Factors Influencing Women to Choose Breast Reconstruction - Dissertation Example

 Factors Influencing Women to Choose Breast Reconstruction. A critical review of the literature Aim: The aim of this paper is to clearly understand the factors that influence women to choose breast reconstruction after mastectomy. Background: Breast reconstruction restores the shape of the breast but can not restore the normal breast sensation. However Breast reconstruction often makes women more comfortable with their bodies and helps them feel more attractive. Breast surgery or radiation to the breasts does not have any deterring effect on the sexual life of women. Their QOL is similar to that of normal women. Technological developments that had lead surgery to make easy adds more to breast reconstruction. The technology has developed to such a stage that breast reconstruction can immediately be performed after mastectomy unlike the previous years when reconstruction had been carried out after so many calculations and waiting. The agony of waiting along with the expectation to restore the lost breasts again in the shape has pulled more women towards immediate breast reconstruction. Use of external prosthesis was brought to cessation due to breast reconstruction. This also influenced more women to opt for breast reconstruction. The more the news about breast reconstruction spread among the breast cancer patients, the more they were inclined to know still more in expectation of regaining their breasts. Medical journals and research people have contributed much in this area to give wide publicity especially in western countries. Thus the factors that stand cause for the women to opt for breast reconstruction grow mounted. Of the factors that influence reconstruction, some are purely clinical and some are purely psychological. Medical literatures have focused much on this area. Method: Findings: On sifting the five literatures selected for study/review, it is found that many authors emphasise that breast reconstruction is still cosmetic oriented. The developments in medical science towards breast reconstruction are purely ‘shape’ oriented. Many researchers ascribe this to the psychological satisfaction that the women get after being reconstructed their breasts. Physiological aspects are being well attended to by the surgeons who under take reconstructive surgery. With regard to psychological elements, the surgeons and the entire medical team have to rely completely upon the satisfaction of the patients diagnosed with breast cancer. Once it has become the matter of satisfaction, the entire job becomes analogous to a business where customer satisfaction is the most vital one. The developments aimed are all towards the same direction of satisfaction. In this process medical profession has to encounter certain bottle-necks too like after-effects of surgery and the resultant dissatisfaction. Conclusion: Although breast reconstruction has gained momentum during the last two decades, the clinical approaches are yet to be developed in terms of social and economical perspectives. Amputation sustained in consequence of an accident or illness is not bothered. But amputation of breasts is viewed seriously by many women. They are prepared to look crippled in other parts of their body but not their breasts. This is because breasts are universally considered as anatomical identity of femininity. Hence in addition to medical perspective, socio economic perspective is needed to have a complete understanding of breast reconstruction, despite the fact that breast reconstruction brings many feelings of comfort among women. INTRODUCTION : Breast reconstruction Universally breasts are considered as anatomical identity of femininity. Therefore loosing the identity is a critical concern for women who are to undergo mastectomy. The factors that drag them towards reconstruction, although can be classified into two major groups namely, clinical and emotional; they constitute many other intricate factors within the major classifications. Breast reconstruction is the most rewarding surgical procedure of the present day. Scientific and technological developments have made the procedure more sophisticated so that women can have almost similar breasts that they had before mastectomy. The chief aim of breast reconstruction is to give a near natural look to the breasts of the women who underwent mastectomy. The surgical procedures are usually conducted either immediately after mastectomy (IBR) or at a delayed stage (DBR). Delayed breast reconstruction is normally advised for patients whose nicotine intake is considerably high. There is mixed response for both IBR & DBR. Some prefer IBR while some other want to get their breasts reconstructed at a delayed stage for which they have their own reasons like interruption of adjuvant therapy. (C. J Callaghan et al, 2002) Both the patients and surgeons and nurses have to come to a consensus like compromise to win the battle against the monstrous cancer. Surgical treatment options are thus necessarily to be placed before the patients for an effective result to be arrived at. Surgical Treatment methods and implications are to be well defined and placed as information to be supplied to the patients in order to help them in the decision making process. Clinical aspects of breast reconstruction are constantly placed in the realm of research and ongoing development. Medical research and development in harmony with emotional