Decision-making In Breast Reconstruction Research Articles

Challenges and Solutions for the Implementation of Shared Decision-making in Breast Reconstruction.

Background:Patient-centered care is a hallmark of quality in healthcare. It is defined as care that is respectful of, and responsive to, individual patient preferences, needs, and values, while ensuring patients are informed and engaged in the treatment decision-making process.Methods:We reviewed the literature and drew upon our own experiences to study the implementation of tools intended to facilitate shared decision-making in breast reconstruction.Results:For women with breast cancer, decision-making about breast reconstruction is often a challenging and perplexing process. The variety of choices available regarding timing and type of reconstruction and the unique individual patient and clinical treatment variables to consider can further complicate decisions. Accordingly, strategies to facilitate the decision-making process and enable patients and clinicians to make high-quality decisions about breast reconstruction are an essential component of comprehensive breast cancer care. Shared decision making is one proposed model to support informed and preference-sensitive decision-making in line with the principles of patient-centered care. Despite an emerging level of interest in shared decision making, there remains a lack of clarity regarding what the process involves and how to effectively implement it into clinical practice.Conclusions:Thus, widespread adoption of shared decision making remains lacking in clinical practice for women considering postmastectomy breast reconstruction. To address these gaps, this article reviews the principles of shared decision making, explores ways shared decision making can be utilized for patients who are candidates for breast reconstruction, and provides a practical overview to facilitate implementation of shared decision making into clinical practice.

A Randomized Controlled Trial Evaluating the BREASTChoice Tool for Personalized Decision Support About Breast Reconstruction After Mastectomy.

To evaluate a web-based breast reconstruction decision aid, BREASTChoice. Although postmastectomy breast reconstruction can restore quality of life and body image, its morbidity remains substantial. Many patients lack adequate knowledge to make informed choices. Decisions are often discordant with patients' preferences. Adult women with stages 0-III breast cancer considering postmastectomy breast reconstruction with no previous reconstruction were randomized to BREASTChoice or enhanced usual care (EUC). Three hundred seventy-six patients were screened; 120 of 172 (69.8%) eligible patients enrolled. Mean age = 50.7 years (range 25-77). Most were Non-Hispanic White (86.3%) and had a college degree (64.3%). Controlling for health literacy and provider seen, BREASTChoice users had higher knowledge than those in EUC (84.6% vs. 58.2% questions correct; P < 0.001). Those using BREASTChoice were more likely to know that reconstruction typically requires more than 1 surgery, delayed reconstruction lowers one's risk, and implants may need replacement over time (all ps < 0.002). BREASTChoice compared to EUC participants also felt more confident understanding reconstruction information (P = 0.009). There were no differences between groups in decisional conflict, decision process quality, shared decision-making, quality of life, or preferences (all ps > 0.05). There were no differences in consultation length between BREASTChoice and EUC groups (mean = 29.7 vs. 30.0 minutes; P > 0.05). BREASTChoice had high usability (mean score = 6.3/7). Participants completed BREASTChoice in about 27 minutes. BREASTChoice can improve breast reconstruction decision quality by improving patients' knowledge and providing them with personalized risk estimates. More research is needed to facilitate point-of-care decision support and examine BREASTChoice's impact on patients' decisions over time.

PEGASUS: the Design of an Intervention to Facilitate Shared Decision-making in Breast Reconstruction

Studies have found varying levels of satisfaction after breast reconstruction surgery with a substantial group of patients reporting some level of regret about their decision. The variable outcomes reported by women undergoing breast reconstruction surgery suggest a role for improved pre-operative communication and shared decision-making (SDM) between patient and health professional. Pragmatic approaches such as decision aids have been evaluated, but the aim of the Patient Expectations and Goals Assisting Shared Understanding of Surgery (PEGASUS) intervention is to facilitate closer interaction between the patient and clinical team. PEGASUS is a standardised two-stage process, in which patients’ goals are first elicited, ranked in importance and recorded before being used to frame discussion and decision-making with the surgeon managing care. Following the Medical Research Council (MRC) model, feasibility and acceptability studies have already been reported and a 4-year multicentre randomised controlled trial of 180 participants is underway, (completion 2020). This paper therefore focuses on the design of the intervention itself, in line with recent advice that interventions, in comparison with evaluations, commonly lack a theoretical base and are often under reported. We report a retrospective application of the Capability, Opportunity, Motivation-Behaviour (COM-B) model to provide explicit detail of each step in the intervention design. This is intended to facilitate replication by other clinicians and to provide systematic guidance for others wishing to develop PEGASUS as a strategy for implementing SDM in other clinical populations. Trial Registration: ISRCTN 18000391 (DOI 10.1186/ISRCTN18000391) 27/01/2016.

