Center News Magazine: Life After Breast Reconstruction

Tuesday, December 1, 2009
Plastic surgeon Andrea Pusic Plastic surgeon Andrea Pusic

Memorial Sloan Kettering Surgeons and Nurses Make Important Contributions to Patients' Postsurgical Quality of Life

An overarching area of research in Memorial Sloan Kettering's Plastic and Reconstructive Surgical Service is measuring patients' quality of life after reconstruction. “How do you measure whether a patient is satisfied?” asked Peter G. Cordeiro, Chief of Memorial Sloan Ketterings Plastic and Reconstructive Surgical Service. “How do you measure expectations? Because expectations to a large extent determine what a person's satisfaction level may be.

We're very good as surgeons at knowing whether a patient will survive, whether they'll tolerate an operation, whether they're going to have complications — we have that data. But the question is: What did the surgery really do for them? How can you measure patient perceptions of the results of surgery? And it turns out that there are psychometric ways to develop surveys to answer what seem on the surface to be these very subjective questions.

The development of objective measurements of quality of life after reconstructive surgery is a critical movement,” added Peter T. Scardino, Chair of the Department of Surgery. “At Memorial Sloan Kettering, we are certainly taking the lead in this, and I see it expanding worldwide and ultimately justifying the use of plastic surgery in much of oncology.

In 2008, Memorial Sloan Kettering's plastic and reconstructive surgeons performed nearly 1,300 reconstruction procedures. Most of these — 1,069 — were reconstructions after surgery for breast cancer, followed by head and neck reconstructions (140). The goal of breast reconstruction after mastectomy (the removal of a breast) is to restore anatomy and symmetry, either with artificial implants or by using a woman's own tissue. Of the 1,069 breast reconstructions performed in 2008, 936 were with implants while 133 were autologous tissue reconstructions, meaning that the patient's own tissue was used.

In addition to her clinical role, Memorial Sloan Kettering plastic surgeon Andrea L. Pusic works to develop tools to measure patient satisfaction and quality of life after reconstructive surgery. “In plastic surgery, we don't save a life, per se. What we try to do is improve the quality of that life,” said Dr. Pusic. “For cancer survivors across the spectrum of disease, improving the quality of their lives is our goal.

For breast cancer patients, Dr. Pusic and colleagues developed what is known as a patient-reported outcome measure. Patient-reported outcome measures are questionnaires that quantify health-related quality of life and/or other significant outcome variables from the patient's perspective. In-depth patient interviews were conducted with an eye to understanding what issues are most important to women following breast surgery. Based on the results of those interviews, a questionnaire called the BREAST-Q© was created.

What women told us was that it isn't just about what breasts look like,” Dr. Pusic explained. “It's also about physical, psychosocial, and sexual well-being. It's about their satisfaction with their surgeon, with the information they were provided, and with their interactions with their medical team.” The questionnaire “is a 360-degree look at the entire experience and a woman's perceptions of the outcome of her breast surgery,” Dr. Pusic said.

The BREAST-Q is now used nationally and internationally. “It has been translated into Spanish, Polish, Chinese, French, Swedish, German, Italian, and Icelandic,” said Dr. Pusic, “and is currently being translated into Japanese. In the United Kingdom the National Health Service is using the BREAST-Q to survey 10,000 women having mastectomy followed by reconstruction.” In the United States, the BREAST-Q has been adopted by the American Society of Plastic Surgeons as its outcome measure.

At Memorial Sloan Kettering, all new breast patients are invited to complete a portion of the BREAST-Q preoperatively and can do so by registering on the Center's patient portal. (The portal — called MYMSKCC — is a private online link that allows patients to access their personal medical information and communicate with their physicians and nurses.) “That data then comes to each of the surgeons in the clinic,” explained Dr. Pusic. “So I can look at a patient's responses from the first time I meet her and can follow her in terms of her satisfaction and quality of life over time.

At intervals during the course of her treatment, a patient will be asked to complete portions of the BREAST-Q. In the early postoperative period, she is asked to answer questions that gauge pain, discomfort, and physical well-being. As she moves further along in her reconstruction, BREAST-Q questions survey her satisfaction with her breasts and her psychosocial functioning. “All of this is a way of enhancing the dialogue between a surgeon and a patient.” said Dr. Pusic. “It's not meant to be a surrogate for communication but to facilitate communication. In addition, the BREAST-Q asks about expectations — before and after surgery — because we find that it's the unexpected things that can be a source of dissatisfaction. If I know what a patient's expectations of surgery are before I take her to the operating room, I can see if they match what I can reasonably deliver. If not, I can make sure that my patient clearly understands what a reasonable expectation would be.