aspects and ethical issues concerning clinical modalities are sure to fetch results acceptable both to the patients and medical professionals. Since the treatment options of breast cancer is slightly away from the topic selected for our current research, only a few treatment options are enlisted. This has been done in a view to provide the reader an overall review of the treatment options and with the assertion that any treatment for breast cancer is not against their wish to reconstruct their breasts with acceptable cosmetic satisfaction of the patients. Potential use of spleen tyrosin kinase(SYK) was found to give remarkable effect in breast cancer treatment, as it supported the use of AZA – a DNA methyltransferase inhibitor 5-aza-2’-deoxycitidyne—as a new reagent to the management of advanced breast cancer making the invasion suppression practically possible.( Yunfei Yuan, et al, 2004) Sentinel Node Biopsy was found to be an effective method of breast cancer treatment providing valuable prognostic information. Andrew Spillane, 2004 is of the opinion that adequate self-audit is necessary for the patient to give an informed consent. (Andrew Spillane, 2004)While comparing the survival rate of the breast cancer patients after treatment, Hiroyuki Takei of Japan, 2006, found that a SLNB (Sentinel Lymph Node Biopsy) was more safe than the ALND ( Axillary Lymph Node Dissection) that had no impact on prognosis of the patients. The team has determined this fact by a negative histologic investigation, wherein tumor size (Tis, T1–2 versus T3–4), histologic nodal involvement (negative versus positive), nuclear grade (NG) (1, 2 versus 3), lymphatic vessel invasion (LVI) (absent, weak versus intense), estrogen receptor (ER) status (positive versus negative), type of axillary surgery (SLNB alone versus ALND), type of breast surgery (partial versus total mastectomy), and radiation therapy (yes versus no) significantly correlated with DFS(Disease Free Survival) by univariate analysis, demonstrating better DFS in the SLNB only.( Hiroyuki Takei et al, 2006) Finding a way out for mastectomy is being considered all along over the time. The new surgical techniques, namely the oncolplastic techniques in recent years to optimise the efficacy of conservative surgical methods both in terms of local controls and cosmetic results are still under research and ongoing observations. (Riccardo Masetti et al, 2006) . Surgical procedures adopted for breast reconstruction include the introduction of the transverse rectus abdominis musculocutaneous (TRAM) flap, which made reliable autologous breast reconstruction a reality. The subsequent application of microsurgical principles to this procedure brought further refinements in terms of improved blood supply and lessened donor site morbidity. Finally, the wide acceptance of the skin-sparing mastectomy by oncologic surgeons has allowed further progress in the aesthetic possibilities that can be realized by the plastic surgeon. (James C. Grotting et al, 2003) Dr.Ananian et al, 2004 discusses about patient consent and patient autonomy in respect of breast cancer patients. This study group also emphasised the fact that information provided by health care providers, surgeons and attending nurses added much to the score of patients opting for BR. Bringing the patients awaiting mastectomy to the process of dialogue in order to provide them the information they seek for and clearing their doubts before conducting mastectomy is the best way for effective reconstruction. Option for IBR was found to be the effect of the surgeons’ interaction with patients awaiting mastectomy. Even the sophisticated TRAM (Transverse Rectus Abdominis Myocutanous) flap – based reconstruction technique depends on the patients build and co-existing medical conditions together with the likely hood of the need for post operative radiotherapy as part of the primary local treatment. (Fentiman I.S, H. Hamed, 2006). Hence guiding the patients before mastectomy by the surgeons has necessarily to involve careful suggestive approach. Relatively greater number of women opting for IBR rather than DBR may also be out of sensitivity of avoiding pain, damage to the tissues of breast by radiation therapy or scarring and other related inconveniences like discomfort, wound infection, itching, tingling, numbness and difficulty in moving etc, at a protracted period. THE REVIEW: AN OVERALL ANALYSIS OF THE APPROVED PAPERS. : The approved papers are :- 1) Ananian P et al, 2004 Determinants of patients’ choice of reconstruction with mastectomy for primary breast cancer. Annals of Surgical Oncology 11 (8): 762-771 2) Contant CME et al, 2000 Motivations, satisfaction and information of immediate breast reconstruction following mastectomy. Patient Education and Counselling 40, 201-208 3) Keith DJW et al, 2003 Women who wish breast reconstruction: characteristics, fears and hopes. Plastic and Reconstructive surgery 111 (3): 1051-1056 4) Neill K.M et al, 1998 Choosing reconstruction after mastectomy: A qualitative analysis. Oncology Nursing Forum 25 (4): 743-750 5) Nissen M.J et al 2002 Quality of life after postmastectomy breast reconstruction. Oncology Nursing Forum 29 (3); 547-553. A sequential perception of the literature has prompted to arrange them in the chronicle order as follows. 