Satisfaction survey on a preoperative explanation method using 3-dimensional breast imaging for breast cancer patients considering breast conserving surgery

doi:10.21203/rs.3.rs-1660260/v1

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Research Article

Satisfaction survey on a preoperative explanation method using 3-dimensional breast imaging for breast cancer patients considering breast conserving surgery

https://doi.org/10.21203/rs.3.rs-1660260/v1

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Purpose

Women diagnosed with early breast cancer are faced with a choice of surgical procedures. Although one of the essential factors in surgical shared decision making is the impact on the body image, the breast morphology after breast conserving surgery is particularly difficult to explain in a uniform manner due to large individual differences.

Methods

Patients with breast cancer eligible for breast conserving surgery (BCS) were recruited between June 2020 and October 2021. We surveyed the patients’ satisfaction with our explanation method about breast morphology after BCS using 3D breast imaging in the form of a questionnaire.

Results

A total of 162 patients were enrolled and 137 (84.6%) answered the questionnaire. One hundred and sixteen patients (84.6%) answered that they were very satisfied or satisfied with our explanation method and 100 (73.0%) patients were very satisfied or satisfied with the 3D breast imaging. Some patients answered that visually understanding the breast morphology by 3D breast imaging helped them to prepare for BCS, or on the contrary, made them chose mastectomy with breast reconstruction because the postoperative deformation of BCS was found to be unacceptable. Only a few patients who actually underwent BCS felt that their postoperative morphology was more deformed than the preoperatively imagined one.

Conclusion

Our results suggest that our preoperative explanation method using 3D breast imaging was useful for shared decision making. We think that 3D breast imaging can help the patients to visualize the individual shape of their breast, and the tumor position and size.

Breast cancer

breast conserving surgery

patient satisfaction

3D imaging

shared decision making.

Breast cancer is the most common carcinoma among women, with more than 93,000 Japanese women diagnosed annually [1]. Women who are diagnosed with early breast cancer are faced with a choice of surgical procedures, such as breast conserving surgery (BCS) or total mastectomy with or without breast reconstruction. In Japan, about 60% of operable breast cancer patients undergo BCS [2]. In terms of overall survival, BCS combined with postoperative whole breast irradiation has been shown to be comparable to total mastectomy [3, 4]. For this reason, the patient’s wishes are taken into consideration when deciding the surgical procedure.

However, a previous study revealed that approximately half of the Japanese women with early breast cancer reported some regret regarding the treatment decision–making process [5]. Another study on decision aids for surgical procedures identified the need for better communication between the patient and physician [6]. During shared decision-making for early breast cancer treatment, it is essential to include not only information on survival, but also information on the postoperative alteration in body image. On the other hand, the breast morphology after BCS is particularly difficult to explain in a uniform manner due to large individual differences, since each patient has a different original breast size, and tumor size and location.

Various efforts have been made to explain the postoperative breast morphology after BCS. Vos et al. reported that a higher tumor volume/breast volume ratio measured by magnetic resonance imaging (MRI) is related to a poor cosmetic result; therefore, this ratio could enable more informed surgical treatment decision making [7]. Another study evaluated the acceptability of 3-dimensional (3D)-printed breast models derived from MRI and their impact on the decisional conflict. The authors concluded that 3D-printed breast models were acceptable tools [8]. However, it remains unclear how explaining postoperative breast morphology to patients can achieve satisfactory results.

At our institution, we use 3D breast imaging to explain the breast morphology after BCS in cases where BCS is judged to be feasible. The purpose of this study was to improve shared decision-making by surveying the satisfaction of patients with our explanation method, and how patients who actually underwent BCS think the postoperative morphology compared to the preoperatively imagined morphology.

Study design

Patients with breast cancer aged 20 years or older who were judged to be eligible for BCS at our institution were recruited between June 2020 and October 2021. Patients with metachronous bilateral breast cancer, previous ipsilateral breast surgery, men, or other patients deemed ineligible for study participation were excluded. Written informed consent was obtained from all individual participants. This study was approved by an institutional review board.

