Annelotte van Bommel

156 leads to altered anatomy and scarring, which may lead to pain and discomfort and therefore decreased physical well-being. A strength of the current study is that it included a representative sample of the breast cancer population in the Netherlands. Limitations are the possibility of recall bias, due to the retrospective design, and response bias, which is inherent to the use of questionnaires. Also, our response rate of 46%was lower compared to other studies, which varied from 56% to 74% 21,22,23,26,27 possibly because we did not send any reminders. The mean time between mastectomy and the questionnaire was approximately 17.5 months (range 3 – 34 months), which is relatively short, however, we excluded patients still in the process of reconstruction. Unfortunately, no preoperative information on the outcome domains was available in our study, similar to most breast cancer surgery studies using the BREAST-Q. 28 The difference in baseline characteristics (younger, employed, more healthy patients and patients with lower stage tumors without radiotherapy have a higher change of receiving IBR) might have resulted in treatment indication bias. A multivariate linear regression analysis was performed to adjust for patient characteristics when comparing mastectomy with IBR versus without IBR. Nevertheless, other (unknown) factors may have contributed to health-related quality of life and may therefore limit the conclusions drawn from this research. Patients with an indication for mastectomy should receive sufficient preoperative information enabling informed shared decision-making about IBR. It may be seen as a challenge to inform patients about all available and relevant surgical options for breast cancer, including their advantages and disadvantages, enabling a patient to make her own informed decision. In a study previously reported by our group, patients who had received IBR had been better informed about IBR and felt more involved in shared decision-making compared to patients without IBR. Moreover, patients being preoperatively informed about IBR had a 14-fold higher chance of receiving IBR. 16 Others reported that one third of the patients who underwent a mastectomy felt they had not received sufficient information about breast reconstruction, or were dissatisfied with the reconstruction decision- making process (13%). 29