Annelotte van Bommel

108 DISCUSSION Hospital variation in IBR after mastectomy can partially be explained by variation in patient and tumor characteristics (i.e., case-mix factors) that cannot be altered. 11 In addition, differences in patient preferences may also be a cause of variation. 6,26 However, variation in IBR due to hospital organizational factors 18,24 or personal opinions towards IBR of individual physicians is undesirable. 26 As found in the present study, surgical oncologists and plastic surgeons differ in their information provision to patients about IBR. More importantly, personal opinions towards IBR differ between surgical oncologists and plastic surgeons as well. Surgical oncologistsmore frequently reported cancer related factors to be a contra-indication for IBR compared to plastic surgeons, whereas the lattermentioned factors affecting complications or reconstruction failure more frequently. Preoperative information provision The Dutch, evidence-based NABON breast cancer treatment guideline recommends that every patient undergoing mastectomy should be considered for IBR. 3 Interestingly, in the present study all surgical oncologists discussed the possibility of IBR with their patients, while other studies reported lower rates of information provision about IBR, ranging from 23% in Japan 27 to 74% in the United States. 28 It seems justified that surgical oncologists inform patients about the existence and possibility of IBR and delayed reconstruction, while details about the reconstructive procedures, shared decision-making and patient expectations are managed by plastic surgeons, indicating that patients need to be referred to a plastic surgeon for complete and correct information on IBR. Patient related contra-indications Surgical oncologists in another study considered age (37%) as a factor affecting the decision to refer patients to the plastic surgeon for IBR. 28 Age has been described in literature as a factor significantly affecting the prevalence of IBR, 11,13–15,19,26 but also as a risk factor (age >55 years) for implant loss after IBR. 29 In the current study, we found that age was not considered as amajor contra-indication by both professions,