When deciding on the surgical procedure in the outpatient consultation, the physician provided a verbal explanation about the breast morphology after BCS, and by using hand-drawn drawings, postoperative photographs of other patients, and 3D breast imaging. The patient made the final decision regarding their surgical procedure. In this study, we surveyed the patients’ satisfaction with the preoperative explanation in the form of a questionnaire. Patients were given explanations regarding the consent explanatory document and written consent was obtained during hospitalization for surgery. The questionnaires were to be filled out at home after discharge from the hospital, and sent by mail in principle. Most questionnaires were returned within one month after surgery.

3d Breast Imaging

Prediction of breast morphology after BCS was presented using 3D breast imaging (SYSPLAN Inc., Japan). The patient's body size and breast morphology (size and droopiness) can be set to any level from small to large. The predicted postoperative morphology is displayed by selecting any location in the breast and setting the expected deformation strength based on the tumor size. The imaging can be rotated in any direction. Figure 1 shows the predicted morphologies. Tugging at the excision site, elevation of the affected breast, and deviation of the nipple position are also expressed.

Patient Satisfaction

A questionnaire was used to survey the patients’ satisfaction. The questionnaire consisted of items for all patients, an item for patients who underwent BCS, and an item for patients who underwent a surgery other than BCS. All patients were surveyed to determine their satisfaction with the preoperative explanation of breast morphology after BCS, the method(s) that were useful in visualizing the breast morphology after BCS, and satisfaction with the explanation using 3D breast imaging. For patients who underwent BCS, we investigated the degree of discrepancy between the expected morphology by 3D breast imaging and the actual postoperative morphology. Patients who underwent a surgical procedure other than BCS were surveyed about the surgical procedure they chose and the reasons why they chose the procedure.

Endpoints

The primary endpoint was satisfaction with our preoperative explanation of breast morphology after BCS. The secondary endpoints were the percentage of patients who found each of the methods to visualize breast morphology after BCS useful, satisfaction with the explanation using 3D breast imaging, patient-rated agreement between the imagined morphology and actual postoperative morphology of patients who underwent BCS, and the reasons why patients who underwent procedures other than BCS did not undergo BCS.

A total of 162 patients were found to be eligible and underwent an operation. Two patients had bilateral breast cancer. Clinical data of the study population are shown in Table 1. The median age was 51 (30–84) years. The mean body mass index (BMI, kg/m²) was 21.9. The tumor was located in the upper-outer area in about 60% of the cases, and the tumor diameter including that of carcinoma in situ was 20 mm or less in about 90% of the cases. The actual surgical procedure chosen by the patients was BCS in 101 cases, mastectomy without breast reconstruction in 36 cases, and mastectomy with breast reconstruction in 27 cases. The questionnaire was answered by 137 out of 162 cases (84.6%) (Fig. 2). Figure 3 shows the survey results of the patients’ satisfaction with the preoperative explanation of breast morphology after BCS evaluated on a 5-point scale. A total of 116 patients (84.6%) answered that they were very satisfied or satisfied. The most useful method to visualize breast morphology after BCS was 3D breast imaging (69.3%), followed by oral explanations and handwritten drawings by a doctor (65.7%), and postoperative photos of other patients (40.1%) (Fig. 4). There was an opinion that the combination of these explanation methods deepened the understanding.

The survey result of satisfaction with 3D breast imaging revealed that 100 patients (73.0%) patients were very satisfied or satisfied with the 3D breast imaging (Fig. 5). The reasons for supporting 3D breast imaging were that it was visual and easier to understand than a verbal explanation, it was three-dimensional and could be seen from various directions, and the position of the nipple was expressed as having a slight difference between the affected and unaffected sides. Some patients answered that visual understanding of the morphology by 3D breast imaging made them prepared to undergo BCS, or on the contrary, made them chose mastectomy with breast reconstruction because the postoperative deformation of BCS was found to be unacceptable. On the other hand, there was an opinion that it was difficult to visualize the postoperative morphology of the breasts because the image was not very realistic. Some patients also answered that the shock caused by the diagnosis of breast cancer was so great that they did not remember the details of the explanation.

