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Consent:

The principle of consent is an important part of medical ethics and international human rights law.[20]

Is a written document that crystallizes the communication ongoing between surgeon and patient and that proves that the patient has made an informed decision evaluating pros and cons and possible alternative treatments and gives consent for that specific treatment.

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I usually give a consent form to the patient during the second or third clinic appointment, sometimes even later if more complex surgery is required or if a prophylactic mastectomy is involved.

After having discussed in a way that is understandable for the patient: her diagnosis and potential prognosis, the likelihood of success, the potential complications, recommended alternatives including no treatment and their risks and potential follow-up.

I divide complications into generics linked to surgery and anesthesia (like pain, scar, bleeding, infection, recurrence, fat necrosis, lymphedema, seroma, anesthesia-related complications, and DVT). and specific to the surgery chosen by the patient, for instance, if this patient chooses an implant-based reconstruction there will be specific mention of capsular contracture, implant rotation, rippling, implant rupture, asymmetry needs for further surgery, implant loss, BIA-ALCL needs to be discussed with every patient considering implant-based reconstruction, asymmetry, loss of sensation.

If the patient chooses an autologous reconstruction, then I will discuss flap loss, flap necrosis, donor site morbidities, and delayed healing.

I will also discuss approximate operative timing, postoperative analgesia, recovery times, the need for the use of a drain, and the time to remove it.

All this information is not only on the consent form but also recorded in the patient’s notes and all communication with the patient and GP, including the names of those who were present at the consultation.

The consent form will then be re-signed on the morning of surgery giving the patient time to ask further questions if needed before I will do the preoperative checks.

The consent form I use includes consent for medical photography.

Surgical plan for this patient:

I have never had a patient with breast cancer after treatment for HL, but I have cared for three patients who had mantle radiation for HL and requested bilateral prophylactic mastectomies, all of them chose implant-based reconstruction and immediate implant-based reconstruction.

Building on this experience I believe that both implant-based reconstruction and autologous reconstruction are valid options, and it will be the patient preference to guide me.

If her choice would be an autologous flap I will present her to the reconstruction MDT and the joint clinic with plastic surgeons.

If her choice of implant-based reconstruction will be discussed at MDT, I would favor a two-stage reconstruction with very careful expansion.

Adjuvant treatment:

After surgery the histological results will be discussed at post-op MDT and an adjuvant treatment plan will be defined.

In consideration of her ER PR status, this patient will be prescribed an aromatase inhibitor for 5 years. Large, randomized studies have shown that the adjuvant use of Tamoxifen for 5 years decreases the risk of recurrence of breast cancer by 45–50% and the risk of death by 31%, and the benefit persists for years after therapy is discontinued [21].

Several trials have assessed the utility of AIs in post-menopausal women with ER or PR breast cancer. AIs are less likely than tamoxifen to increase the risk for thrombotic events or endometrial cancer; however, they are more likely to be associated with arthralgia and osteoporosis. [21].

Since she had previous radiotherapy, she will not be recommended further radiotherapy as part of her adjuvant treatment.

If the Nottingham Prognostic Index or Predict demonstrates an intermediate risk Oncotype DX will be requested to assess if she would benefit from chemotherapy. However, due to the unique molecular biology of ILC, treatment response to chemotherapy is often predictably poor.

Recommended surveillance and follow-up

I will review this patient 2 weeks postoperatively to check her wounds and see how she is progressing.

Will refer her to Oncology to discuss in detail her adjuvant treatment.

I will follow her with a clinical follow-up appointment in year one and year 2 and with an annual surveillance mammogram for 3 years. From a reconstruction point of view during the first year, they will have an appointment a 3-month,6 months, and 1 year in the reconstruction clinic after that if they have any problem, they can contact the named reconstruction nurse who if needed will provide them with rapid access to the clinic.

The BCN will contact her with a phone call a 6-week post-op, and then at 6 months, all patients are actively encouraged to contact the breast care nurses if they have any problems or questions.

An onco-psychologist is available i,f at any point of their journey, they feel they need any psychological help. Oncologists will see her every 6 months for the first year and then yearly for the first 5 years. If she had an autologous flap plastic surgeon will guide the surgical follow-up.