1. Neill K.M et al, 1998 2. Contant CME et al, 2000 3. Nissen M.J et al 2002 4. Keith DJW et al, 2003 5. Ananian P et al, 2004 Keith in 2003. also used self-report questionnaire like Research by Contant al (2000). Keith’s attention was chiefly on anxiety and depression while Contant used the same for more than 27 findings broadly classified into five main categories. Caroline’s attention was found to lay on motivation and QOL .While Keith was doing their research on newly diagnosed patients of breast cancer, Caroline did the same with 103 patients who wished reconstruction immediately after the mastectomy. The scales used by Contant to express the outcome of their research is self explanatory. The order of precedence of the out come is as follows: Information, Body image, Physical QOL, Satisfaction, Sexual functioning, Psychological QOL. Usage of Crobach’s α had helped them to give out a clear picture of the research findings. Keith’s approach in evaluating the attitude of women towards breast reconstruction was technically psychological in which the patients were kept in dark during assessment about the type of surgical procedure that would be applied on them. Presentation of the data derived on assessment in a simple form of percentage format is lucid. This makes the report understandable to common man too. Neill K.M. 1998, qualitative analysis represents an early approach in breast reconstruction. The strength of this report lies mainly on the admittance by the authors that still more miles were to go in breast reconstruction technology and the acceptance of the same by women from wide corners. The latest Dr. P.Ananian’s research had done the same job in a different way. The questionnaire offered to the patients to assess their choice of preferences for breast reconstruction was tactfully compared with response derived from surgeons too who were asked what the patient would choose considering the clinical, social and psychological aspects pertaining to each patient. The exclusion criteria similar to that adopted by Neill K.M. in 1998, made the knowledge base of the justification for their refusal or non response fully concealed. Design of the questionnaires might have landed the authors to exclude such refuters and non responders. However this shows that indirect methods can be designed to assess the reasons for their refusal. Although much time need not be wasted in assessing the reasons for refusal, a record of refusal and its justification is likely to give a spark sometimes for future studies. IBR vs DBR Being the earliest among the literature reviewed, the literature of Neill K.M. et al of 1998 answered the RQ leaving several more questions for further research. As IBR was not available at the time of the study by the team lead by Keith DJW in 2003, the recommendations of this team are now found to be aptly presented in terms of the patients’ need for ample information.The advantage of IBR over DBR is discussed in detail at the literature of Contant et al, 2000 only. Table 3 presented in the literature depicts the detailed results of their findings. The team had given a supporting data of motivation for IBR too in Table 2. This team had analysed the satisfaction level of the sample subjects too in relation to IBR. The team had an excellent opportunity to compare the relation ship of the satisfaction with treatment option and with information imparted to the patients. The design of research by this team is nice and generates data at all levels including patients and surgeons. The design selected by Ananian et al included patients who opted for BR this was further grouped into two as IBR & DBR. The socio demographic data and clinical info gave way to generate still more data for analysis. In respect of Keith et al, the design was up to the mark; as the questions in the Questionnaire were specific and clear, the design of presenting the Questionnaire to the patients who were diagnosed to breast cancer worked well to yield as much data as required by the study team. With regard to Timing of BR, it is discussed by Ananian et al in comparison with one another viz, IBR & DBR. According to their study women with advanced tumour stage opted DBR. As the literature by Contant et al talked merely about IBR, the question of timing did not arise in their literature. And in case of the review by Keith DJW et al, 2003, IBR was not at all available during their study. Postmastectomy chest wall and nodal radiation therapy is found to decrease local recurrence and improves disease-free and overall survival. A report on the experience of irradiating the chest wall and regional lymph nodes after a TRAM flap reconstruction and description of the acute side effects, flap viability, and cosmetic outcome out of the research conducted by … established that the technique for delivery of radiotherapy to the chest wall in patients who had undergone a mastectomy and immediate TRAM flap reconstruction is well tolerated. The acute toxicity was also manageable. There were no TRAM flap losses or revisions performed secondary to the radiotherapy. (Vivek K. Mehta , Don Goffinet 2004) Factors influencing womens’ decision making to undergo BR Age: All the five literature reviewed selected the sample of subjects with an average age range of 24 – 70. Keith DJW et al concluded that younger women and more depressed women opted for BR. The Mean of age of sampling group was 47.27 who opted BR. The mean age in the literature of Ananian et al was 53.9 and that of Contant et al group was 41.5 years. Ananian and Contant had not specifically the impact of age in influencing the decision on BR, but from the mean