64 (54-80)
Expectations of support from medical staff	54 (38-78)
Expectations of recovery after breast reconstruction (first week)	54 (43-65)
Expectations about how you will feel about yourself	100 (86-100)
Expectations of sexuality	82 (62-82)
Physical well-being (abdomen)	80 (71-100)
Physical well-being	78 (69-86)
Psychosocial well-being	59 (50-74)
Satisfaction with breast	47 (34-58)
Sexual well-being	43 (35-54)

Abbreviation: IQR, interquartile range.

^a Scores ranged from 0 to 100 on Rasch index.

As assessed by multivariate regression, a longer interval between cancer diagnosis and reconstruction, greater BMI, and need for adjuvant therapy were associated with a greater expectation of pain with breast reconstruction (P < .05). A longer interval between cancer diagnosis and reconstruction (P < .05) and the need for radiation therapy (P < .05) were associated with a slower expectation for recovery within the first week after breast reconstruction (Table 5). A longer interval between cancer diagnosis and reconstruction was not associated with expectations of support from staff, expectations of coping, expectations of appearance, expectations of self-perception, or expectations of sexuality after breast reconstruction (Supplemental Table 1).

Table 5.

Multivariate Regression Models Examining the Effect of Delay of Breast Reconstruction on Patient Expectations and Health-Related Quality of Life.^a

Dependent Variable	Covariate	β	SE	95% CI	P Value
Expectations of pain after breast reconstruction	Latency (days) from cancer diagnosis to reconstruction	0.484	0.005	0.003 to 0.027	.024b
	BMI	0.331	0.702	0.011 to 3.448	.049b
	Adjuvant therapy	0.432	7.362	1.340 to 37.368	.039b
Expectations of recovery after breast reconstruction (first week)	Latency (days) from cancer diagnosis to reconstruction	−0.464	0.004	−0.021 to −0.001	.040b
	Radiation therapy	−0.665	5.711	−31.121 to −4.114	.018b
Preoperative satisfaction with breast	BMI	−0.760	1.196	−7.611 to −2.096	.004b
	Recurrence	0.503	21.138	5.752 to 103.239	.033b
Preoperative psychosocial well-being	Latency (days) from cancer diagnosis to reconstruction	0.578	0.009	0.002 to 0.046	.033b
	BMI	−0.767	1.090	−6.882 to −1.843	.004b
	Recurrence	0.616	19.274	15.080 to 103.972	.015b
	Radiation therapy	−0.653	12.640	−59.957 to −1.659	.041b
Preoperative physical well-being (abdomen)	BMI	−0.642	1.069	−4.994 to −0.066	.045b
Preoperative sexual well-being	BMI	−0.720	0.965	−6.067 to −1.618	.004b
	Recurrence	0.623	17.054	17.121 to 95.773	.011b

Abbreviations: β, beta coefficient; SE, standard error; CI, confidence interval; BMI, body mass index.

^a Only significant covariates for each scale are shown. Covariates included: latency (days) from cancer diagnosis to reconstruction; BMI; psychiatric diagnosis; alcohol use; recurrence; need for radiation therapy; need for adjuvant therapy.

^b Statistically significant.

Preoperative Health-Related Quality of Life

Preoperative satisfaction with breast (M = 47, IQR = 34-58), psychosocial well-being (M = 59, IQR = 50-74), and sexual well-being (M = 43, IQR = 35-54) in women undergoing breast reconstruction fell near the 50th percentile. Ratings of overall physical well-being (M = 78, IQR = 69-86) and physical well-being of the abdomen (M = 80, IQR = 71-100) neared the 75th percentile (Table 5).

As assessed by multivariate regression, greater BMI (P < .005) was found to predict a poorer preoperative satisfaction with breast, whereas cancer recurrence (P < .05) was found to be associated with a greater satisfaction with breast preoperatively. Latency from cancer diagnosis to reconstruction (P < .05) and recurrence (P < .05) were both found to be associated with an increase in preoperative psychosocial well-being. Greater BMI (P < .005) and need for radiation therapy (P < .05) were both associated with poorer preoperative psychosocial well-being. Greater BMI was associated with poorer preoperative physical (abdominal) well-being (P < .05) and poorer preoperative sexual well-being (P < .005). Cancer recurrence was associated with greater preoperative sexual well-being (P < .05; Table 5).

