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Many women do not feel well prepared to make this decision.</p><p id="spar9005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Aim:</span> Using the Ottawa Decision Support Framework, this study seeks to describe the reasons that women choose or do not choose BR, their knowledge of BR, decision-making preparation and decisional conflict regarding BR. We also assessed possible demographic and clinical correlations, and attitude and decisional conflict regarding breast reconstruction.</p><p id="spar8005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Methods:</span> Fifty-five women with early stage breast cancer participated taken from the reference data of a randomised pilot study that assessed the efficacy of a decision-making support system for patients with breast cancer considering BR.</p><p id="spar7005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Results:</span> The women's major reasons for choosing BR were the desire for breasts of the same size, to come round from surgery with their breast in place, and the discomfort caused by a scar without a breast. The reasons ranked highest for not choosing BR related to the risks and surgical complications. The regression analyses indicated that decisional conflict was associated more as a reason for not choosing BR, and being less well prepared for the decision.</p><p id="spar6005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Conclusions:</span> The results suggest that patients with breast cancer considering BR could benefit from decision-making support.</p><p id="spar5005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Implications:</span> for clinical practice Health professionals can facilitate decision-making by focussing on each patient's reasons for uncertainty and concerns that have not been addressed. All patients, even those who have consulted a plastic surgeon and are unsure of their decision, could benefit from appropriate advice from health professionals.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Commentary</span><p id="par0005" class="elsevierStylePara elsevierViewall">Breast cancer is the most common tumour in women worldwide. The choice of treatment depends principally on the characteristics of the tumour. It is estimated that 45% of diagnosed cases will require mastectomy, which can result in a loss of self-esteem, impaired body image and have great emotional impact.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">There are different reconstruction options to help reduce the problems that add to the cancer process itself. Breast reconstruction is a term that describes a variety of surgical procedures ranging from immediate reconstruction implants to reconstruction using the woman's own tissue. Implants are placed under the pectoral muscle starting with the placement of an expander and require gradual filling with saline for several months until the necessary size is achieved to then place the definitive implant in a surgical procedure.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Implant surgery is not complication-free; the data show incidences of rupture (8%), suture dehiscence (10–30%), and infection (1–30%).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Encapsulation and healing problems can occur in the long term, and even cause the procedure to fail. Patients should also be informed that reconstruction with autogenous tissue, although it is the most natural remedy that enables reconstruction of the nipple and areola, also has significant risks of extensive scarring and muscle weakness.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Most studies focus on assessing the benefits of breast reconstruction (BR) are in favour of choosing the treatment and defend its great benefits in terms of body image and quality of life.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> However, decision-making is a stressful and complex process because it comes after the impact of a recent cancer diagnosis and, above all, due to the extensive and confusing information sometimes provided by sources such as the internet, social networks, family and friends. Therefore, an in-depth examination of women's satisfaction during preparation for decision-making and of the role played by knowledge and attitudes in this process is lacking.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In this context, the objectives of this study were to identify the level of knowledge about breast reconstruction of women diagnosed with early-stage breast cancer in the process of choosing mastectomy or lumpectomy, to describe the reasons for choosing or not choosing BR, the decision-making preparation process, and to identify decisional conflict.</p><p id="par0030" class="elsevierStylePara elsevierViewall">We undertook a randomised clinical trial to assess the efficacy of a decision-making help and support website for patients with breast cancer considering BR.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The inclusion criteria were: a primary diagnosis of breast cancer in situ, or at stage I, II, IIIA, being in the phase of considering the option of BR (those who were considering between either mastectomy or lumpectomy, as well as those who had chosen mastectomy were included), women for whom BR had been indicated by the surgeon, over 18 years of age, English-speaking, and wishing to participate by giving their informed consent. Initially 104 patients were chosen, of whom 97 met the eligibility criteria, and 55 of these women agreed to participate in the study. The reasons for some of the women not wishing to participate included the lack of benefit to them from the project in terms of their own specific illness. The patients were identified and chosen in person after consultation with their surgeon or by telephone when they had been referred by the oncologist. They were given a written informed consent form, and a questionnaire that was sent later by post.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The method used shows a major commitment in highlighting the proposed aims using different validated questionnaires providing greater consistency to the results and the relationship with the socio-demographic and clinical variables.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In terms of the results, it is noteworthy that the main reasons for choosing BR were in relation to the desire to have breasts of a similar size, coming round from surgery with their breast in place, and rejecting a scar without a breast. The reasons mentioned less that forced the decision were improved relationship with their partner, and improved sexuality.