selected, one can infer the findings of Keith et al to be decisive. Medical History: Medical history of a patient is certainly bound to have its impact on the treatment and the awareness of the medical data stored already is bound to lay its effect on decision – making process. P.Ananian et al had discussed in detail about the medical history of the subjects and stored the results. Factors like tobacco consumption, high blood pressure, first degree relative breast cancer, and size of the tumour were found to have an inversely relation ship with the willing ness to opt for BR. Level of Education: Educational level issue was also discussed by Ananian only. He concluded that less highly educated subjects preferred DBR. The other four literatures did not speak of the education levels of the subjects. Marital Status: Marital status of the sample group plays crucial role in decision making process by the patients. Ananian’s literature revealed that married women when compared with single women opted for BR.(76%) Keith ‘s report also goes in conformity with these findings.(85.5%). The other three literature did not make any mention of these factors. Emotional State: Emotional state of the patient is an important aspect that lays its changing pattern on decision making of the patients. Keith et al had performed well in these area and the emotional aspects that influence the women to opt for BR is well placed on record. Contant et al had approached the same area via assessing the satisfaction levels and motivation for BR. The subtle difference is that Contant et al had concentrated on those patients who opted for IBR with silicone implant only. The source triangulation and method triangulation study conducted by Holtzman,2005 indicated that the meaning of IBR was related to hopes, normality and a ‘wholeness’.( J. Holtzmann, H. Timm, 2005) Health Care Services: The role of breast surgeons in Australia however is noteworthy. Their struggle to occupy a standard position is able to be understood in the works of Maria Teresa Nano, 2004, who made it clear that LDMF (Lassitimus Dorsi Mascular Flap) technique was useful in breast reconstruction allowing breast conservation with satisfactory resection margin and good cosmetic and functional results. (Maria Teresa Nano et al, 2004) However the reconstruction operation carried out by the breast surgeons were found to be effective with an acceptable rate of complications and a high level of patient satisfaction. Maria Teresa Nano, 2005 carried out an evaluation at Royal Adeleid Hospital Breast Unit, Australia, between 1990-2002. The team collected the cases of 219 patients of which 18 latissimus dorsi mini flaps, 83 tissue expander/implants, 43 latissimus dorsi flaps and 75 TRAM flaps included. Systemic complications were exhibited in four patients and implant related complications were found in four patients only. An overall 77% patients were highly satisfied. (Maria Teresa Nano et al 2005) Surgeon’s Influences: Surgeons’ influence on decision making is virtually considered more important than that derived from the close associate/partner. This is well indicated in the works of Keith et al wherein it is seen that 81% patients wished to have consultancy with their surgeons and 71% with the breast care nurses while 55% wished to consult with partner. Information Available: The information made available to the patients before surgery was the key factor discussed in all the five literature. This had been well established by the authors of the literature in different ways. The recommendations of the authors of the team of P.Ananian are chiefly the thorough communication link between the patients and the surgeons and medical professionals. This is well established by them in their findings that young women who wish to have IBR also were found to have contributed much to the decision if they were provided with more than sufficient information-both clinical and psychological- from the surgeons who attend them or advice them. Contant et al also made a stress on more information, which indicated the need for still further research towards the patients’ reaction until the impact of IBR with silicone implant is fully understood by all the concerned including the medical professionals. As in the words of Neill K.M et al ‘becoming normal again’ was the driving force of the women who were to undergo BR. Information seeking was behind this urge for ‘back to normalcy’. Healthcare professional support: Health care support obtained from the valuable and conceivable information works well with patients to opt for breast reconstructive surgery. For this, the women expect their surgeons and medical professionals to be in a state of ever growing knowledge. Lisa Martinez, the executive Director of Women’s Sexual Health Foundation, Cincinnatti, OH is of the view that for the past two decades the women were the driving force behind getting insurance coverage for reconstructive surgery postmastectomy. (Anne Katz , et al, 2007). Contant et al made this clear by citing Winer et al, 1993 in which health care providers were required to give priority for the concerns of the women undergoing BR. Social support: Social support for breast reconstruction can really be retrieved from patients who have already undergone BR. Talking to those mates can relieve of several pains by way of pouring more information. Hence having discussion with such associates would be beneficial even before surgery. (www.cancerhelp.org.uk). The