Sensitivity Analysis

A post hoc sensitivity analysis was conducted a posteriori, removing all patients who had undergone lumpectomy. All data analyses described previously were then recomputed substituting latency from time of cancer diagnosis to reconstruction with latency from time of mastectomy to reconstruction.

The mean latency from cancer diagnosis to reconstruction was 719.67 days (±960.97) when compared to the latency from mastectomy to reconstruction, 312.58 days (±663.86). Multivariate regression revealed a significant worse expectation of recovery in patients with greater latency from mastectomy (P < .05). Additionally, patients who had cancer recurrence were found to have greater expectations of coping (P < .05; Supplemental Table 3). When specific health-related quality-of-life scales were evaluated, a higher BMI was associated with poorer satisfaction with breast (P < .05), worse psychosocial well-being (P < .05), and poorer rating of physical well-being of abdomen (P < .001). Patients receiving adjuvant therapy also reported worse physical well-being of abdomen (P < .05; Supplemental Table 4).

Our sensitivity analysis revealed numerous similarities between outcomes when latency from mastectomy and latency from diagnosis were compared. Among these include the most robust associations between higher BMI and poorer health-related quality-of-life scales and poorer expectations of recovery. Nevertheless, this post hoc analysis is ultimately underpowered and thus may be unable to detect the associations previously described.

Discussion

In this study, we found that the greater time interval between cancer diagnosis and breast reconstruction was associated with greater patient expectations of pain and poorer expectation of recovery after breast reconstruction; however, it did not negatively impact preoperative psychosocial well-being. Additionally, we identified that higher BMI was associated with greater expectations for pain, poorer preoperative satisfaction with breast, poorer preoperative psychosocial well-being, poorer preoperative physical (abdomen) well-being, and poorer preoperative sexual well-being. The implications of these findings are that interventions aimed at improving expectations in women facing prolonged intervals between cancer diagnosis and reconstruction have the potential to impact overall reconstructive outcomes. Furthermore, efforts should be aimed at improving the preoperative health-related quality of life in patients with higher BMI, as this may impact overall satisfaction with breast reconstruction.

The strengths of the present investigation include the use of valid and reliable measures of expectations and health-related quality of life in breast reconstruction; the recruitment of a diverse patient population at different stages of breast reconstruction; and the description of novel, potentially modifiable associations between poor expectations for breast reconstruction and greater duration since breast cancer diagnosis.

To our knowledge, this is the first study to examine the impact of the time interval between diagnosis and breast reconstruction on patient expectations. The importance of clarifying patient expectations regarding surgical results is an essential preoperative undertaking. Previous studies have unequivocally documented that unrecognized or unfulfilled expectations are associated with poor patient satisfaction,^35-41 and others have stressed the importance of ongoing development of valid measures of perioperative patient expectation.⁴² Despite its perceived importance, few studies have examined the impact of patient expectations on breast reconstruction.²⁹ Snell et al, who conducted in-depth interviews with women undergoing implant-based reconstruction, found that women may have unclear expectations of the reconstructed breast, which they found corresponds to disappointment with reconstructive outcome.⁴³ Consultations for breast reconstruction are involved and are invariably time limited to a certain degree and potentially limit the discussion of expectations with patients. Inadvertently, unsatisfactorily addressing preoperative expectations has the potential to impact patient-reported outcomes in breast reconstruction. By incorporating additional resources, such as a class or module addressing the recovery period, surgeons may be able to successfully modify negative beliefs of outcomes.⁴⁴ This finding is confirmed by research in the breast reconstruction literature, which has shown that patient satisfaction with preoperative information and with surgeon interaction is strongly associated with satisfaction with the outcome of breast reconstruction.²⁸ Research by Pusic et al²⁹ has subsequently led to the development of a novel multimedia platform for addressing these concerns in the clinical setting. Surgeons and multidisciplinary teams should strive to incorporate open discussions of expectations with patients in consultation, using patient-centred communication.^45,46 The incorporation of novel educational methods, such as web-based platforms, which have been shown to improve patient engagement and comprehension²⁹ are also encouraged.