"Waiting for breast reconstruction": An interpretative phenomenological analysis of heterosexual couples' experiences of mastectomy for breast cancer.

Treatment decisions, such as breast reconstruction is made by the dyad patient-physician, but close others can have an influence on the process. Shared decision-making models include close others but current studies generally investigate physician-patient interactions only. Moreover, little is known about couples' interactions throughout the breast cancer journey and treatment decision-making. Thus, the aim of the present study was to explore couples' experiences of mastectomy and breast reconstruction decision-making, the month following the mastectomy. Ten unstructured individual interviews, with five couples facing mastectomy for breast cancer, were conducted. A dyadic interpretative phenomenological analysis (IPA) was carried on the data set. Eight super-ordinate themes emerged from the data. Couples' experiences were marked by the experience of the disease, the mastectomy and the impact they produced. The relationships with health professionals and partners were also important. Partners were not only supportive and protective, but directly (i.e., couples talk about treatments) and indirectly influenced (i.e., women make a decision taking into consideration how it will impact their couple) the women in their decision to have or not a breast reconstruction. The interpretative accounts underline how women and partners cope with the disease thinking about the aftertreatment. This study explains for the first time how intimate partners influence breast reconstruction decision-making and how couples cope individually with the disease immediately after mastectomy. Health professionals need to involve partners more in the treatment decision-making process as the women consider and talks to them about the choices they have to make.

Couples' Experience of the Decision-Making Process in Breast Reconstruction After Breast Cancer: A Lexical Analysis of Their Discourse.

One in 3 women with breast cancer will have a mastectomy and face the decision of whether to have breast reconstruction (BR). This decision is shared by the women and their physician, as well as discussed with her partner. This study aimed to understand the decision-making process of BR through a lexical analysis of the women and their partners' discourse. A secondary aim was to identify the differences between the couples when the woman had, or did not have, BR. We conducted semistructured interviews with 9 women, and their partners, who underwent a mastectomy after a first episode of breast cancer. A lexical analysis using IRaMuTeQ software was carried out. The analysis yielded 3 classes, each one being more represented by one of the different BR categories. Class 1 contained words reflecting a preoccupation with body modification. Class 2 was related to the surgery and its consequences. Words contained in class 3 were about the couples' issues regarding surgeries, treatments, and medical care. The question of temporality emerged particularly in classes 2 and 3. This study underlines the differences in the discourse of couples when talking about BR decision-making. Furthermore, it shows the importance of giving women time to think about BR and discuss its issues. Decisions about BR are difficult to make and should always be discussed between the women and health professionals, as BR is not always possible or desired by women. Partners need to be included in treatment decision-making.

Oral presentationsSystematic review of the factors associated with health behaviours related to obesity among refugee childrenPreliminary development of quality of life scales for children and adults with Niemann-Pick Type CThe diversity of diabetes-related self-monitoring and problem-solving practices across health literacy levels: An interview studyResilience as a predictor of burnout, depression and hope among medical studentsThe lived experience of parents with

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The influence of partner involvement in the decision-making process on body image and decision regret among women receiving breast reconstruction.

This study examines the influence of partner involvement in decision-making for breast reconstruction (BR) on women's body image and post-BR decision regret. A cross-sectional and correlational approach was used in a convenience sample of 105 women in Taiwan who had breast cancer (BC) whose partners were involved in decision-making for BR. A structured questionnaire including the Involvement in the Breast Reconstruction Decision-Making Process Scale, the Body Image Scale, and the Decision Regret Scale was administered. Pearson's r and path analysis were used to examine the relationships among the dyadic BR decision-making process, women's body image, and decision regret. The greater the amount of medical information women had, the better their body image and the less decision regret they experienced. Moreover, partner involvement was not related to women's body image, though it was inversely related to women's decision regret. The final path model showed that the amount of medical information women obtained was directly related to body image and decision regret, while body image also directly influenced decision regret. Overall, the amount of medical information women obtained and their body image explained 45% of the variance in decision regret. Medical teams should provide female BC patients with complete medical information, and through partner involvement, women can be supported to make an appropriate decision regarding BR to achieve optimal levels of body image and lower levels of decision regret.

