Stakeholders’ Perspectives on Postmastectomy Breast Reconstruction: Recognizing Ways to Improve Shared Decision Making

Background: Postmastectomy breast reconstruction (PMBR) is an elective, preference-sensitive decision made during a stressful, time-pressured period after a cancer diagnosis. Shared decision making (SDM) can improve decision quality about preference-sensitive choices. Stakeholders' perspectives on ways to support PMBR decision-making were explored. Methods: Forty semi-structured interviews with stakeholders (20 postmastectomy patients, 10 PMBR surgeons, 10 PMBR nurses) were conducted. Clinicians were recruited from diverse practices across the United States. Patients were recruited using purposive sampling with varying PMBR experiences, including no reconstruction. The interview guide was based on an implementation research framework. Themes were identified using grounded theory approach, based on frequency and emotive force conveyed. Results: Engagement in SDM was variable. Some patients wanted more information about PMBR from clinicians, particularly about risks. Some clinicians acknowledged highlighting benefits and downplaying risks. Many patients felt pressured to make a choice by their clinicians. Clinicians who successfully engaged patients through decisions often used outside resources to supplement conversations. Conclusions: Patient–clinician trust was critical to high-quality decisions, and many patients expressed decision regret when they were not engaged in PMBR discussions. Patients often perceived a race- or age-related bias in clinician information sharing. Interventions to support SDM may enhance decision quality and reduce decision regret about PMBR, ultimately improving patient-centered care for women with breast cancer. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Published online 13 November 2017. Received for publication September 18, 2017; accepted September 21,2017. Ms. Grabinski and Ms. Philpott contributed equally to this work. To be presented at the Society for Medical Decision Making, 39th Annual Meeting, October 22, 2017, Pittsburgh, Pa. Supported by the Siteman Cancer Center through a Siteman Investment Program Pre-R01 Award, funded by the Cancer Frontier Fund through the foundation for Barnes-Jewish Hospital and Siteman Cancer Center, to Drs. Myckatyn and Politi. Dr. Parikh is supported by a National Institutes of Health Institutional National Research Service Award (T32CA190194). Ms. Grabinski was supported by a grant from the Siteman Cancer Center Leah Menshouse Springer Summer Opportunities Program. This study was approved by the Washington University Institutional Review Board (IRB# 201701045) and Siteman Cancer Center's Protocol Review Management Committee. Dr. Politi has a research contract (2017–2019) and previously (2016) received a speaker fee from Merck Sharpe & Dohme, both on topics unrelated to this article. Dr. Myckatyn is a consultant for and received investigator-initiated grant funding from Allergan Medical, Acelity, RTI Surgical, on topics unrelated to this article. The Article Processing Charge was paid for by The Siteman Investment Program Pre-R01 award. Supplemental digital content is available for this article. Clickable URL citations appear in the text. Mary C. Politi, PhD, Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, 660 S. Euclid Avenue, St. Louis, MO 63110, E-mail: mpoliti@wustl.edu Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.

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