five literatures selected for discussion do not pay much attention towards the point of satisfaction of patients who underwent BR at a later period after surgery. The problems met by the patients were not at all touched by any literature except in one literature, ie. Contant et al that made a mention of possible complications met by just three subjects associated with silicone implant. The team had ascribed the disappointing experiences with silicone prosthesis to inadequate information. Choice of surgical procedures Choice of surgical procedure normally is vested with the patients and surgeons both general and plastic under whose best consultation alone a patient can give her informed consent. Regarding the allowance of time for reconstruction, the literature by Keith alone talked about it. It made it clear that patients when given a choice of 3 months or 6 months to perform reconstructive surgery, most of the women preferred 3 months. A point to be noted at this stage is that IBR was not available at the time of their study. To talk about the advantages and disadvantages of different surgical methods one has to have an overall understanding of the procedures normally followed and the impact of them on the patients. The five literatures under discussion mostly talk about the advantage of IBR over DBR in relation to the satisfaction level of the patients. The patients in all the five literature are found to focus on cosmetic aspects of reconstruction enabling them to avoid external prosthesis. The more important point in their option for IBR was chiefly the contentedness they expect to derive on getting up from the operation table with breasts that were near original. However the satisfaction towards implants was not complete as 100%. Fear of recurrence hangs many patients even to opt MA. Disadvantage of breast reconstruction processes such as post operative complications were not paid due heed by the literatures. Complications like wound infection, flap failure, partial loss of the flap, fluid under wound, hardening and distortion of the implant, leakage of the implant contents, wrong size breast and abdominal hernia were some complications that arise after reconstructive surgery. Educating the patients with the possible treatment options for the complications and their consistency must be made part of dissemination of information. Psychological support available for women undergoing BR The specialist breast care nurses are bound to extend their fullest support to the patients in decision making. Methodological flaws currently persisting in the area of clinical assistance to patients diagnosed with breast cancer must invariably be eliminated by way of evolving accommodation of changes to policy and provision of care. (Diana Harcourt, Nichola Rumsey 2001). Imparting essential and guiding information to the patients continuously alone would fetch the desired result in this area of decision making by the patients in consultation with the surgeons. All the five literature we review are unilaterally of the same recommendation without any difference. The claims and recommendations made by the authors of all the five literature reveal this. The claims made by the authors of Ananian et al that IBR is mostly welcome by majority of young women go in harmony with the recommendations that a thorough communication link between the medical professionals and patients are a must. In case of Contant et al, too the authors’ claim that majority of the subjects selected for study opted for IBR go in harmony with their recommendation that the information to be imparted to patients be ever growing. The expectation level analysis conducted by the authors reveal a direct proportional relation with the need for more information and an inverse relation with satisfaction level. The main recommendation of the team lead by Keith DJW et al had revealed that the psychological anticipation, hopes and concerns of the patients ought to be given due weight and consideration. Fear of recurrence was inherent in the study results of Nissen et al, 2002. Despite the information provided the women were having still more expectations with regard to information to be imparted to them in some aspects. Role of family: The role of family in giving support to the patients of post mastectomy and breast reconstruction is highly crucial. Support from relatives especially husband is also of utmost pivotal in decision making. One Ms. Theresa’s husband gave her whole hearted assent of him for breast cancer treatment, saying “I married you, not your breast.” (Jenifer Sabol, 2006). Depression was keenly attended to by the team lead by Keith DJW. In his research only HADS (Hospital Anxiety Depression Scale), EPQ (Eyesenck Personality Questionnaire) were used to measure the depression levels in patients. These had facilitated easy measurement of extroversion, neuroticism and tough mindedness. Importance of information and support: Naturally success of any surgical operation is possible only with the cooperation of the patient. Breast reconstruction – a surgical technology that grows fast in recent years—is no exception to it. The general surgeons, plastic surgeons and breast care nurses are all under one team to evolve new ways and means and procedures to carry out the reconstructive operations. This naturally is possible only with the cooperation of the patients, who in turn will render better cooperation only after being given reliable and feasible facts. The