Dear Editor
Approximately one in every seven women will be diagnosed with breast cancer in their lifetime. For women who undergo surgical cancer treatments, breast reconstruction is an option. Women’s decision-making processes in breast cancer surgical procedures are clearly influenced by doctors’ recommendations1. Patient–clinician trust is thus critical for high-quality medical decision-making in postmastectomy breast reconstruction. It is not surprising then that research has shown that increased preoperative information and surgeon interaction significantly influence patient satisfaction after breast reconstruction2,3. Optimal outcomes regarding elective medical procedures require effective communication between patients and the medical professionals involved4. However, very few metrics are available for analysis in relation to duration of consultation between surgeons, nurses, and patients, and particularly how patients perceive and are influenced by the expert knowledge they receive.
A survey was distributed to 53 specialist breast surgeons, 101 breast care nurses, and 689 former or current patients with breast cancer, seeking data relating to the duration of first consultation, level of knowledge of the individuals involved, and level of involvement of each party in the final choice of therapy5.
Patients’ self-assessed knowledge differed by surgeon, nurse, and patient in the expected order (all differences statistically significant at 0.1 per cent level). Although the perception of patients’ knowledge did not differ significantly between patients and surgeons (difference 5.6 per cent; P = 0.536) or surgeons and nurses (difference 5.2 per cent; P = 0.851), nurses’ perception was significantly lower than patients’ self-assessed knowledge by 10.9 per cent (P = 0.005) (Fig. 1a).
Perceived level of patients’ knowledge, involvement in decision-making, and duration of consultations
a Perceived level of patients’ knowledge about the breast cancer reconstruction procedure, b patient involvement in decision-making process, and duration of consultation with c plastic surgeon and d nurse by patients, surgeons, and nurses. a,c,d Values are mean with 95 per cent confidence interval. *P < 0.050, †P < 0.010, ‡P < 0.001 (2-tailed t test adjusted for multiple comparisons using Bonferroni correction). b Dots represent individual data points, and ‘violins’ the relative kernel density across the entire range of values. Median value (bold line), i.q.r. (box), and 1.5 × i.q.r. (whiskers) are also shown.
The distribution of patients’ perception of their involvement in the decision-making process differed considerably from the perception of patient involvement by the surgeon and nurse participants (Fig. 1b). This was particularly concentrated at the middle and upper end (mostly patients’ input, relative to surgeons’ decision).
Time spent with the breast surgeon and plastic surgeon in the first consultation did not differ among all patients (mean difference 1.29 min; t = 0.936, P = 0.349). However, for the 294 patients who had already undergone or were waiting to have a reconstruction, the time spent with the breast surgeon was significantly greater than that spent with plastic surgeon (by a mean of 3.40 min; t = 3.18, P = 0.002). These patients also stated that they spent significantly more time with surgeons than nurses in the first consultation, by 12.54 min (t = 7.77, P < 0.001) and 9.11 min (t = 5.37, P < 0.001) respectively.
Although surgeons stated that they spent more time with patients than the nurse did in the first consultation (by 24.17 min; t = 8.15, P < 0.001), nurses, on the other hand, stated that patients spent more time with the nurse than with surgeon (by 18.48 min; t = 8.15, P < 0.001). On average, patients’ perception of time spent with the plastic surgeon or nurse fell between the estimates of the surgeon and nurse participants (Fig. 1c,d). However, although the difference between patients’ and surgeons’ estimated time spent with the surgeon (difference 7.45 min; P = 0.014) was similar in magnitude to the difference between the patients’ and nurses’ estimates (difference 7.31 min; P = 0.002), the discrepancy between nurses’ and patients’ estimates of time spent with the nurse (difference 22.11 min; P < 0.001) was much larger than that between surgeons and patients (difference 5.77 min; P = 0.239).
These results showed significant divergence between patients’, nurses’, and surgeons’ perceptions of breast cancer treatment knowledge, as well as duration of initial consultation. This descriptive analysis relating to perceived onus of choice of breast reconstruction indicated that a large proportion of women feel or believe that their surgeon effectively made a decision on their behalf when it came to their reconstruction. Such a finding raises concerns in relation not only to informed consent before surgery, but more importantly to patient expectations of reconstructive surgery.
Disclosure. The authors declare no conflict of interest. D.W.H. declare being a founder and shareholder of BellaSeno.
Acknowledgements
Some participants in this research were recruited from the Breast Cancer Network Australia (BCNA) Review and Survey Group, a national online group of Australian women living with breast cancer who are interested in receiving invitations to participate in research. The authors acknowledge the contribution of the women involved in the Review and Survey Group who participated in this project. They also thank the Australian Society of Aesthetic Plastic Surgeons, Australian Society of Plastic Surgeons, BCNA, Breast Wishes Journey, McGrath Foundation, and Dragon Abreast Australia for their support and promotion of this study to their respective members. Data and code are available from the corresponding author on request. There is no external funding to declare. All research was conducted in accordance with Queensland University of Technology Human Research Ethics Committee approval (no. 1800000669). D.W.H. is a founder and shareholder of BellaSeno.
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