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."