Seventy-five of the 88 patients (85.2%) felt that their breast morphology after surgery was as good as or better than expected before surgery (Fig. 6). The most common reason for choosing a procedure other than BCS (49 patients) was to reduce the risk of ipsilateral breast cancer recurrence (32 patients). Eight patients chose mastectomy with breast reconstruction because they found the deformity after BCS unacceptable. Six patients answered that they did not want to undergo irradiation.

Previous studies have pointed out that better communication between the patient and physician is needed for breast cancer surgical decisions [6], as approximately half of Japanese women with early breast cancer reported some regret regarding the treatment decision–making process [5]. In this regard, improving the patients’ satisfaction with the preoperative explanation has been an issue. In order to solve this problem, we explained the postoperative morphology after BCS using 3D breast imaging in addition to the conventional methods such as oral explanations and handwritten drawings by a doctor and postoperative photos of other patients. Our study surveyed patient satisfaction with this explanation method and found that many patients were satisfied with this explanation method, and that the patients found 3D breast imaging to be particularly useful among the various preoperative explanation methods.

Three-dimensional imaging has begun to be applied clinically in the field of plastic surgery such as breast augmentation or breast reconstruction. Efforts are being made to improve the decision-making process and improve patient satisfaction by showing preoperative simulations using 3D imaging [9–11]. Two studies of breast augmentation showed that 3D imaging was useful in envisaging breast augmentation [10] and choosing an implant [11]. Another study on breast reconstructive surgery reported that 3D imaging is an effective method for enhancing patient preparedness prior to surgery [9]. In the field of BCS, there have been reports on the use of 3D imaging as a method for assessing postoperative morphology [12, 13], but only a few studies have examined its use in preoperative morphological prediction [14, 15].

Our results are consistent with the findings of previous studies on plastic surgery, where 3D imaging was reported to be useful as a preoperative explanation. More patients answered that 3D imaging was useful than those who answered conventional methods such as oral explanations and handwritten drawings by a doctor or postoperative photos of other patients were useful. The advantage of 3D imaging is that the patients can visually recognize the individual shape of their breast, and the tumor position and size. The patients’ opinion that a more accurate understanding of the postoperative breast morphology helped them to prepare for BCS and, conversely, that they decided to undergo breast reconstruction after finding the deformity unacceptable suggests that 3D breast imaging may be useful as a decision making tool.

When patients who actually underwent BCS were asked about the degree of postoperative deformation, 85.2% answered it was comparable or better than what they had imagined. Although it is necessary to take into consideration that this survey was conducted at approximately one month postoperatively, the fact that only a few patients felt that their morphology after BCS was more deformed than what they had preoperatively imagined suggests that they had been adequately prepared for the postoperative breast morphology.

The 3D breast imaging used in this study produces a predictive postoperative morphology by inputting the preoperative breast morphology, tumor location, and its size. Because scanned photographs of the patient were not used, the skin tones and textures may not be reproduced satisfactorily, as noted in some of the survey responses. However, since this 3D breast imaging setup is not time consuming, it can be performed on many patients in a limited time during outpatient care. From this point of view, this tool is easily applicable in actual daily clinical practice.

A limitation of this study is that it was not a randomized control trial. Although the impact of 3D breast imaging may not have been directly assessed, we chose this study design because 3D breast imaging is noninvasive, yet it is likely to be beneficial based on the results of previous studies in the field of plastic surgery. We believe that the results of this study sufficiently demonstrate that 3D breast imaging is beneficial to breast cancer patients.

In conclusion, our study suggests that our preoperative explanation method using 3D breast imaging is useful for shared decision making. We think that 3D breast imaging can help patients to visualize the individual shape of their breast as well as the tumor position and size. Further studies are needed to confirm the long-time patient satisfaction to widely translate this explanation method into daily clinical practice.

Conflicts of interest:

There are no conflicts of interest

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Table 1 is available in the Supplementary Files section.

Table20220416.xlsx
Table1：Clinical data of this study population

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Version 1

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You are reading this latest preprint version

Satisfaction survey on a preoperative explanation method using 3-dimensional breast imaging for breast cancer patients considering breast conserving surgery

Status:

Version 1

Abstract

Figures

Introduction

Methods

Study design

3d Breast Imaging

Patient Satisfaction

Endpoints

Results

Discussion

Declarations

References

Tables

Supplementary Files

Status:

Version 1