Interestingly, we identified that longer delay from cancer diagnosis to reconstruction was associated with higher levels of preoperative psychosocial satisfaction, results that are supported by previous longitudinal studies. Helgeson et al identified a number of unique recovery trajectories, which are largely dependent on the degree of social and personal resources available to the patient.⁴⁷ In this study, the largest proportion of women were described as having a high baseline level of psychosocial functioning that remained stable in the posttreatment period. Two other major trajectories were a slow and steady increase in psychosocial functioning and a rapid improvement over a 13-month period, respectively. Only 12% of the 363 women studied had a decline in the psychosocial functioning in the posttreatment period. We speculate that the degree of psychosocial stress experienced by breast cancer survivors decreases as patients become more removed from the stressful events of diagnosis and treatment. This theory is in part grounded in recent evidence supporting low levels of chronic acute stress in this group of patients.⁴⁸ Nonetheless, further study is necessary to elicit the characteristics that confer this degree of psychosocial strength, as time alone has not been found to explain these patterns of recovery.⁴⁷ Furthermore, the authors are also reserved in their conclusions, as this result may also be a function of the study’s small sample size.

In patients undergoing breast cancer surgery, previous studies have shown that higher expectations of pain in the postoperative period were strongly associated with greater clinical pain intensity and poorer response to analgesics.⁴⁹ These findings also parallel those described in the experimental setting.⁵⁰ Once again, interventions aimed at identifying negative expectations of pain and recovery are essential and are of particular importance in patients who may have a lengthy delay between cancer diagnosis and reconstruction. The treatment of postoperative pain in breast reconstruction has evolved immensely in the last decade and now includes advanced regional anesthesia, such as paravertebral blocks, thoracic epidurals, interfacial, and intrapleural blocks, and liposomal bupivacaine infiltration.⁵¹ As such, multidisciplinary discussion, with involvement of anesthesia, is an important consideration in preoperative counseling of patients consulting for breast reconstruction. Adequate pain management and, more importantly, understanding of the options for postoperative pain management among patients consulting for breast reconstruction have the potential to reduce opiate requirements, reduce hospital stay, and improve postoperative health-related quality of life.

Patients with elevated BMI are at an increased risk of developing postoperative complications when undergoing breast reconstruction.^52-58 As a result of a well-documented increase in complication rate, some sites have advocated for delayed reconstruction in obese patients undergoing reconstruction.⁵⁹ Thus, despite well-documented psychosocial benefits of immediate breast reconstruction, certain patients may be poor candidates. Our analysis identified numerous concerning associations between health-related quality of life and elevated BMI, including poorer preoperative satisfaction with breast, poorer preoperative psychosocial well-being, poorer preoperative physical (abdominal) well-being, and poorer preoperative sexual well-being. Interventions aimed at improving breast reconstruction outcomes in patients with elevated BMI have shown that a decrease in preoperative BMI is associated with improved satisfaction with appearance of breasts and social appearance and may reduce the rate of complications.^59,60 In patients undergoing reconstruction despite a significantly elevated BMI, careful and considerate preoperative counseling, including a discussion of perioperative pain management, and potential complications, is essential. In patients delaying breast reconstruction as a result of elevated BMI, interdisciplinary care groups should target an improvement in quality of life. Of particular importance, sexual dysfunction is strongly associated with health-related quality of life⁶¹ and is an important, but often missed, component of comprehensive oncology care. Couple-based interventions have been shown to be among the most effective,⁶² although limited communication between health-care providers and patients concerning this difficult topic may ultimately limit referral.⁶³

It remains unclear why cancer recurrence was associated with higher levels of preoperative satisfaction with breast appearance and preoperative psychosocial and sexual well-being. The authors speculate that women faced with cancer recurrence may develop added psychological resilience, a phenomenon previously documented.⁶⁴ Additionally, the metrics used in this study specifically petition patients on their psychosocial well-being in the context of their breasts. It may be that women who develop recurrence of their breast-cancer are less concerned about reconstruction and focus more on the oncological aspects of their care, including safety of any added procedures. Finally, this result could represent a sampling error considering the sample size of our study. In regard to sexual well-being, the findings of this study are in agreement with previous reports showing that recurrence does not have a negative impact on sexual well-being,⁶⁵ further highlighting the strength and resilience in this cohort.