Cost-effectiveness of the BRECONDA decision aid for women with breast cancer: Results from a randomized controlled trial.

To report on the cost-effectiveness of BRECONDA (Breast RECONstruction Decision Aid), a web-based decision aid to facilitate decisions regarding breast reconstruction surgery, with usual care for women with breast cancer. The economic evaluation was conducted alongside a randomized controlled trial. Women diagnosed with breast cancer or ductal carcinoma in situ and eligible for breast reconstruction following mastectomy were randomized to access BRECONDA for 6months+usual care (n=106) or usual care (n=116) and were assessed at baseline preintervention, and then 1-month and 6-months post-randomization. Decisional conflict, satisfaction with information, decisional regret, and utilities were assessed by using maximum-likelihood linear mixed effects models. Costs included the fixed costs of BRECONDA, health care provider time, and health care resource use. Nonparametric bootstrapping was used to estimate incremental cost-effectiveness ratios. BRECONDA resulted in significantly less decisional conflict and greater satisfaction with information over time. Quality-adjusted life years did not differ between participants who received the decision aid compared with usual care. The cost of BRECONDA was estimated to be small (AUD$10) relative to other health care interventions and resulted in decreased health care costs overall (AUD$764). Based on the point estimates, the decision aid was more effective and less costly (dominant) for all measures of effectiveness. It was estimated that the decision aid has an 87% probability of being cost-effective at $60000 per quality-adjusted life year gained. The BRECONDA web-based intervention designed to facilitate decisions regarding breast reconstruction surgery is likely to be cost-effective compared with usual care for women with breast cancer.

Facilitating decision-making in women undergoing genetic testing for hereditary breast cancer: BRECONDA randomized controlled trial results

BackgroundDecision-making concerning risk-reducing mastectomy for women at hereditary risk of breast cancer entails complex personal choices. Deciding whether and how to restore breast shape after risk-reducing mastectomy is a key part of this process. We developed a web-based decision aid, BRECONDA (Breast Reconstruction Decision Aid), to assist women in decision-making regarding breast reconstruction. MethodThis study assessed the efficacy of BRECONDA to assist women at increased risk of breast cancer in making decisions regarding risk-reducing mastectomy in terms of decisional conflict, knowledge, and satisfaction with information. Women at hereditary risk of breast cancer (N = 64) were recruited into this randomized controlled trial from four Australian hereditary cancer clinics. Participants initially provided online consent and completed baseline questionnaires assessing decisional conflict, knowledge, and satisfaction with information. They were then randomly assigned to either: 1) Intervention – unlimited access to BRECONDA, with usual care; or, 2) Control – usual care. At 2-months follow-up (N = 60) the outcomes were re-assessed. Intervention participants also completed user acceptability ratings for the intervention overall and specific key modules. ResultsMANCOVA analyses indicated that Intervention participants reported lower decisional conflict (P = 0.027), and greater knowledge (P = 0.019) and satisfaction with information (P < 0.0005) at 2-months follow-up compared with Controls. Intervention participants reported high user acceptability and satisfaction with the intervention. ConclusionBRECONDA benefits women considering risk-reducing mastectomy by reducing decisional conflict, and improving knowledge and satisfaction with information. These benefits, coupled with high user acceptability, demonstrate the feasibility of implementing BRECONDA in the hereditary cancer risk context.

A Qualitative Study of Breast Reconstruction Decision-Making among Asian Immigrant Women Living in the United States

Despite research supporting improved psychosocial well-being, quality of life, and survival for patients undergoing postmastectomy breast reconstruction, Asian patients remain one-fifth as likely as Caucasians to choose reconstruction. This study investigates cultural factors, values, and perceptions held by Asian women that might impact breast reconstruction rates. The authors conducted semistructured interviews of immigrant East Asian women treated for breast cancer in the New York metropolitan area, investigating social structure, culture, attitudes toward surgery, and body image. Three investigators independently coded transcribed interviews, and then collectively evaluated them through axial coding of recurring themes. Thirty-five immigrant East Asian women who underwent surgical treatment for breast cancer were interviewed. Emerging themes include functionality, age, perceptions of plastic surgery, inconvenience, community/family, fear of implants, language, and information. Patients spoke about breasts as a function of their roles as a wife or mother, eliminating the need for breasts when these roles were fulfilled. Many addressed the fear of multiple operations. Quality and quantity of information, and communication with practitioners, impacted perceptions about treatment. Reconstructive surgery was often viewed as cosmetic. Community and family played a significant role in decision-making. Asian women are statistically less likely than Caucasians to pursue breast reconstruction. This is the first study to investigate culture-specific perceptions of breast reconstruction. Results from this study can be used to improve cultural competency in addressing patient concerns. Improving access to information regarding treatment options and surgical outcomes may improve informed decision-making among immigrant Asian women.

