Breast reconstruction after mastectomy is an important treatment option for the many thousands of women who undergo mastectomy each year. Its insurance coverage is mandated by federal law. Many women who want reconstruction, particularly women from racial and ethnic minorities, never receive it, and some women who undergo reconstruction regret having it, raising concern about the quality of decisions about the procedure. Little is known about the quality of breast reconstruction decisions, defined as the extent to which decisions are informed and concordant with patients' preferences. A lack of reliable methods for evaluating preference concordance has resulted in a paucity of research in this area. Deciding about breast reconstruction requires a patient to predict how she would feel after the procedure, a process called affective forecasting. Extensive psychological research has shown that people have difficulty making accurate predictions about how they will feel, tending to overestimate the effects of disease and treatments on their well- being and to underestimate their ability to adapt to change and the effects of other aspects of their lives. Despite the importance of affective forecasting to decisions about breast reconstruction, no research has examined this aspect of those decisions. We propose to conduct a pilot cohort study of breast cancer patients undergoing mastectomy, with or without reconstruction with the following specific aims:
Aim 1 : To evaluate the quality of decisions about breast reconstruction by assessing patient knowledge, concordance between preferences and treatment, and decision making processes;
Aim 2 : To assess the accuracy of patients' preoperative predictions about their post-operative body image and well-being and the association between prediction accuracy and satisfaction with decisions;
and Aim 3 : To assess the effects of breast reconstruction on quality of life and body image and the potential modification of these effects by preference concordance. This study is innovative in its use of a validated measure of knowledge that is specific to reconstruction, its use of a technique derived from marketing research called conjoint analysis to assess preference concordance, its focus on affective forecasting, and its prospective assessment of decisions. Our findings will inform a subsequent R01 to conduct a multi-site cohort study of decision making and outcomes of breast reconstruction. We believe this line of investigation will lead to more appropriate use of reconstruction and more patients achieving the outcomes they value. The candidate is a plastic and reconstructive surgeon with education and experience in health policy whose long-term goal is to improve the quality of surgical treatments for cancer. The specific objectives of this career development award are 1) To obtain education in psycho- oncology, outcomes research, and psychology of decisions; 2) to obtain skills in quality of life measurement, patient interviewing, preference elicitation, assessment of affective forecasting errors, enrollment and retention of incident cancer patients, and analysis of longitudinal observational data; 3) to evaluate the patient-reported outcomes of breast reconstruction and the role of decision making processes in those outcomes, in preparation for a multi-site cohort study; and 4) to develop the expertise, pilot data, and publication record necessary to be an independent investigator. This K07 career development award would position the candidate to become a leader in the decision sciences and clinical effectiveness research.
Deciding whether or not to have breast reconstruction after mastectomy is highly challenging for many patients. This study will examine patients' decisions about reconstruction and the effects of reconstruction on quality of life and body image. This research will eventually lead to more patients receiving the treatments they prefer and ultimately to better quality of life for women with breast cancer.
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