Decision Analysis Aimed at Informed Choices on Breast Reconstruction

A new process borrowed from the business sector helps women evaluate alternatives for breast reconstruction, using a decision analysis technique.

The approach helps surgeons and patients evaluate alternatives for breast reconstruction, leading to a good decision that reflects the woman’s preferences and values.

The special topic article introduces plastic surgeons to the use of decision analysis to help women navigate decisions about breast reconstruction after mastectomy for breast cancer.

“Decision analysis provides structure for methodic, thoughtful decision-making through the use of reason, logic, and mathematics,” the authors write.

Decision analysis, routinely used in business, is increasingly applied to complex medical decisions as well. The model provides women options based on statistical outcomes.

Women facing breast reconstruction may need to sort through a bewildering array of options — such as immediate versus delayed reconstruction, using implants or their own tissues — while dealing with the emotions of their breast cancer diagnosis and the uncertainty characteristic of difficult decisions.

“When making decisions about breast reconstruction, it is the patient who must live with the consequences,” the authors write.

They outline a process that plastic surgeons can follow in guiding patients through decision analysis.

The surgeon provides information about the available alternatives for breast reconstruction; and the probability of different outcomes — for example, the need for repeated surgeries, possible complications, and aesthetic results.

Based on the patient’s preferences, her values are assigned to possible outcomes. This information is used to create a “decision tree,” incorporating the options, the likelihood of various outcomes, and the values assigned to each outcome.

Researchers walk readers through the decision analysis process for a hypothetical patient considering breast reconstruction.

Their article includes a link to an educational spreadsheet that shows surgeons an example of how the decision analysis process works.

A step called sensitivity analysis weighs the impact of changing different variables that might affect the decision—for example, different assumptions regarding the risk of complications or out-of-pocket costs.

“If the decision remains the same, it is robust and likely good,” the authors write.

A study earlier this month found that while double mastectomy rates have dramatically increased in recent years, survival rates for this surgery remain similar to that of a lumpectomy (where only a section of the breast is removed). That study of 200,000 women followed for over 10 years, published in JAMA, showed those who received a double mastectomy carried a survival rate of 81 percent. That compares with 83 percent for patients who underwent a lumpectomy.

Researchers emphasize that decision analysis doesn’t guarantee a good outcome of breast reconstruction. However, it can help the patient reach a “good decision” — defined as “one that takes into account her preferences and the uncertainties inherent in reconstructive surgery.”

The authors add, “By making good decisions, patient outcomes may be improved.”

Although it can be “computationally intensive,” the researchers believe decision analysis has important benefits for women facing decisions about breast reconstruction.

They write, “Ideally, its application will attenuate worry, safeguard against regret, transmute uncertainty into certainty, and grant some measure of peace in what may ultimately be a very difficult decision.”

The methodology is discussed in an article in Plastic and Reconstructive Surgery.

Source: Wolters Kluwer Health