Discussion: A Qualitative Study of Breast Reconstruction Decision-Making among Asian Immigrant Women Living in the United States.

Atlanta, Ga. From private practice. Received for publication September 29, 2016; accepted September 30, 2016. Disclosure:The author has no financial interest to declare in relation to the content of this Discussion or of the associated article. Amy K. Alderman, M.D., M.P.H., The Swan Center for Plastic Surgery, 4165 Old Milton Parkway, Suite 200 East, Alpharetta, Ga. 30005, [email protected]

Qualitatively understanding patients' and health professionals' experiences of the BRECONDA breast reconstruction decision aid.

Women diagnosed with breast cancer or ductal carcinoma in situ and those with a genetic susceptibility to developing this disease face the challenging decision of whether or not to undergo breast reconstruction following mastectomy. As part of a large randomized controlled trial, this qualitative study examined women's experiences of using the Breast RECONstruction Decision Aid (BRECONDA) and health professionals' feedback regarding the impact of this resource on patients' knowledge and decision making about breast reconstruction. Semistructured interviews were conducted with women who accessed the BRECONDA intervention (N=36) and with their healthcare providers (N=6). All interviews were transcribed verbatim and subjected to thematic analysis by 3 independent coders. Participants reported an overall positive impression, with all interviewees endorsing this decision aid as a useful resource for women considering reconstructive surgery. Thematic analysis of patient interviews revealed 4 themes: overall impressions and aesthetics; personal relevance and utility; introducing BRECONDA; and advantages and suggested improvements. Analysis of health professionals' interviews also revealed 4 themes: need for BRECONDA, impact of BRECONDA, potential difficulties that may arise in using the decision aid, and recommending BRECONDA to patients. Patients indicated that they derived benefit from this resource at all stages of their decision-making process, with the greatest perceived benefit being for those early in their breast reconstruction journey. These findings support the use of BRECONDA as an adjunct to clinical consultation and other information sources.

Reducing Decisional Conflict and Enhancing Satisfaction with Information among Women Considering Breast Reconstruction following Mastectomy: Results from the BRECONDA Randomized Controlled Trial.

Deciding whether or not to have breast reconstruction following breast cancer diagnosis is a complex decision process. This randomized controlled trial assessed the impact of an online decision aid [Breast RECONstruction Decision Aid (BRECONDA)] on breast reconstruction decision-making. Women (n = 222) diagnosed with breast cancer or ductal carcinoma in situ, and eligible for reconstruction following mastectomy, completed an online baseline questionnaire. They were then assigned randomly to receive either standard online information about breast reconstruction (control) or standard information plus access to BRECONDA (intervention). Participants then completed questionnaires at 1 and 6 months after randomization. The primary outcome was participants' decisional conflict 1 month after exposure to the intervention. Secondary outcomes included decisional conflict at 6 months, satisfaction with information at 1 and 6 months, and 6-month decisional regret. Linear mixed-model analyses revealed that 1-month decisional conflict was significantly lower in the intervention group (27.18) compared with the control group (35.5). This difference was also sustained at the 6-month follow-up. Intervention participants reported greater satisfaction with information at 1- and 6-month follow-up, and there was a nonsignificant trend for lower decisional regret in the intervention group at 6-month follow-up. Intervention participants' ratings for BRECONDA demonstrated high user acceptability and overall satisfaction. Women who accessed BRECONDA benefited by experiencing significantly less decisional conflict and being more satisfied with information regarding the reconstruction decisional process than women receiving standard care alone. These findings support the efficacy of BRECONDA in helping women to arrive at their breast reconstruction decision.

