Annelotte van Bommel

133 Information provision of immediate breast reconstruction majority of patients will face the trade-off between choosing IBR with a hazard of experiencing the negative effects of radiotherapy, or omitting IBR and therefore omitting its positive effects on quality of life and psychosocial functioning. Therefore, patients should be fully aware of these effects in order to make an informed decision. Interestingly, Flitcroft et al. reported that when patients (two- stage with tissue expander) were informed about potential negative esthetic side- effects of post-mastectomy radiotherapy on IBR, 63% still opted for IBR. 51 In our study, 39% of patients who had been informed about the effects of radiotherapy had undergone IBR. Strengths and limitations With a response of over five hundred patients from a large geographically diverse and randomly selected nationwide sample, we believe that we accurately reflected reconstructive care for mastectomy patients in the Netherlands. This was confirmed by our analysis of the characteristics of respondents versus non- respondents. Furthermore, patient experiences and clinical data were combined, therefore creating a broad dataset for each patient. However, also some limitations in the design of our study can be identified. Because patients had undergone mastectomy in 2013 or 2014, whereas our survey was conducted in 2015, potential bias lies in the patients’ ability to properly recall the exact process of decision-making and information provision. 52 In addition, there may have been a reduction of inconsistencies between current beliefs and previous decisions (“cognitive dissonance reduction”). 53 Finally, inherent to an online survey, and despite the possibility to provide paper based questionnaires, respondents were younger than non-respondents, leading to a slightly lower response rate in the group without IBR. Since we used a non-validated questionnaire, not all invited patients responded, respondents’ characteristics were not equal over both groups, which are limitations inherent to patient-reported data, and therefore interpretation of the results should be done with caution. We recommend that every woman who faces mastectomy is informed about all relevant options for breast reconstruction. 54 She consequently also should receive 7