importance of giving ample information to the patients stressed in all the five literatures are thus making a lot about reconstruction. Satisfaction with BR Women of the study group mentioned in all the five literatures were given questionnaire to fill up the data either just before the operation or after IBR. The satisfaction levels measured in these ways are purely fluid that may at any time later would change. As most of the subjects were concerned either with cosmetic aspects or body image, the satisfaction data enumerated are just the ones got half the way towards the research in assessing the complete satisfaction levels. The complete satisfaction levels can be measured only with those patients who had undergone BR – either IBR or DBR—a few years before. The pains, discomfort, inconvenience and physical injuries experienced by them must be subjected to separate research to bring out a near complete out come of the satisfaction over BR. Complications especially post operative complications were not identified in the literatures. Contant et al just cited Merkatz et al, 1993 in finding a relation between disappointing experiences and lack of information. METHODOLOGICAL ISSUES AND LIMITATIONS OF THE RESEARCH The five literatures cited have done well as far as their research purposes were concerned. But the purpose chosen by the teams did not lead to any vivid recommendations except that all of them were able to stress that more information need be imparted to women undergoing BR. No literature was clear in their recommendations what information need be given before surgery and what information need be given during surgery and what after surgery. However Contant et al 2000 were frank in their discussion to admit this kind of limitation and were able to suggest that the expectation level of the patients was correlated with the satisfaction leading to the fact that a standard code of information dissemination could not be made. As regarding the clarity of their research questions all the literature were clear in their goal. Here too Contant et al 2000 were aware of their limits. Despite the fact that the aim can not be considered to have arrived at a clear cut destination of wholesome fact finding, the authors have involved in a job of assessing the psychological implications in satisfaction levels and were clear in arriving at their targeted goal of fixing the motivation and satisfaction levels. Formation of the five questions were made in such a way that the answers to the questions were susceptible to analysis. The construction of scale established this fact. Keith DJW et al, 2003 showed their prudence in framing their questionnaire. As the study involved the assessment of chiefly the psychological impact of BR the authors had shown clarity in their research by way of framing apt Questionnaire. The questions in the Questionnaire were clear cut allowing the patients to express their views without any hesitation out of ignorance. Allowance for ignorance had facilitated such clarity and feasibility of filtering the ignorant group. Of course the questions in the Questionnaire were definite and easily answerable by the subjects. Four questions altogether in Table III, IV & V were purely assertive and one about awareness. All the questions in Table V were diligently framed in the form of opinion, which would naturally ease any subject to reveal their ideas whatever they may be. In respect of data generation all the four team which adopted the questionnaire method were able to arrive at data generated by the methods the quality of which were merely statistical. In case of Nissen M.J.et al, 2002 conductance of focus group sessions had laid a direct impact of the subjects’ opinions. Responses received from semi structured and open-ended questions were analysed further to arrive at an answer for the RQ. When the approaches to the data were looked into, all the literatures had done well in their job. The approach of P.Ananian et al, 2004 in framing a surgeon’s questionnaire strengthened the research purpose to elucidate the factors that prompt women to have BR . Approaches by Cantant et al, 2000 to data were cutely calculated. Assessing motivation and advantage of IBR from the patients had given way to ample chance of creating further data and analysis. Satisfaction level analysis had been classified into satisfaction with treatment and satisfaction with information. This had leaded further to analyse the relationship of satisfaction on IBR with need for more information and factors like sexuality, body image and QOL. Absence of ambiguity in questions framed by Keith DJW et al, 2003 had paved way to fast collection of data meant for analysis. For example, patients were given choice of persons to whom they had discussed and with whom they prefer to discuss about reconstruction as found in Table IV. Sizes of sampling groups were apt individually although in some cases it may look insufficient. As P.Ananian, 2004, selected the sampling group in France where free BR facility is offered to those who undergo mastectomy, the size sufficed their research. When we look into the sampling group of Contant et al, 2000, patients were selected from a single Hospital at Rotterdam over a period of five years from 1990 to 1995. Although the size of the sample ie 103 may look insufficient as far as the subjects were from same locality/hospital, the size did not have any detrimental effect on the study, since the subjects selected were