Framing Bias in breast reconstruction
April 2, 2022
December 7, 2021
.
By Dr. Andrew Campbell-Lloyd

Framing Bias in breast reconstruction

Something I have always observed in my reconstructive work is the fact that patients have often had information presented to them in remarkably biased ways. More importantly, this impacts on their treatment decisions, very often leading to what I would consider poor outcomes that could otherwise have been avoided. I guess the classic illustration of this is the profound regrets that some of my patients express when they present to me to have their reconstruction revised.

This is worth considering, so let’s look at an example.

The most obvious example is a lady with breast cancer who is considering her choices about her cancer treatment and her reconstruction.

Most ladies will be referred initially (either from Breast Screen, or from their GP) to a general breast surgeon. Some of these surgeons will perform limited forms of breast reconstruction, which typically involves an implant-based reconstruction. For the sake of this example, let’s assume that our hypothetical patient has been diagnosed and referred by her GP to a general breast surgeon who performs breast cancer surgery, and who also performs some implant-based breast reconstructions.

Now, to make it easy, lets assume that this lady is around 45 years old. She has a normal build, with a C cup breast. She would be considered a suitable candidate for both implant based reconstruction, and DIEP flap reconstruction.

So, this lady has a discussion with the breast surgeon about her options. The surgeon may discuss with her the option for mastectomy, and the option to treat just one breast or both. This is the first point where the way in which surgical options are presented can have a massive impact.

Let’s consider two scenarios (both of which reflect versions that I have heard or patients have told me about):

1. The breast surgeon points out that our lady has a relatively small breast cancer which is hormone receptor positive, and there is no evidence that the tumour has spread to her lymph nodes. Perhaps there is some surrounding DCIS, and given her modest bust, therefore it is considered best to proceed with a mastectomy rather than breast-conserving surgery (that is another topic for discussion, but we’ll park that for now). The surgeon indicates that on the basis of what we know about this lady’s cancer, the risk of cancer in the opposite breast is in no way increased. Perhaps the breast surgeon says something like:

“Given that there is no increased risk of cancer in the opposite breast, there is no reason to remove a perfectly healthy breast. Whilst there is always a small risk of developing cancer in that healthy breast at some point, that risk is no higher than anyone else’s. Removing your healthy breast is a bit like a lady with no cancer choosing to have her breasts removed, just because there is a risk that at some point in life, she might develop breast cancer.”

2. Alternatively, the surgeon could say something like:

“Even though there is no increased risk of cancer developing in your healthy breast, imagine the anxiety and stress that you will have each time you have a mammogram or an ultrasound. You will constantly be wondering if there is another cancer. Most of my patients choose to have a double mastectomy because that way, they don’t have to worry. And we can reconstruct both of your breasts at the same time which will look better anyway.”

Now, I am sure you will appreciate that I am taking some liberties in how I present the two options above, but I am also sure that there will be ladies who can recognise in these examples, similarities to the information they were given when they were in the same situation. I can tell you truthfully that the second example is how a few of my patients have recounted their interaction when they were diagnosed. Not great.

The point of course is this: the patient presented with information as in example #1 is going to view her options about single vs.double mastectomy quite differently to the patient presented with information as in example #2.

 

So let’s think also about how a breast reconstruction might be presented.

Let’s consider two more examples:

1. Our lady sees the breast surgeon who also chats to her about reconstructive options. Perhaps in this example, she has also (for whatever reason) decided to have a double mastectomy. The breast surgeon says something like:

“You could have either an implant or your could use your own tissues. If you have an implant reconstruction, this is a much simpler operation with a quicker recovery. You'll be back at work in no time. But if you have a tissue reconstruction, this is really risky surgery, you’ll be in hospital for 10 days, and you’ll also end up with an enormous scar on your abdomen.”

2. Alternatively, the surgeon could say:

“If you have an implant reconstruction, there are a few risks to consider. In about 10% of cases we may have to remove one or both of the implants for one reason or another. The implants will always feel very different to your natural breasts, and they may harden over time. Some ladies will experience pain from their implants. On the other hand, if you would like to consider a tissue reconstruction, I can arrange for you to see a Plastic Surgery colleague who can go through that with you. The tissue reconstruction will normally offer a more natural result.”

In a similar way to the question of single vs. double mastectomy, you can appreciate that the information presented about reconstruction will almost certainly sway a patient one way or another.

 

What we are talking about here is a thing called “framing bias”. If information about a certain surgical option is presented to a patient in a positive or negative way, it will impact on the likelihood of a patient choosing to proceed with that option. It isn't about a surgeon actually lying to their patients. It is about the biases which influence what that surgeon thinks of certain surgical options.

A recent study in the journal 'Plastic & Reconstructive Surgery' this month has demonstrated that the effect of this framing bias is statistically significant in how patients choose to proceed with surgery. Perhaps even more importantly, framing bias can have a significant impact in how breast care nurses interpret information about reconstruction, and this may lead to enormous differences in how they then counsel patients with breast cancer about their surgical options.

 

The reality is that EVERY surgeon has biases. I tend to declare my biases straight up to all of my patients. Whilst I generally consider tissue reconstruction with a DIEP flap to be the best choice, and I am open about that, I also think that implant reconstruction is the right choice for some of my patients.

The difference between what I think is best, and what I think is right for my patients is an important distinction. There is much more to consider than just the operation and its outcome.

We also have to consider the various influences for any patient including family, children, work, social life, life stage, body image and so much more. These are the factors that can determine what the RIGHT decision will be, regardless of what I (or any surgeon) considers best.

It is reasonable to ask any surgeon what their biases are. Perhaps you'll be able to have an enlightened discussion about that. Perhaps not. That might be a useful insight into the kind of surgeon you're dealing with.

It is not for a surgeon to make a decision for a patient. It is our responsibility to present information to our patients in a way that is unbiased (if possible), so that our patients can make their own decisions with the necessary information to hand.