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Section 18
Breast Reconstruction, Part II: Decision-Making & Psychotherapy

Table of Contents | NCCAP/NCTRC CE Booklet

Decision-making and breast reconstruction
Recent British policy documents (Expert Advisory Group on Cancer to The Chief Medical Officer of England and Wales 1995, NHS Executive 1996a) have encouraged care providers to offer women a choice of treatment following diagnosis of breast cancer. However, many women find this choice stressful (Pierce 1993, Fallowfield et al. 1994), particularly when the diagnosis has just been given and their capacity to process information, to think clearly and critically, and to make important decisions is adversely affected (Rosenqvist et al. 1996). More than a quarter of the women in Bremner-Smith et al.'s (1996) study found it difficult to make their decision concerning reconstruction, despite being satisfied with the discussions about the options available to them. Similarly, Clifford (1979) stated that several women felt, retrospectively, that insufficient time had been devoted to the decision-making process.

To date, a paucity of research has examined the process by which women decide whether or not to undergo breast reconstruction. Exceptionally, Reaby (1998a, 1999) classified the decision-making style used by 95 women who decided for (n = 31) or against (n=64) reconstruction according to the degree of conflict, information-seeking, deliberation and regret experienced. Most women electing not to have reconstructive surgery were classified as `sideliners' -- choosing the alternative that was the simplest to implement. These women made rapid, conflict-free decisions but were prone to regret at a later date. None of the reconstruction patients made their decision in this way, tending instead to demonstrate the `contented' pattern -- having a strong preference for reconstruction based on individual personal needs and showing little regret. This pattern was also used by 12% of the women electing not to undergo reconstructive surgery. More than 30% of the women who underwent reconstruction and 12% of those having mastectomy alone were classified as `shifters' -- vacillating between possible alternatives and relying upon other people to make the decision for them. One woman used the `panic-stricken' approach, being too distressed to process information and choosing reconstruction without any recollection of doing so.

None of the women in Reaby's study had actively sought out information and weighed up the available alternatives in a rational, methodical and `enlightened' approach deemed unlikely to result in postdecisional regret. It is unclear whether the four women who underwent a delayed procedure reported decision-making processes or levels of postdecisional regret comparable with those reported by immediate reconstruction patients. Furthermore, the retrospective interviews did not investigate the decision-making process whilst it was taking place.

Many women facing the option of breast reconstruction choose not to make such decisions themselves, preferring to pass these decisions back to health professionals (Anderson & Kaczmarek 1996). If breast reconstruction is to be offered to all women then health professionals (including breast care nurses) need to be able to offer psychological support and to help women to make informed choices. The necessity to support women facing decisions about their primary treatment for breast cancer has been widely acknowledged (Fallowfield et al. 1994) and it is reasonable to suggest that this support should extend to decisions concerning reconstructive surgery (Rosenqvist et al. 1996).

Psychological support for women considering breast reconstruction
Typically, it is assumed that psychological support for women with breast cancer will be provided by specialist nurses, yet relatively little attention has been given to how breast care nurses can most effectively and beneficially support women facing the option of breast reconstruction.

In aiming to clarify the role of health professionals in this area, Winder and Winder (1985) and Reaby (1998a, 1998b) have stressed that women considering reconstruction should have access to a trained professional who provides basic, clear, relevant, up-to-date information; helps them prepare for medical consultations; provides support; encourages the involvement of family and friends; ensures women have sufficient time to make their choice and is aware of the psychological issues around breast loss and body image disturbance.

It is also important to discuss the nature and possibility of surgical complications with women contemplating breast reconstruction. Whilst any kind of surgical procedure is an anxiety-provoking and stressful event (Johnston 1988), women with high expectations and hopes pinned upon the outcome of reconstructive surgery may be especially vulnerable to severe distress and disappointment if complications occur, thereby compounding the psychological trauma of mastectomy. However, Borah et al. (1999) report that the possibility of such psychological complications is rarely discussed.

Personal Reflection Exercise #4
The preceding section contained information regarding decision-making and psychotherapy with clients undergoing breast reconstruction. Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 18
According to Reaby, what were the differences in the decision-making styles of women who opted for reconstructive surgery and those who didn’t? Record the letter of the correct answer the NCCAP/NCTRC CE Booklet

NCCAP/NCTRC CE Booklet
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