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The surgical risks and the complications after surgery such as healing and pain were highlighted as reasons for not choosing BR. The regression analysis shows that decisional conflict is associated with more reasons for not choosing BR, and with low levels of preparation for decision-making.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Furthermore, with regard to decisional conflict, the women who had consulted a plastic surgeon about BR had a higher level of knowledge and were more prepared to make a decision, although they also had higher anxiety. Almost half the sample stated that they had taken a decision regarding BR. Of these women, 22 confirmed that they had chosen reconstruction, compared to a minority who had chosen an implant. Twenty-eight women had still not made a decision.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The main limitations of this study were the low number of participants, and therefore significant associations were not found for some variables. For this reason the data cannot be generalised and it should be considered a pilot study.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The need for support in decision-making is a constant in the area of oncological care. Its importance lies in the lack of reliable information that women with breast cancer receive on their condition in general, the lack of information on the different treatments such as surgery and the possibilities of reconstruction. We must start by considering that women with breast cancer, in this case, are and must be at the centre of care and are the protagonists of their condition and therefore it should be they, and not health professionals unilaterally, who take the decision for reconstruction, which is contrary to what has been happening.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The results indicate that women want to claim an active role in their health and require support in decision-making based on improved information that can be safely offered by many sources. Support in decision-making improves their coping with the process, treatment and complications of their disease. Women with cancer are becoming increasingly, and better, informed and if they are not, our starting point must be to provide them information to support their decision-making.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In most cases, hospitals do not have a formal structure to support women in decision-making and therefore they state that they require more time to reflect. Therefore the decision to undergo reconstruction surgery after mastectomy is made under stressful circumstances and this means that many women do not feel sufficiently prepared to take this decision.</p><p id="par0080" class="elsevierStylePara elsevierViewall">From a nursing perspective, there are educational interventions to improve the competences of women with breast cancer in the follow-up stage of the disease based on self-care, which include expert assessment by nurses.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Therefore, the role of advanced practice cancer nurses is essential in follow-up, accompaniment and advice, as well as decision-making support that includes information on the advantages and disadvantages that reconstructive surgery might offer each individual woman.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> Nursing interventions in the area of oncology, from Primary Care and Hospital Care, contribute to everything required for improving their decision-making, offering quality information based on the best evidence on the cancer process, applying results to their specific case, emphasising self-care and placing the tools necessary for effective decision-making within their reach.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Practically speaking, this requires better training and responsibility so that nurses can offer appropriate support and improve the self-care competences that are necessary for women to cope with breast cancer and decision-making about their future. Moreover, it will be necessary to study and assess the nursing interventions that are made in this field to improve their practice by focussing on the self-care of people with cancer, and support in their decision-making.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Commentary" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-12-19" "fechaAceptado" => "2018-12-19" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Merino Navarro D. Actitudes y conflicto de decisiones acerca de la reconstrucción en pacientes con cáncer de mama. Enferm Clin. 2019;29:54–56.</p>" ] ] "multimedia" => array:1 [ 0 => array:5 [ "identificador" => "tb0005" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0047" class="elsevierStylePara elsevierViewall">Manne SL, Topham N, Kirstein L, Myers Virtue S, Brill K, Devine KA, Gajda T, Frederick S, Darabos K, Sorice K. Attitudes and Decisional Conflict Regarding Breast Reconstruction Among Breast Cancer Patients. Cancer Nursing, 2016; 39 (6):427–36.</p></span>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Accessed 14 Nov 2018. 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Merino-Navarro" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2012" "editorial" => "Alicante" "editorialLocalizacion" => "RUA" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0055" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Accessed 12 Jun 2016. Available from: http/::hdl.handle.net:10045:132534" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Autocuidados y Salud en mujeres afectadas de cáncer de mama" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M.I. Mariscal-Crespo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2006" "editorial" => "Alicante" "editorialLocalizacion" => "RUA" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0060" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Estrategias para la mejora del cuidado del paciente oncológico: resultados del proyecto SHARE" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.C. Reñones-Crego" 1 => "D. Fernández Pérez" 2 => "C. Vena Fernández" 3 => "A. 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Journal Information
Vol. 29. Issue 1.
Pages 54-56 (January - February 2019)
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Vol. 29. Issue 1.
Pages 54-56 (January - February 2019)
Evidence-based nursing
Attitudes and decisional conflict regarding breast reconstruction among breast cancer patients
Actitudes y conflicto de decisiones acerca de la reconstrucción en pacientes con cáncer de mama
Dolores Merino Navarro
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Facultad de Enfermería, Universidad de Huelva, Campus El Carmen, Huelva, Spain
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