What Women Want: Study Unravels Choices about Breast Reconstruction

A new study led by Duke University School of Medicine looked at what matters most to women when choosing breast reconstruction surgery after a mastectomy.  

As more women opt for breast reconstruction, due to rising incidence of breast cancer and more insurance companies paying for the procedures, it’s important for them to be satisfied with the results.

Yet, many women regret their choice.

The new JAMA Surgery study showed when considering breast reconstruction women prioritized potential abdominal side effects, chance of complications, number of operations needed, how the breast looks afterword and recovery time. A clearer grasp of these factors could help women stand by their decisions with confidence.

“Patient decision-making is a big part of breast reconstruction, but sometimes it’s hard for patients to know what option is best for them,” said senior study author and plastic surgeon Scott T. Hollenbeck, MD.   

“And it’s even more complicated if the surgeons, doctors, and friends they talk to have a certain perspective or limitations of their own knowledge so women are not necessarily presented with all the options,” he said.  

Hollenbeck, professor and chair of the Department of Plastic Surgery at the University of Virginia School of Medicine, worked on the study while at Duke with lead study author Ronnie Shammas, MD, a resident in the Division of Plastic, Maxillofacial and Oral Surgery at Duke School of Medicine.  

"Our goal is to weave this data into a shared decision-making process, ensuring the surgeries offered to women truly align with their values and desired treatment outcomes," Ronnie Shammas, MD.

They worked alongside Shelby Reed, PhD, and Anna Hung, PhD, of the Department of Population Health Sciences and Duke Margolis Center for Health Policy, in addition to co-senior author Rachel Greenup, MD, chief of breast surgery at Yale School of Medicine.  

The team represents surgeons and health services researchers studying medical decision-making with long-lasting consequences, like breast reconstruction.  

The Decision Conundrum    

Many patients diagnosed with breast cancer, after undergoing a mastectomy (breast removal), face a breast reconstruction crossroads – breast implants vs natural tissue or foregoing reconstruction altogether.  

Shelby Reed, PhD; Anna Hung, PhD
Shelby Reed, PhD, and Anna Hung, PhD

For the study, researchers conducted an adaptive choice-based conjoint analysis, which is traditionally used in marketing. Applied to health care, it helps discern individual preferences for treatment.  

During the analysis, women were presented with potential tradeoffs of different treatments, such as do I choose more surgeries if it means bouncing back in four weeks instead of eight?  

“The need for patients to make tradeoffs in these exercises helps prioritize what’s most important to them,” said Reed, director of the Center for Informing Health Decisions, a professor of medicine and member of the Duke Clinical Research Institute. “Health care providers can use this information as a starting point when discussing treatment options with patients.”   

The preference-elicitation method empowers patients to communicate their wishes to their doctors directly, without external pressure or the need for detailed explanations. “I like this approach,” Reed said.  

Between March 2022 and January 2023, 105 women at Duke University Medical Center, undergoing mastectomies due to breast cancer or genetic risks like BRCA mutations, were analyzed.  

Researchers also engaged 301 women from the Love Research Army Registry, named after breast surgeon and women’s advocate, Susan Love, MD.  

Path to Personalized Care    

About 85% of women in the study preferred implant-based reconstruction, a trend that’s emerged following reversal of the silicone breast implant ban.  

Some women who were open to using their own body tissue, usually taken from the abdomen, for reconstruction (known as “flap” reconstruction) focused on achieving a natural look and having fewer surgeries. Women choosing implants were wary of abdominal morbidity and potential complications. 

Ronnie Shammas, MD
Ronnie Shammas, MD

Certain social factors also played a part. Being married correlated with a preference for flap reconstruction, perhaps because women had more social support during the extended recovery, authors said.  

The fresh insights pave the way for a more personalized approach to care.  

“Our goal is to weave this data into a shared decision-making process, ensuring that the surgeries offered to women truly align with their values and desired treatment outcomes,” said Shammas, who is also leading a study to better understand breast reconstruction preferences of Black women, a group that’s less likely to choose breast reconstruction than white women.  

Bridging patient values with medical decisions represents a vital shift in addressing women’s post-surgery concerns.  

After 15 years of performing reconstructive surgery, Hollenbeck said post-surgery regret can vary. For some patients, it’s unexpected costs that sting. For others, coming to terms with how their body looks and feels presents challenges.  

“We’re currently tapping into what patients want ahead of time,” Hollenbeck said. “Whether it’s a quick return to work or being available for their children. Dr. Shammas is taking that a step further and making our approach even sharper.  

“The best thing that could come from a study like this is fewer regrets and more patients feeling good about their choices.”  

Additional authors: Alexandria Mullikin; Amanda R. Sergesketter; Clara N. Lee; and Laura J. Fish.  

Funding: National Endowment for Plastic Surgery grant awarded to Dr. Shammas by the Plastic Surgery Foundation.