Annelotte van Bommel

130 DISCUSSION The objectives of the current study were to gain insight into the underlying decision- making process of IBR and to determine the effect of preoperative information provision about IBR on receiving IBR. Based onmore than five hundred completed questionnaires, we found that patients treated with IBR had been better informed about IBR, more often had weighed the advantages and disadvantages of IBR in discussion with their physician, and more often had experienced shared decision-making regarding IBR compared to patients without IBR. Furthermore, our multivariate logistic regression showed that being informed about IBR increased the probability for receiving IBR fourteen-fold. Because of our large sample, we were able to statistically control this relation for patient, tumor, treatment, and hospital factors. Since we found that being informed about IBR had a large effect on receiving IBR, it may well be that the uninformed mastectomy patients would have opted for IBR if they had received information about IBR. A prospective study by Ananian et al. reported that patients who opted for breast reconstruction more frequently recognized the importance of discussing breast reconstruction with their surgeon, and women who had benefitted more frequently from discussions with their physician in general tended to prefer IBR over DBR. 34 Other factors that significantly reduced the chance of receiving IBR in the multivariate regression analysis, mainly were risk-factors for postoperative complications after IBR (age over 55, BMI over 30, radiotherapy), as stated in the national guideline. 17 We found that patients without IBR were less often informed about IBR as a treatment option and its advantages and disadvantages than patients with IBR. However, it is the preoperative information discussed between patient and physician that is particularly considered carefully when making a choice 34,35 and not so much the information the patient collects herself from other resources. Guidelines, including the Dutch guideline on breast reconstruction published in 2015, already stress the importance of starting the discussion on different breast