The BREAST-Q is used not only for clinical care but as a research tool. “As our surgical techniques are becoming more sophisticated, we need to be able to look at them with a much more sophisticated lens in terms of research,” Dr. Pusic asserted. All the scales in the BREAST-Q go from zero to 100, and it was designed so that the scales can be tailored to answer different researchers' questions. For example, the BREAST-Q could facilitate comparisons of different surgical techniques from a patient perspective. “If I have an idea about a new method of breast reconstruction,” elaborated Dr. Pusic, “I might use the questionnaire as a study tool, adapting it with specific questions, so I'm able to learn from patients if — from their point of view — the new approach is better.

The contribution of nursing

Nasrin Vaziri Plastic and reconstructive surgical nurse Nasrin Vaziri counsels a patient

The role of skilled nursing care in reconstructive surgery, whether of the breast or another part of the body, cannot be overstated. “The nurses who care for our reconstruction patients are with them right from the beginning and are vital members of the team,” said Dr. Cordeiro. Even before patients have surgery, the Plastic and Reconstructive Surgical Service office practice nurses meet with patients to help them know what to expect. During the immediate postsurgical recovery period in the Post-Anesthesia Care Unit (PACU), and after patients are moved to a floor in the hospital, nurses who are expert in post-reconstruction care are at the bedside. Finally, after patients are discharged, office practice nurses maintain regular telephone contact with them and participate with surgeons in the delivery of appropriate care when patients return for their regular follow-up visits. “It's an extraordinary continuum of care,” said Dr. Cordeiro, “and the contribution and expertise of our nurses is invaluable.

Five nurses work mainly in the offices of the five attending surgeons on the Plastic and Reconstructive Surgical Service and three more work at the ambulatory clinic where patients are seen on an outpatient basis after surgery.

Nasrin Vaziri, who has been at Memorial Sloan Kettering for 30 years, works with Dr. Cordeiro as his office practice nurse. “Our nurses — from the PACU to inpatient floors and office practice — must all be extremely knowledgeable about every aspect of reconstructive surgery,” she pointed out. “This is because we are a secondary service — meaning that the primary oncologic surgeon first does the operation to remove the cancer and then our plastic surgeons follow, reconstructing the surgical defect. So nurses on our service not only need to know all about the reconstructive procedure performed by our own surgeons, we also need to be familiar with the surgeries being done by surgeons from the Breast, Head and Neck, Thoracic, Gynecology, Colorectal, Urology, Pediatric, Orthopaedic, and Dermatology Services, and the Department of Neurosurgery.

At Memorial Sloan Kettering, the success rate for a procedure known as microvascular free-tissue transfer is between 98 and 99 percent. One of the reasons for this high success rate is the vigilant monitoring of flap circulation postoperatively. (Free-tissue transfer refers to taking living tissue from one place on a patient's body to the site where tissue is missing after surgery to remove cancer. Flap is the medical term for the piece of tissue that is being transferred. Microsurgical techniques are used to attach the very tiny blood vessels that will allow the transplanted tissue to live.) Astute postoperative monitoring of flaps by nurses is critical in making certain that the tissues survive and heal properly. “Flaps are monitored by checking the temperature of the tissue, the blood flow through the vessels, and the look of the flap - the color of the skin and the feel of the tissue. Is it healthy and soft? Is it swollen or hard?” said Ms. Vaziri. “If there are subtle changes in a flap, our nurses are able to pick these up at a very early stage and prevent complications.

For patients who are going to have a reconstruction procedure after breast cancer surgery, a monthly, two-hour class that was established in 1988 by Ms. Vaziri seeks to educate patients and their families about all facets of reconstructive surgery. “The class prepares them for everything — from approximately how long they'll be in the operating room, to what to expect during postsurgical care, to psychosocial issues,” explained Ms. Vaziri. “And I always make a point of saying, 'You're not going through this alone.'

This is the second in a three-part series on plastic and reconstructive surgery at Memorial Sloan Kettering. The first part, A Return to Normal: The Collaborative Art and Science of Breast Reconstruction, is available online in the October 2009 issue of Center News.