purely specific in respect of the treatment and willingness. This clinical aspect had reduced the load of studying large number of subjects. The size of 125 picked by Keith DJW et al, 2003 was found to be comfortable for the study team as all the subjects were those who had no previous cancer therapy. This had made them reach maximum accuracy in their findings. Rigour of the research was equal in all the five literatures. The hard work of the research teams are well established in rigour. The rigour of the study by P.Ananian et al, 2004, lies in passing light on the findings by the authors. The results of the study are thus discussed prudently to establish that BR outweighs the number of patients who opted for MA. The QOL after BR was discussed with supporting data. The rigour of the research by Contant et al, 2000, lies in establishing the satisfaction level and making a comparative study of satisfaction with both the treatment and information. The relation ship of information with expectation in turn envisages the negative relationship of satisfaction with expectation. The rigour of the study by Keith DJW, 2003, et al, lies in accentuating the psychological anticipation of the patients with regard to BR. The team had attained their goal by framing about ten questions of opinion type that alleviated the hesitation from the subjects and precipitated much information. Reliability of the research is put to test in the following manner. The clinical aspects were recorded in the study by P.Ananian et al, 2004, as mere statistics and the discussion were not made in depth. Laying relatively less stress over the psychological aspects might be the cause of such clinical toning down. But Contant et al, 2000, framed clinical aspects in a vital manner. Psychological framework of satisfaction viewed through factors like sexual functioning, body image and psychological QOL are interwoven throughout the research methods. The selection of sampling of subjects opted for IBR with silicone implant facilitated the right destination of measuring accurate satisfaction level and motivation for breast reconstruction. Similar to Contant et al, Keith DJW et al, 2003, had given much importance to the psychological aspects like depression, neuroticism, psychoticism. In addition this team had considered the tumor size also as a factor in the study. The real clinical significance found in the recommendations was almost stereotyped. All the authors have placed stress only on the information to be given to the patients before surgery. However Neill K.M et al, 1998, being the earliest among the literatures selected for review, was able to locate the source for the need for more information by the patients as ‘becoming normal again’ was the driving force of the women who were to undergo BR. Information seeking was behind this urge for ‘back to normalcy’. CONCLUSION AND RECOMMEMDATIONS Despite quality of life benefits of BR lower BR rates are found to occur in many regions. The study and review of the literatures related to breast reconstructions reveal that the factors influencing women to opt for breast reconstruction were chiefly cosmetic and body image. The research done in this area so far have emphasised only the clinical and psychological aspects that lead women to disclose their informed consent for breast reconstruction. The social acceptance, financial implications are yet to be studied in detail. Insurers in many countries view breast reconstruction as merely cosmetic. (JAMA, Vol.295,No4 ,25.01.2006 ). This has resulted preferably in high cost and low preference for breast reconstruction. The research conducted by P.Ananian et al, 2004, at France is a proof for this aspect where free breast reconstruction facility is offered to all those who undergo mastectomy. There too the information supplying is not up to the mark. This might be due to the insufficiency in the research in the field of breast reconstruction. The comfort, pain, convenience and discomfort and everything related to BR experienced by the patients need be placed before every prospective patient diagnosed with breast cancer and advised mastectomy. Hitherto all the researchers have landed at the conclusion that still more information must be imparted to the patients before surgery. Research to elucidate what information and what kind of information need be given to the patients must be made in greater volume. Low rate of BR is also ascribed to the ‘fear’ factor in patients. The more reliable information is fed into the minds of breast cancer patients, the more they would prefer BR without any hesitation. The role of medical professional in this regard is very crucial as the surgery is related to sexuality of women. Ethical issues are to be addressed diligently and attended to. In total, socio economic research in terms of breast reconstruction is much needed. *** **** ***** ****** ******* Reference list— Andrew Spillane ,2004 , “Sentinel node biopsy in breast cancer and melanoma requires adequate self-audit” ANZ Journal of Surgery 74 (5), 308–313 Anne Katz , Bets Davis , Cathie Fogel , Beverly Johnson , Susan Kellogg, Meika Loe, Lisa Martinez 2007, “Sexuality and Women: The Experts Speak”, Nursing for Women's Health 11 (1), 36–43 C. J Callaghan, E Couto, M. J Kerin, R. M Rainsbury, W. D George, A. D Purushotham 2002, “Breast reconstruction in the United Kingdom and Ireland”, British Journal of Surgery 89 (3), 335–340. 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