Increasing latency to breast reconstruction was not found to be associated with significant changes in satisfaction with breast, physical, or sexual well-being. Previous studies examining women receiving immediate breast reconstruction have demonstrated higher identical preoperative baseline BREAST-Q characteristics relative to those consulting for delayed reconstruction. These findings point to the adverse emotional and psychological impact of cancer resection on these quality-of-life characteristics. As the majority of patients in this study had undergone ablative surgery at the time of BREAST-Q completion, lower aggregate scores on measures of satisfaction and well-being are consistent with previous reports. Encouragingly, long-term studies have demonstrated enhanced psychosocial well-being following reconstruction, with no detectable differences between immediate and delayed cohorts at 2 years post-operatively.⁶⁶

This study should be considered in the context of several limitations. Sample size and sample diversity, including single surgeon practice setting, may limit the external validity of results presented. Our a priori assessment of sample size may also underestimate these factors and the degree of sample heterogeneity. Future studies of this nature, particularly when assessing multiple covariates, should aim to fully characterize the study populous and adjust power analyses accordingly.

Given the nature of this study, the true direction of effect cannot be determined. From the cases that were reviewed, however, time to consultation with a plastic surgeon was delayed primarily as a result of inability to coordinate immediate reconstruction with the patient’s oncological surgeon, delayed treatment secondary to adjuvant and neoadjuvant therapy, and lengthy surgeon wait list. Although certainly possible that patients who have greater expectations of pain and suspect a poor recovery (eg, as a result of their ablative surgery) are more likely to delay seeking consultation for reconstruction, we believe this not to be the primary driver of the increased latency to reconstruction observed.

As rates of immediate reconstruction in major centres continue to grow,⁶⁷ this study describes an increasingly unique assessment of delayed breast reconstruction. Although a formal assessment of rates of immediate versus delayed reconstruction at our centre was not conducted, significant barriers to immediate reconstruction, particularly autologous reconstruction, remain. For example, the average wait time for consultation for reconstruction in our province is approximately 2 years.⁶⁸ If wait times continue to rise, the health system featured in this article will become increasingly anomalous. As reconstructive teams worldwide move toward providing timelier, and more immediate breast reconstruction, the concerns raised by this study will become—for the better—less generalizable.

In order to meet this growing demand, the senior author (S.F.), when initially establishing practice, received numerous consultations for delayed autologous reconstruction, contributing to the unique nature of the sample described herein but which may represent a degree of sampling bias. The high rate of recurrence found may also be a function of this unique group, with oncological treatment further delaying reconstruction. High rates of unilateral reconstruction are explained by low rates of contralateral prophylactic mastectomy at our centre, which is mirrored by a recent Canadian consensus statement.⁶⁹

Additional research assessing the impact of increased time interval between cancer diagnosis and breast reconstruction on patient expectations is warranted. Future studies should expand on patient characterization, including the description of race and sociodemographic factors, and would ideally sample from a larger population or include multiple centres. This study is also limited by its cross-sectional nature and only describes BREAST-Q scores at a single point in time. Finally, the authors propose numerous interventions, which ultimately require further evaluation in the context of breast reconstruction.

Conclusions

This study describes the association between the delay of breast reconstruction and poorer expectations of pain and recovery in the postoperative period. Furthermore, multiple associations between BMI and poorer expectations of breast reconstruction and quality of life were found. Educational interventions aimed at understanding and modifying negative patient expectations in the preoperative setting may improve health-related quality of life and patient-related outcomes in breast reconstruction.