Decision analysis can help women make breast reconstruction choices

Patient preferences can help in sorting through reconstruction options

September 26, 2014
American Society of Plastic Surgeons (ASPS)

Decision analysis techniques can help surgeons and patients evaluate alternatives for breast reconstruction, leading to a "good decision" that reflects the woman's preferences and values, according to an article in the October issue of Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons (ASPS).

The article by Mia K. Markey, PhD, and colleagues of the University of Texas at Austin and the University of Texas MD Anderson Cancer Center in Houston 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 said.

Decision analysis helps sort through breast reconstruction options

Decision analysis is defined as "an exhaustive, iterative process that involves identifying alternatives, obtaining information about the uncertainty of outcomes, and clarifying preferences and values." Routinely used in business, decision analysis is increasingly applied to complex medical decisions as well.

Women facing breast reconstruction may need to sort through a bewildering array of options - such as immediate versus delayed reconstruction and 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," wrote Dr. Markey and coauthors.

They outline a process that plastic surgeons can follow to guide patients through the decision analysis. The surgeon provides information about the available alternatives for breast reconstruction and the probability of different outcomes, e.g., 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. Dr. Markey and coauthors 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.

'Good decisions' reflect women's preferences and values

A step called sensitivity analysis weighs the impact of changing different variables that might affect the decision, e.g., different assumptions regarding the risk of complications or out-of-pocket costs. "If the decision remains the same, it is robust and likely good," said the authors.

Dr. Markey and colleagues emphasize that a decision analysis doesn't guarantee a good breast reconstruction outcome. 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 added, "By making good decisions, patient outcomes may be improved."

Although it can be "computationally intensive," Dr. Markey and coauthors 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 paper appears as ASPS prepares to observe National Breast Reconstruction Awareness (BRA) Day on October 15, 2014. National BRA Day seeks to "close the loop on breast cancer" by helping to ensure that women know their options for breast reconstruction after mastectomy.