The influence of plastic surgeon age and gender on decision-making in breast reconstruction: a national survey of American plastic surgeons

There are numerous options for breast reconstruction after mastectomy, and the final reconstructive option is often influenced by patient preference. This study surveyed plastic surgeons regarding their personal preferences for breast reconstruction after mastectomy to identify the impact of gender and age on reconstructive preference. An anonymous online survey was distributed to plastic surgeons in the American Society of Plastic Surgeons member directory and current plastic surgery residents. Female surgeons were asked to select reconstructive options for themselves as patients, while male surgeons were asked to answer the same questions as if advising a loved one. After unilateral mastectomy, 60.2 % of respondents preferred implant-based reconstruction, increasing to 67.8 % after bilateral mastectomy. Top reasons for selecting implant-based reconstruction were recovery time (78.0 %) and hospital length of stay (54.5 %). In contrast, respondents who preferred abdominal flap-based autologous reconstruction cited the longevity (83.3 %) and the aesthetic appearance of the final result (82.7 %) as top reasons. Female surgeons were significantly more likely to choose implant-based reconstruction than male surgeons (68.7 vs. 56.6 %, p = 0.001). Younger male surgeons preferred autologous reconstruction (58.8 %). Plastic surgeons’ reconstructive choices parallel current patient-based surveys favoring breast reconstruction with implants. Respondents’ reasons for selecting one reconstructive method over another are consistent with prior patient-based surveys. Female plastic surgeons prefer implant-based reconstruction to a greater extent than male plastic surgeons. This survey identifies the need for further prospective study of physician perspectives of patient experiences.

Acceptability and pilot efficacy trial of a web-based breast reconstruction decision support aid for women considering mastectomy.

The study aim was to test the acceptability and preliminary efficacy of a novel interactive web-based breast reconstruction decision support aid (BRAID) for newly diagnosed breast cancer patients considering mastectomy. Fifty-five women considering mastectomy were randomly assigned to receive the BRAID versus the Cancer Support Community's Frankly Speaking About Cancer: Breast Reconstruction pamphlet. Participants completed measures of breast reconstruction (BR) knowledge, preparation to make a decision, decisional conflict, anxiety, and BR intentions before randomization and 2weeks later. In terms of acceptability, enrollment into the study was satisfactory, but the rate of return for follow-up surveys was lower among BRAID participants than pamphlet participants. Both interventions were evaluated favorably in terms of their value in facilitating the BR decision, and the majority of participants completing the follow-up reported viewing the materials. In terms of preliminary efficacy, both interventions resulted in significant increases in BR knowledge and completeness and satisfaction with preparation to make a BR decision, and both interventions resulted in a significant reduction in decision conflict. However, there were no differences between interventions. A widely available free pamphlet and a web-based customized decision aid were highly utilized. The pamphlet was as effective in educating women about BR and prepared women equally as well to make the BR decision as compared with a more costly, customized web-based decision support aid. Copyright © 2015 John Wiley & Sons, Ltd.

Social-cognitive variables as predictors of intention to undergo breast reconstruction

Abstract The aim of the study was to determine the role of self-efficacy, outcome expectancies, and risk perception (including consequences of mastectomy) in formulating the intention to undergo breast reconstruction in 178 women after total mastectomy. The social-cognitive variables were measured in the context of breast reconstruction, while depression was assessed using the Beck Depression Inventory. The structural equation modeling revealed that among the predictors there were only two that accounted for the intention to undergo breast reconstruction, i.e. self-efficacy and outcome expectancies (R2 = .67). Subsequent analyses of the related moderators, i.e. depression, age, and duration of the disease indicated a good fit to the data. Nevertheless, in subgroups with poorer resources (older age, depression, and longer duration of the disease) the direct effects of self-efficacy on intention were less noticeable or non-existent. The results suggest that self-efficacy may play the regulating role in making a breast reconstruction decision if individual resources are taken into account.

Understanding the factors that influence breast reconstruction decision making in Australian women

BackgroundBreast reconstruction is safe and improves quality of life. Despite this, many women do not undergo breast reconstruction and the reasons for this are poorly understood. This study aims to identify the factors that influence a woman's decision whether or not to have breast reconstruction and to better understand their attitudes toward reconstruction. MethodologyAn online survey was distributed to breast cancer patients from Breast Cancer Network Australia. Results were tabulated, described qualitatively and analyzed for significance using a multiple logistic regression model. Results501 mastectomy patients completed surveys, of which 62% had undergone breast reconstruction. Factors that positively influenced likelihood of reconstruction included lower age, bilateral mastectomy, access to private hospitals, decreased home/work responsibilities, increased level of home support and early discussion of reconstructive options. Most common reasons for avoiding reconstruction included “I don't feel the need” and “I don't want more surgery”. The most commonly sited sources of reconstruction information came from the breast surgeon followed by the plastic surgeon then the breast cancer nurse and the most influential of these was the plastic surgeon. ConclusionsA model using factors easily obtained on clinical history can be used to understand likelihood of reconstruction. This knowledge may help identify barriers to reconstruction, ultimately improving the clinicians' ability to appropriately educate mastectomy patients and ensure effective decision making around breast reconstruction.