NICE guidelines 2018 [4] state that everyone who has had treatment for early breast cancer should have a copy of a written care plan. The care plan has information about follow-up and signs and symptoms to look out for. It will also include contact details for specialist staff, such as breast care nurses.

Relevant Lifestyle factors:

Certain breast cancer risk factors are related to personal lifestyle factors like diet, drinking alcohol, weight gain postmenopausal obesity, and taking postmenopausal long hormonal replacement. Some modifiable risk factors decrease the risk of breast cancer like exercise or breastfeeding (4,3% reduction in relative risk of breast cancer for every 12 months of breastfeeding) [22]

This patient had chest wall radiation 20 years before and this certainly increased her risk of breast cancer. She attended a breast screening

I don’t think there is anything more specific she could have done if not maintaining a healthy body weight and physical activity.

Patients Reported Outcome Measures PROMs

Proms. (Patient Reported Outcome Measures) are procedure-specific questionnaires, designed to measure outcomes that are important to the patient.

In breast surgery, PROMs enable patients to quantify their symptoms and QoL about their cancer and enable them to evaluate the impact and effectiveness of their treatment. [23]

The BREAST-Q™ and The European Organisation of Research and Treatment of Cancer’s Quality of Life Questionnaire (EORTC QLQ) are two validated PROMs that have been widely utilized in breast surgery outcome assessment. [24]

The BREAST-Q is PROM questionnaire has been validated for patients undergoing breast reconstruction to enable measurement of quality of life (QoL) and satisfaction in this specific population of patients [25]

The EORTC QLQ-C30 and BR-23 despite being the most widely used questionnaire in Europe for assessing breast patients, although validated PROMs are not specific for breast reconstruction.

QLQ-C30 is a cancer-specific health-related QoL questionnaire analyzing domains such as physical, emotional, cognitive, and social functioning and sequelae of disease such as pain, nausea, and fatigue, while QLQ-BR23 is a PROM validated for breast cancer patients, assessing factors such as body image, sexual functioning and enjoyment, cancer symptoms, and systemic therapy side effects.

A systematic review by Cordova “ PROMs following mastectomy with breast reconstruction or without reconstruction” did show that breast reconstruction following mastectomy has led to better patient-reported outcomes compared to mastectomy-alone in the great majority of trials But care must be taken when interpreting the data the lack of randomized controlled trial [26]

A systematic review by Phan “The Use of Patient Reported Outcome Measures in assessing patient outcomes when comparing autologous to alloplastic breast reconstruction” demonstrated that breast reconstruction after mastectomy has been associated with positive psychological outcomes. When comparing autologous and alloplastic-based reconstruction, it is apparent from the patient’s perspective that autologous reconstruction is no less favorable and has a higher satisfaction of breast rate than alloplastic reconstruction techniques. Physical and sexual well-being were equivocal between the two reconstructive groups. [27]

Medico-legal aspects:

In the past the majority of complaints against breast surgeons were due to delays in breast cancer treatment and diagnosis, but with the introduction of MDT meetings and tighter National guidelines, improved radiology techniques it has become unusual to have a significant delay in diagnosis once a patient is under the care of the breast team [28].

Litigation concerning cosmetic and reconstruction surgery outcomes has now become the most frequent cause of medico-legal problems. The appearance of the breast has become a critical component even in breast cancer treatment. Reconstruction surgery is not the equivalent of aesthetic surgery in terms of outcomes and judgments. It is and remains both an oncologic and a reconstructive procedure with all the oncologic limits in its background. [29] As the majority of the allegations arise from unrecognized or unmet expectations, all the limitations of reconstruction must be discussed with the patient and included in the informed consent to avoid errors of interpretation and communication between the surgeon and the patient (29). Clear, detailed documentation of clinical examination, diagnosis, MDT meetings, informed consent, and shared decision plus photographic documentation of pre and postoperative results, follow up and adjuvant treatment plan should be stored in the patient file.

Adherence to national guidelines local protocols and regular clinical governance would reduce the chance of medico-legal problems.

#heathcare #medical #medicalcare #pharmaceuticals #healthcareprofessional #nurses #healthprofessionals

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