Positive and negative aspects of well-being as correlates of breast reconstruction decision

The aim of the study was to explore the role of positive and negative aspects of well-being in a breast reconstruction decision, described in terms of the trans-theoretical model of change (TTM). The study comprised 216 women after total mastectomy in the cross-sectional design. The positive aspects of well-being were measured using the Rosenberg Self-Esteem Scale and Generalised Self-Efficacy Scale; the negative aspects were assessed using the Beck Depression Inventory and State-Trait Anxiety Inventory (T-Anxiety scale). The multinomial logistic regression analyses were implemented, and the action stage was chosen as a relevant category. McFadden's pseudo R-squared for positive, negative and combined aspects of well-being models equalled 0.28, 0.13 and 0.27, respectively. For the first model, the differential effects were observed for well-being, age and relationship status (54 % correctly classified cases), whereas for the model with negative aspects-only age and well-being (44 % correctly classified cases). For a model combining two aspects of well-being, the pattern was similar to the one observed for positive well-being (53 % correctly classified cases). The likelihood of classifying women in the action stage rather than in the pre-contemplation stage was determined by three variables: being in a relationship, better well-being and younger age. For the contemplation stage, the same relations were obtained for well-being and age. Finally, for the preparation stage, the well-being effect disappeared. The results suggest that positive rather than negative aspects of well-being, after control for sociodemographic variables, may be significant correlates of breast reconstruction decision.

Plastic Surgeon Expertise in Predicting Breast Reconstruction Outcomes for Patient Decision Analysis.

Background:Decision analysis offers a framework that may help breast cancer patients make good breast reconstruction decisions. A requirement for this type of analysis is information about the possibility of outcomes occurring in the form of probabilities. The purpose of this study was to determine if plastic surgeons are good sources of probability information, both individually and as a group, when data are limited.Methods:Seven plastic surgeons were provided with pertinent medical information and preoperative photographs of patients and were asked to assign probabilities to predict number of revisions, complications, and final aesthetic outcome using a questionnaire designed for the study. Logarithmic strictly proper scoring was used to evaluate the surgeons’ abilities to predict breast reconstruction outcomes. Surgeons’ responses were analyzed for calibration and confidence in their answers.Results:As individuals, there was variation in surgeons’ ability to predict outcomes. For each prediction category, a different surgeon was more accurate. As a group, surgeons possessed knowledge of future events despite not being well calibrated in their probability assessments. Prediction accuracy for the group was up to 6-fold greater than that of the best individual.Conclusions:The use of individual plastic surgeon–elicited probability information is not encouraged unless the individual’s prediction skill has been evaluated. In the absence of this information, a group consensus on the probability of outcomes is preferred. Without a large evidence base for calculating probabilities, estimates assessed from a group of plastic surgeons may be acceptable for purposes of breast reconstruction decision analysis.

‘Use what God has given me’: Difference and disparity in breast reconstruction

African-American women are significantly less likely to undergo postmastectomy breast reconstruction compared to white women in the USA. These observed differences have been interpreted as evidence of a healthcare disparity. The current study examines breast reconstruction decision-making among African-American women, locating reconstruction decisions in a context of culture, racial inequality and biomedicalisation. Semi-structured interviews were conducted with 27 African-American women who underwent mastectomy for breast cancer to add patient-centred perspectives to existing conceptualisations of racial/ethnic differences in reconstruction. Participants were socio-demographically diverse, and resided in the New York metropolitan area. Data analysis was informed by grounded theory. Spiritually and culturally informed body ethics often guided surgery decisions. Participants expressed reservations about breast implants, preferring autologous procedures that use ‘what God has given’. For some, breast reconstruction restored a sense of normalcy after cancer; others challenged an imperative to reconstruct. Several participants redirected our focus on access to reconstruction toward access to alternatives, noting the low reimbursement for prostheses, or their unavailability in patients’ skin tones. We suggest that a framework of ‘stratified biomedicalization’ better addresses the complexities of race, class and gender that inform preference, access and recommendations for breast reconstruction, and focuses attention on access to high and low-tech interventions.